Every finding on record at The Laurels of Mt. Pleasant

Based on observation and interview, the facility failed to maintain the facility flooring and ceilings in good repair. Findings include: On 07/20/2026 at 10:28 AM, while in the nourishment room on the Central hallway, there was standing water observable under the floor tiles between the refrigerator and the ice machine. Upon further observation, the tiles were loose, and water would come up over the tile when the tile was stepped on. Kitchen Manager (KM) D and Certified Dietary Manager (CDM) S who were present at the time of observation were able to confirm that they also observed the standing water. On 07/20/2026 at 2:12 PM, missing ceiling tiles and exposed piping were observed by the exit door on the 400-hall. The exposed ceiling tile area was approximately a two foot by ten-inch area, starting from the exterior wall. On 07/20/2026 at 3:20 PM during interview with Maintenance Director (MD) A, MD A stated that there seems to be a leak at the connection of the drain line and the bottom of the ice machine. The tiles from the nourishment room floor on Central hallway had been removed at time of the interview. On 07/20/2026 at 3:25 PM, MD A stated there had been a leaking pipe from the heating lines which affected the ceiling tiles. The plumber had been called to repair the lines; currently there is not a timeline for the repairs needed. The ceiling tiles had not been replaced at time of interview.

Based on observation, interview and record review, the facility failed to ensure proper food safety handling measures, resulting in the potential to spread food borne illness among residents that consume food from the kitchen. Findings include: On 07/20/2026 at 11:10 AM, Dietary [NAME] (DC) D was observed walking into the walk-in cooler, walking out with a plastic container of ham, and then proceeding to remove portions of the ham with bare hands and placing it in the food processor. When asked, DC D indicated that they would not normally handle the ready-to-eat ham with bare hands. On 07/20/2026 at 11:11 AM, during interview with Kitchen Manager (KM) E, KM E confirmed dietary staff are required to wear gloves when handling ready-to-eat foods with their hands. According to the 2022 FDA Food Code section 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.

This citation pertains to intake 3008033. Based on interview and record review, the facility failed to maintain a clear and concise Electronic Medical Record (EMR) for one resident (R93) of 82 residents reviewed for accuracy of medical records. Findings include:Review of an admission Record revealed R93 admitted to the facility on [DATE] with pertinent diagnoses which included malignant (cancerous) neoplasm (growth) of the lung and the brain, depressive disorder, and chronic respiratory failure. In an interview on 7/21/26 at 3:13 PM, Family Member (FM) T reported that R93 had passed away in the facility on 6/12/26. FM T reported that on 4/9/2026 R93 was being transferred by one nursing assistant in which R93 stumbled, almost fell, and scraped his left arm on the grab bar beside the toilet. Review of R93's Hospice Visit Note Report dated 4/17/26, revealed .left forearm skin tear.onset date 4/13/26.wound assessed by facility staff. Review of R93's Physician's Orders on 7/22/26, revealed a discontinued order that was initiated on 4/9/26 which directed nursing staff to .cleanse abrasions to left arm with soap and water, apply zinc paste (a thick, medicated topical skin protectant) and wrap with a 4x4 kerlix (protective dressing) daily for 3 days. Further review of R93's Physician's Orders revealed a treatment initiated on 4/11/26 that directed nursing staff to cleanse left forearm with wound wash, pat dry, and apply visco paste (medicated open-weave cotton bandage impregnated with a 10% [NAME] oxide paste) and cover with kerlex and coban (stretchy bandage) every 3 days. Interview on 7/22/26 at 1:00 PM, the Director of Nursing (DON) reported she was not aware of an occurrence where R93 stumbled during a transfer and obtained a skin tear. Interview on 7/22/26 at 1:53 PM, Registered Nurse Unit Manager (RN/UM) N reported that the order was initiated by her related to a skin tear obtained when R93 was in the shower and stumbled during the transfer and R93's left arm made contact with the assist bar on the shower wall. RN/UM N reported she did not document the incident or complete an incident report. RN/UM N reported she should have. Review of the facility policy/procedure Skin Management, revised 1/28/2026, revealed .all skin tears will be evaluated, documented, and treated based on physician's orders.an incident accident report is to be completed.the licensed nurse is responsible for documenting skin tears upon occurrence and monitoring on a weekly basis until healed.notify the practitioner and responsible party of the occurrence, document the notification in the medical record and initiate an order, as needed.

Based on observation, interview, and record review, the facility failed to administer a nebulizer treatment and sanitize the nebulizer mouthpiece appropriately for one resident (R56) out of three residents reviewed for respiratory care. Findings include:Review of an admission Record revealed R56 initially admitted to the facility on [DATE] with pertinent diagnoses which included dementia, chronic obstructive pulmonary disease, and mild cognitive impairment. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R56, with a reference date of 6/5/2026 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 11, out of a total possible score of 15, which indicated R56 was moderately cognitively impaired. In an observation on 7/20/26 at 10:46 AM, R56's nebulizer mouthpiece was on the stand beside R56's bed uncovered. In an observation on 7/21/26 at 8:49 AM, R56's nebulizer mouthpiece was on the stand beside R56's bed uncovered. In an interview on 7/21/26 at 8:50 AM, Registered Nurse (RN) U reported that the nebulizer mouthpiece and canister should be rinsed in the sink after each use and placed on a paper towel to dry. RN U reported that the nebulizer mouthpiece and nebulizer canister should be stored in a bag. Review of R56's Physician Orders dated 7/22/26 at 12:43 PM, revealed an active order for albuterol sulfate inhalation nebulizer solution (used to treat and prevent bronchospasm) to be given via a nebulizer four times a day for shortness of breath. Further review of R56's Physician Orders revealed no active order for the sanitation or storage of the nebulizer tubing or mouthpiece. In an observation on 7/22/26 at 9:33 AM, R56 was in her room alone with the nebulizer machine on and clear liquid in the nebulizer container. R56 had the mouthpiece in her mouth talking to herself. R56 was moving the mouthpiece in and out of mouth and the mist from the medication was not being inhaled. In an observation and interview on 7/22/26 at 9:37 AM, Licensed Practical Nurse (LPN) F was at the nurse's station. LPN F went into R56's room and reported that R56 was capable of self-administration of a nebulizer treatment to assist R56's shortness of breath. R56 continued to remove the nebulizer treatment away from her mouth multiple times not allowing the medication to be inhaled. In an interview on 7/22/26 at 9:40 AM, Registered Nurse Unit Manager (RN/UM) G reported that R56 has a urinary tract infection and R56 did become anxious moving her mask and mouthpiece from her mouth. RN/UM G reported the nebulizer mouthpiece should be stored in a bag. RN/UM G reported she would stay outside R56's door to ensure the nebulizer treatment was administered appropriately. RN/UM G reported there was not a self-administration assessment for R56 to administer the nebulizer treatment without a nurse to supervise. In an interview on 7/22/26 at 10:21 AM, the Director of Nursing (DON) reported that R56 should not be left alone during her nebulizer treatments. The DON reported that there was no self-administration assessment completed for R56. Review of facility policy/procedure How to use a nebulizer no review date, revealed .seal the lips tightly around the mouthpiece during the breathing treatment.take slow, deep breaths in and out through the mouth, this helps the medicine get into the lungs.continue breathing like this until all the mist is gone.tap the cup of the nebulizer every few minutes to move any droplets on the side to the bottom of the small cup.follow the directions that came with the nebulizer for how to clean and store it.it is very important to clean and disinfect the machine as directed.this keeps it working well and helps prevent infection.

Based on interview and record review, the facility failed to notify the ombudsman of transfers and discharges for two residents (R92 and R90) of two residents reviewed for transfers and discharges.Findings include: R92 Review of an admission Record revealed R92 admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes, depressive disorder, and end stage renal disease. Review of R92's Nurses Note, dated 4/25/2026 at 10:03 PM, revealed R92 declined dialysis and stated .no, not tonight. I am leaving early in the morning. R92 discharged from facility on 4/26/26 via a private vehicle. Further review of the Electronic Medical Record (EMR) revealed no documentation the ombudsman had been notified of this discharge. In an interview on 7/22/26 at 2:10 PM, the Nursing Home Administrator (NHA) reported that the facility does not complete or send a transfer/discharge log to the LTC Ombudsman. R90 Review of an admission Record revealed R90 admitted to the facility on [DATE] with pertinent diagnoses which included pneumonia and chronic obstructive pulmonary disorder. Review of R90's Nurses Note, dated 4/23/2026 at 11:20 AM, revealed R90 was sent to the local emergency department urgently to be treated for shortness of breath. Further review of the Electronic Medical Record (EMR) revealed no documentation the ombudsman had been notified of this emergency transfer. In an interview on 7/22/2026 at 2:40 PM, the Nursing Home Administrator (NHA) reported she had not been notifying the ombudsman when residents were transferred to the local emergency department. In a telephone interview on 7/22/2026 at 2:45 PM, State Ombudsman L reported she had not been receiving notification from the facility when residents transferred to the local hospital emergency department. Review of facility policy/procedure Transfer and Discharge, revised 4/22/2025, revealed .The notice of transfer or discharge required under this section must be made by the facility in writing at least 30 days before the resident is transferred or discharged . A list of residents can be sent to the ombudsman on a monthly basis. Procedure: Emergency Transfer to Acute Care. When a resident is transferred on an emergency basis to an acute care facility. The ombudsman is notified.

This citation pertains to intake 3008033.Based on observation, interview, and record review, the facility failed to follow up with grievances for one resident (R93) out of three residents reviewed. Findings include: Review of an admission Record revealed R93 admitted to the facility on [DATE] with pertinent diagnoses which included malignant (cancerous) neoplasm (growth) of the lung and the brain, depressive disorder, and chronic respiratory failure. In an interview on 7/21/26 at 3:13 PM, Family Member (FM) T reported that R93 had passed away in the facility on 6/12/26. FM T reported that R93 had missing clothing including two shirts that were unique to the family and a blanket that a family member had given R93 that FM T would like back. FM T reported that she had made several attempts to notify management of the missing items and filled out a Guest Assistance Form. FM T reported she had not heard back whether the missing items were found. Review of R93's Guest Assistance Form dated 6/12/26, revealed that a worker had initiated the form with a complaint related to a missing blanket, grey and white in color, along with missing clothing. The complaint stated, Wife is asking about the blanket because their daughter got if for her father to have something soft to hold. Guest Assistance Form revealed that a staff member had looked for the blanket and could not locate it. Facility Response revealed that there was no inventory sheet filled out and R93's clothing was not labeled at the facility and that the facility would continue to look for R93's blanket. The form was signed with an unrecognized signature, and the date was left blank. A section of the form that states Complainant's Response to the Facility was left blank with no notification to the wife if the blanket or clothing was found. The last section of the form stated Facility Follow-Up was left blank with no follow up documented. In an interview on 7/22/26 at 9:17 AM, the Nursing Home Administrator (NHA) reported R93 was homeless when he admitted to the facility and an inventory form was not completed. The NHA reported that when a guest assistance form is initiated the facility reviews each one in the morning stand up meeting and the appropriate department manager receives the guest assistance form. The facility then provides feedback for each specific concern. The NHA reported there was no follow-up documentation that could be located related to R93's missing blanket and clothing or documentation that R93's wife had received follow-up regarding the missing items. Review of facility policy/procedure Care Program, revised 7/8/25, revealed .staff receiving the grievance should acknowledge receipt of concern and immediately address the concern if possible and document the resolution.that department manager/designee will have 5-7 business days following receipt of the concern to complete the investigation and document his/her conclusions.the Administrator and/or Department manager will contact the resident or person filing the concern as soon as possible but no longer than within 72 hours of receipt of the concern to inform them of the status of the concern.

Based on interview and record review, the facility failed to maintain an accurate Electronic Medical Record (EMR) for 2 residents (R100 and R102) of 7 residents reviewed for accuracy of medical records. Findings include:R100 Review of an admission Record revealed R100 admitted to the facility on [DATE] with pertinent diagnoses which included cellulitis (bacterial skin infection) of the back, sepsis (a body's extreme response to an infection), chronic kidney disease, and adult failure to thrive. Review of R100's Progress Notes, dated 3/18/2026 at 12:47 PM revealed .resident (with) significant weight loss.resident declining in health and refusing meals at times and wanting to stay in bed most of the time.NP (Nurse Practitioner) aware and so is dietician to initiate interventions. During an interview on 5/5/2026 at 9:36 AM, Unit Manager (UM) G reported that she had written the progress note on 3/18/2026 at 12:47 PM and had notified R100's family member about the change in condition but did not document the notification in the EMR. UM G stated I missed that. During a telephone interview on 5/5/2026 at 11:39 AM, Family Member (FM) H reported that the facility notified him of R100's care sporadically but could not remember all of occurrences he had been notified of. FM H reported that R100 had required a new guardian and that the facility had initiated that process. During an interview on 5/6/2026 at 11:50 AM, Social Services Director (SSD) D reported that he had begun the process of guardianship for R100 and had communicated with outside resources but did not document in R100's EMR. SSD D reported he should have documented his actions and processes he put into place for R100 in the EMR. R102 Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included traumatic brain injury and neuromuscular dysfunction of the bladder. Review of a current pain Care Plan intervention for R102, created 8/9/2023, directed staff to administer medication for pain and observe for effectiveness. Further reviewed revealed staff were to evaluate characteristics of pain using a scale. Review of R102's November 2025 Medication Administration Record on 5/5/2026 at 9:50 AM revealed he was receiving morphine every 2 hours for pain and no documentation of R102's pain or response to pain medication was documented. Further review of the Electronic Medical Record (EMR) revealed no further documentation that staff were using a pain scale to monitor R102's pain or the effectiveness of his pain medication. In an interview on 5/5/2026 at 9:55 AM, the DON reported staff should have been using a pain scale to document R102's pain and to verify the effectiveness of his pain medication. The DON reported the order was not placed correctly for this to occur. Review of a facility policy/procedure Medical Records Management, revised 1/31/2022, revealed .A complete medical record contains an accurate and functional representation of the guest's/resident's actual experience in the facility.The medical record must contain enough information to show that the facility knows the status of the guest/resident, has adequate plans of care, and provides sufficient evidence of the effects of care provided. Review of a facility policy/procedure Notification of Change, revised 2/14/2024, revealed .The licensed nurse will document in the resident electronic medical record the notification and the information that was provided, including any additional orders from the practitioner.

This citation pertains to intake #2680498. Based on interview and record review, the facility failed to manage catheters according to physician's orders for two residents (R102 and R103) of 3 residents reviewed for catheter care. Findings include:R102 Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included traumatic brain injury and neuromuscular dysfunction of the bladder. Review of a current suprapubic catheter Care Plan need for R102, created 8/8/2023, directed facility staff to change R102's suprapubic catheter every 30 days. Review of R102's hospice care plan, dated 6/26/2025, revealed .replace the catheter and drainage system (every) 30 days and upon evidence of disconnection, leakage, or (signs/symptoms) infection . In a telephone interview on 5/4/2026 at 11:10 AM, Family Member of R102 I reported R102 discharged from the facility to a hospice facility on 11/13/2025. Family Member I reported the hospice facility was having a hard time changing 102's suprapubic catheter on 11/14/2025 and she contacted the facility by telephone. Facility Registered Nurse (RN) E informed Family Member I that it had been over two months since R102's catheter had been changed at the facility. Family Member I reported R102's catheter was supposed to be changed every 30 days. In a telephone interview on 5/4/2026 at 1:44 PM, RN E reported she was contacted by R102's family after his discharge and after reviewing his Electronic Medical Record (EMR) she found his suprapubic catheter had not been changed in over two months from the date of his discharge from the facility. In an interview on 5/5/2026 at 11:58 AM, the Director of Nursing (DON) reported she had performed an extensive review of R102's chart and confirmed the last time his suprapubic catheter was changed prior to his discharge was on 9/12/2025, over two months from his date of discharge. The DON reported she was unable to find documentation to justify why the facility stopped changing R102's suprapubic catheter every 30 days. The DON reported nursing staff changed R102's order on 7/22/2025 but could find no supporting documentation to explain why this change occurred. Review of R102's urology note, dated 4/19/2024, revealed urology directed the facility to change R102's suprapubic catheter every 4 weeks. R103 Review of an admission Record revealed R103 admitted to the facility on [DATE] with pertinent diagnoses which included malnutrition and obstructive uropathy. Review of a current urinary catheter Care Plan need for R103, created 5/28/2025, revealed R103 had a urinary catheter related to obstructive uropathy. In an interview on 5/4/2026 at 10:26 AM, R103 reported he would like his urinary catheter to be removed. R103 reported he was not sure why the catheter was still in. Review of R103's urology Report of Consultation, dated 6/2/2025, revealed the urology physician ordered an MRI of R103's prostate. Further review of the document showed no evidence that the facility physician reviewed this consultation report. In an interview on 5/5/2026 at 1:50 PM, RN Unit Manager C reported she had reviewed R102's EMR and the facility failed to follow up with his urology order for an MRI of his prostate from June of 2025.

Based on observation, interview, and record review, the facility failed to provide care to dependent residents for three residents (R49, R30, and R81) of four residents reviewed for Activities of Daily Living. Findings: R49 Review of the Electronic Medical Record (EMR) revealed R49 was admitted to the facility 5/19/2023 with pertinent diagnoses that included generalized weakness and medically complex conditions. Review of the Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) dated 5/21/2025 reflected Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 out of 15 which indicated R49 was cognitively intact. The MDS Section GG on functional abilities reflected R49 could eat if staff set up the meal and was dependent on staff to roll the Resident in bed. The MDS reflected R49 was incontinent of bowel and bladder. On 6/24/25 at 12:38 AM the room of R49 was observed to be the last room on the hall and was around the corner making it the farthest room from the nurse's station. On entry to the room, R49 was observed laying on her left side on a flat bed. Next to the bed on an over-the-bed table was a lunch tray with the food covered in plastic and bowls with lids on them. R49 was asked why she had not touched her lunch. R49 reported she had been waiting for about thirty minutes for someone to prop her up so she can eat. R49 reported a staff member brought in her lunch tray and said, you need to get propped up and left the room. R49 reported she can eat on her own if staff will prop her up. R49 was asked if she had attempted to use her call light but replied that she didn't know where her call light was. The cord for the call light was observed behind and out of sight and out of the reach of the Resident. R49 also reported she did not know where her bed control was. On 6/24/25 at 12:51 PM, Certified Nurse Aide (CNA) C was observed collecting food trays from rooms post-meal. CNA C reported she was familiar with R49. CNA C was informed that R49 had now been waiting for over forty minutes for someone to return to her room to assist her to a position so she could eat. CNA C reported that R49 can use her call light, but no call light had been initiated by the resident requesting assistance. CNA C was informed that the Resident said she could not find her call light or her bed control. CNA C reported these were clipped to her dog and immediately went to the room. On entry CNA C observed the untouched meal and the Resident laying on her left side. CNA C retrieved the call light and bed control clipped to a stuffed dog and appeared to have fallen off the bed behind the Resident. R49 reported to CNA C that she was wet (with urine) and needed to be cleaned up. R49 had not been positioned to eat her meal while it was hot, was wet with urine and did not have access to a call light to summon staff when in need. The policy provided by the facility titled Call Lights last revised 3/12/2025 was reviewed. The policy reflected Policy: Call lights will be placed within the resident's reach and answered in a timely manner. And Procedure .3. When a resident is in bed or confined to a chair ensure the call light is within easy reach of the resident. Resident #81 (R81) Review of R81's admission Record, dated 06/25/25, revealed R81 was re-admitted to the facility on [DATE] with multiple diagnoses that included Hemiplegia and Hemiparesis following cerebral infraction affecting right dominant side, aphasia, dysphagia, protein calorie malnutrition, depression and anxiety. R81's 06/03/25 admission MDS reflected resident was unable to participate due to her diagnosis. Review of the ADL's (Activities of Daily Living) revealed R81's Eating Self -Care as Needing Substantial/maximal assistance- Helper does MORE THAN HALF the effort. A review of R81's ADL care plan, last review dated 6/13/25, revealed R81 dependent on one staff member to assist to eat Date Initiated 5/20/2025. A review of R81's weights reflected, On 5/20/25 she weighed 168.4 pounds. On 6/23/25 she weighed 152.6 pounds and reflected a weight loss of 9.38%. On 6/25/25 at 12:10 PM, Certified Nurse Aide (CNA) K was observed closing the nearly empty 200 Hallway lunch cart as this surveyor entered R81's room. R81 was observed to be awake, lying in bed, without a meal tray on her bedside table. However, resident's roommate was observed sitting up eating her lunch. During an observation/interview on 6/25/25 at 12:10 PM, CNA K revealed R81's lunch was not in the 200-hallway meal cart. CNA K further revealed, her lunch might be in another cart I will go check. During an interview on 6/25/24 at 12:12 PM, Certified Nurse Aide (CNA) L revealed (Name of R81) typically does not eat lunch. She does not eat much at all. CNA L stated, she usually needs assistance and goes down to Dining room [ROOM NUMBER], however, (Name of R81) did not want to go. CNA L stated, we should assist (Name of R81) with her lunch in her room when she doesn't want to go (to the dining room), and she probably will just eat a couple bites if she eats. On 6/25/25 at 12:14 PM, R81 was observed sleeping in her bed. R81's Roommate was asked if they offered (Name of R81) any lunch? R81's Roommate stated, No, they just gave me my lunch and left. They didn't say anything to (Name of R81). On 6/25/25 at 12:19 PM, CNA K reported, they were making her a new tray for R81 and she would assist the resident with eating. On 6/25/25 at 12:22 PM, observation of R81's plate revealed that her lunch was pureed. R81 looked at her lunch, curled her nose up in disgust and shook her head no. One of the pureed items had a very thin consistency and was bright green in color. The other pureed food was dark brown and had a thin consistency. The food items were noted to be touching and mixing together. Overall, residents' lunch did not look appealing. CNA K asked R81 again if she would like a drink and to try just a little bite. R81 pointed at the plate and stated NO. During an interview on 6/25/25 at 12:37 PM, DON was informed about a concern with R81's recent weight loss and the lunch observation. DON stated she would have the Unit Manager follow up on it. On 6/25/25 at 3:39 PM, Registered Nurse Unit Manager (RNUM) F provided a signed Educational Opportunity form. The form reflected that All residents should be offered and given a tray whether the resident refuses. The form also reflected under Goals/Expectations to Always give a food tray to resident. Resident #30 Review of an admission Record revealed R30 admitted to the facility on [DATE] with pertinent diagnoses which included heart failure and end stage renal disease. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R30, with a reference date of 6/9/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R30 was cognitively intact. Further review of same MDS assessment revealed R30 required assistance with bathing. Review of a current functional ability Care Plan for R30, initiated 5/7/2024, revealed resident preferred showers on non-dialysis days and required supervision of staff for baths and showers. In an interview on 6/24/2025 at 11:18 AM, R30 reported she did not always receive her showers. R30 reported staff would say she refused when she did not refuse or would say they would come back and then not come back. R30 reported she went to dialysis on Mondays, Wednesdays, and Fridays and wanted her showers to be on off days. R30 reported she had communicated to staff her desire to have showers on days that she did not have dialysis, but staff continued to offer her showers on dialysis days. Review of the facility shower schedule updated 10/30/2024 revealed R30's showers were scheduled to be completed on Thursdays and Sundays. This was handwritten on a typed schedule and therefore the start date of this schedule was unable to be determined. In an interview on 6/25/2025 at 3:30 PM, R30's shower sheets and task documentation were reviewed with Registered Nurse (RN) Unit Manager H. RN Unit Manager H reported staff were required to document showers on shower sheets and in the Electronic Medical Record (EMR) under tasks. RN Unit Manager H acknowledged there were dates she could not verify that showers were offered as scheduled on Thursdays and Sundays. RN Unit Manager H reported staff at times offered R30 showers on days she went to dialysis. RN Unit Manager H reported she was not sure when R30's shower days were changed to Thursdays and Sundays, as this was handwritten on the shower schedule. Review of R30's Census revealed she was out of the facility from 4/23/2025 to 4/26/2025, from 5/8/2025 to 5/15/2025, from 5/26/2025 to 5/29/2025, and from 6/13/2025 to 6/14/2025. Review of R30's shower documentation, including tasks and shower sheets, from 4/1/2025 through 6/25/2025 revealed the following . 4/13/2025 (Sunday)- received shower 4/18/2025 (Friday)- per task documentation refused shower 4/27/2025 (Sunday)- received shower There was no documentation that a shower was offered or refused on scheduled shower days in April 2025 on 4/3/2025, 4/6/2025, 4/10/2025, 4/17/2025, or 4/20/2025. 5/7/2025 (Wednesday)- Shower sheet showed R30 refused shower. 5/21/2025 (Wednesday)- Shower sheet showed R30 refused shower and requested showers be offered on days she did not have dialysis. There was no documentation R30 was offered or refused a shower on scheduled shower days in May 2025 on 5/1/2025, 5/4/2025, 5/8/2025, 5/15/2025, 5/18/2025, 5/22/2025, or 5/25/2025. There was no documentation R30 received a shower on any of the 23 days she was in the facility in May 2025. 6/11/2025 (Wednesday)- Shower sheet showed R30 refused due to dialysis. 6/22/2025 (Sunday)- Shower sheet showed R30 received bed bath. There was no documentation R30 was offered or refused a shower on scheduled shower days in June 2025 on 6/1/2025, 6/5/2025, 6/8/2025, 6/12/2025, 6/15/2025, or 6/19/2025. According to provided documentation R30 received 1 shower/bed bath the 23 days she was at the facility through 6/25/2025. Review of the documentation of showers given, refused, and offered reflected an inconclusive record that gave support to the concern raised by R30.

Based on interview and record review, the facility failed to inform the resident of the risks and benefits of a new psychotropic medication prior to initiation for 1 resident (R51) of 5 residents reviewed for unnecessary medications. Findings include: Review of an admission Record revealed R51 admitted to the facility on [DATE] with pertinent diagnoses which included anxiety disorder and major depressive disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R51, with a reference date of 4/23/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R51 was cognitively intact. Review of R51's Social Services Note, dated 3/28/2025 at 4:21 PM, revealed the medical provider reviewed a recommendation from the mental health nurse practitioner for R51 to begin taking Pristiq (a psychotropic medication used to treat major depressive disorder). Review of R51's active Physician's Orders on 6/26/2025 at 11:00 AM revealed an order for Pristiq started 3/29/2025. Further review of the Electronic Medical Record (EMR) revealed no documentation that the risks versus benefits of Pristiq were reviewed with R51 prior to initiating treatment. In an interview on 6/26/2025 at 11:10 AM, Social Services Assistant E reported she could not find evidence that the facility had reviewed the risks versus benefits of Pristiq with R51. Social Services Assistant E reported the facility performed risk versus benefit education for antipsychotic medications but not for antidepressant medications. Review of facility policy/procedure Psychoactive Medication Management, revised 4/22/2025, revealed .Psychotropic Medication: Any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in categories of antipsychotics, antidepressants, antianxiety, sedatives or hypnotics, anticonvulsants, cognitive enhancers, herbal supplements, and melatonin . Before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. An Antipsychotic Risk Benefit Medication Evaluation form will be completed . In an interview on 6/26/2025 at 11:54 AM, R51 reported she did not know that she was taking Pristiq, and she did not remember receiving education regarding the risks versus benefits of Pristiq prior to starting this new medication. In an interview on 6/26/2026 at 12:16 PM, the Director of Nursing (DON) reported she had reviewed the EMR and could find no documentation that the risks versus benefits of Pristiq were reviewed with R51 prior to initiating this new medication.

Based on observation, interview and record review, the facility failed to access, monitor and identify significant weight loss for 1 resident (R79) out of 18 residents reviewed for weight loss. Review of policy Weight Management last revised 9/22/23 revealed, Policy: Residents will be monitored for significant weight changes on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as unusual body weight and protein levels; . Further review of the Weight Management policy revealed, The Dietary Manager/RD and DON are responsible for coordination of an interdisciplinary approach to managing the processes for prediction, prevention, treatment, monitoring and calculation of unintended weight loss/gain. Review of Practice Guidelines reflects, .5. Residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Residents at risk are: . e. All new admits/re-admits for 4 weeks, f. Residents with insidious weight loss and; 5% in one month, 7.5% in 3 months, 10% in six months; g. Residents with the following clinical condition may also be at risk, this is determined by the IDT, Refusing to eat, Cancer, Diabetes, Depression, Dialysis, COPD, Malnutrition, Infection, Dehydration, Alzheimer's/dementia, . 7. Dietary Manager, Unit Manager and or/RD are to communicate weight changes to the IDT, attending physician and resident's responsible party. This is documented in the medical record. 8. Once an insidious weight loss is identified, the RD further assesses the guest/resident and makes recommendations as indicated to prevent/treat unintended weight loss. Findings include: Resident#79 (R79) Review of R79's admission Record, dated 6/25/25, revealed R79 was admitted to the facility on [DATE] with multiple diagnosis including: Partial Traumatic Amputation of Right Foot, Acute Osteomyelitis Right Ankle and Foot, Vascular Dementia, Depression, Anxiety Disorder, and Type 2 Diabetes Mellitus with Foot Ulcer. Review of the Minimum Data Set (MDS) dated [DATE] revealed R79 had a Brief Interview for Mental Status (BIMS) indicated he was severely cognitively impaired. A review of R79's Nutritional care plan, last reviewed on 5/23/25, revealed resident had a nutritional risk with interventions that included: obtain weight at a minimum of monthly. Report significant weight changes of 5% x 30 days, 7.5% X 90 days, or 10% X 180 days to physician and dietician. Further review of the Nutritional care plan reflected on 5/13/2025 the dietitian recommended ongoing weekly weights. A review of R79's weights reflected, On 5/07/25 he weighed 206.0 pounds. On 6/02/25 he weighed 188.4 pounds and reflected a weight loss of 8.54%. Further review of R79's weights reflected his weekly weight monitoring was discontinued on 6/02/25. During an interview on 06/25/25 at 11:25 AM, NHA was asked about weight loss concerns and monitoring of weights for R79. NHA revealed since February the facility had been without a dietary manager and they only had contract dietician working offsite for them one day a week. On 6/25/25 at 2:41 PM, DON revealed the facility had a new dietary manager starting on Monday and stated they would be going through and checking residents' weights. During interview DON provided further confirmation that R79 was trending downwards for significant weight loss. A review of R79's weight reflected, on 5/07/25 he weighed 206.0 pounds. On 06/25/2025, R79 weighed 184.6 pounds reflecting a weight loss of 10.39 %. Review of R79's progress notes on 6/25/25 at 1549, revealed Med Pass was added TID instead of once daily and Health Shake was added TID to residents food plan due to weight loss. Will continue weekly weights with resident. Review of R79's medical record on 6/25/25 reflected the facility failed to complete a Diet History / Food Preferences Evaluation. Further review of R79's record revealed the evaluation was 45 days overdue.

Based on observation, interview, and record review, the facility failed to: 1) ensure proper use of Enhanced Barrier Precautions (EBP), 2) ensure proper use of Personal Protective Equipment (PPE), and 3) ensure proper sanitizing of shared medical equipment for 2 residents (Resident #12 and #5) of 3 residents reviewed for Transmission Based Precautions (TBP), resulting in the increased potential for cross-contamination, bacterial harborage and spread of infection to the entire 400 hallway. Findings include: Resident #12 Review of an Admission Record revealed Resident #12 admitted to the facility on [DATE] with pertinent diagnoses which included paralysis following a stroke, tracheostomy, and neuromuscular dysfunction of the bladder. Review of a current respiratory Care Plan need for Resident #12, revised 4/2/2024, revealed .Enhanced barrier precautions dcd d/t (discontinued due to) psychosocial detriment resident expressed . Review of Resident #12's Physician's Orders, active 7/22/2024, revealed no order for EBP's or any other type of TBP's. In an observation on 7/22/2024 at 10:33 AM, Resident #12 was resting in their room in bed with a tracheostomy and a urinary catheter. There was no signage visible entering the room regarding PPE requirements or EBP's. In an interview on 7/22/2024 at 11:03 AM, Licensed Practical Nurse C reported Resident #12 required EBP's but the signage embarrassed Resident #12, so the facility took the signage down. In an observation on 7/22/2024 at 11:10 AM, Certified Nursing Assistant (CNA) E performed hand hygiene and entered Resident #12's room with a vitals cart without donning (putting on) PPE and without sanitizing the vitals cart prior to entrance. CNA E took Resident #12's vital signs and left the room. CNA E left the vitals cart next to the nursing station and did not sanitize the cart after performing vital signs on Resident #12. In an interview on 7/22/2024 at 11:21 AM, CNA D reported Resident #12 went to the unit manager because she was embarrassed by the PPE signage for EBP's, and the facility removed the signage. In an interview on 7/22/2024 at 11:24 AM, CNA E reported the vitals tower should be sanitized with sanitizing wipes in between every resident use. CNA E reported she forgot to sanitize the vitals tower before or after taking Resident #12's vital signs. In an interview on 7/23/2024 at 1:20 PM, the Director of Nursing (DON) reported Resident #12 allowed nursing staff to use PPE when performing tracheostomy care but refused to allow CNA's to wear PPE when entering the room for care, including care of the urinary catheter. The DON reported there was not a physician's order directing staff to use EBP's or PPE. The DON reported Resident #12 spoke to the unit manager demanding the signage be removed from her door when EBP's were put into place and the facility was respecting the resident's decision as a resident right and dignity issue. The DON reported shared medical equipment, such as vitals equipment, should be sanitized in between every resident use. Review of facility policy/procedure Enhanced Barrier Precautions, revised 3/26/2024, revealed .Enhanced Barrier Precautions are indicated for residents with any of the following: 1) infection or colonization with a CDC (Centers for Disease Control)-targeted MDRO (Multi-drug Resistant Organism) when contact precautions do not otherwise apply or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO and should remain in place for the duration of the resident's stay . Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies . Implementation . Post signage for precautions on the door or wall outside of the residents room indicating the type of precautions and required PPE . Health care personnel caring for residents on Enhance Barrier Precautions should wear gloves and gowns during high-contact resident care . Examples of high contact resident care activities requiring gown and glove use: Dressing . Bathing/showering . Transferring . Review of the Centers for Disease Control Long-term Care Facilities Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/2024, revealed .28 . Does posting signs specifying the type of precautions and recommended PPE outside the resident room violate Health Insurance Portability and Accountability Act (HIPAA) and resident dignity? . No. Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident . Review of facility policy/procedure Infection Prevention Program, revised 10/11/2023, revealed .Routine cleaning and disinfection of resident care equipment including equipment shared among resident (e.g., blood pressure cuffs) . Review of facility policy/procedure Cleaning and Disinfecting Multi-Use Resident Equipment, revised 10/11/2023, revealed .Cleaning and disinfection are essential for ensuring that multi-use medical equipment does not transmit infectious pathogens to residents . Resident #5 Review of an Admission Record revealed Resident #5 admitted to the facility on [DATE] with pertinent diagnoses which included memory deficit and dementia. Review of a current shingles Care Plan intervention for Resident #5, revised 7/22/2024, directed staff to observe isolation precautions as ordered. In an observation on 7/23/2024 at 8:51 AM, while donning PPE CNA F dropped an unwrapped disposable plastic gown on the hallway floor and proceeded to pick the same gown up off the floor, donned the gown, and entered Resident #5's room to provide care. In an interview on 7/23/2024 at 1:20 PM, the DON reported dropped PPE should be disposed of and not used for patient care.

Based on observation, interview, and record review, the facility failed to ensure call lights were left within reach for 3 residents (Resident #5, #8, and #68) of 3 residents reviewed for availability of call lights, resulting in the potential for unmet care needs and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well being. Finding include: Resident #5 Review of an Admission Record revealed Resident #5 admitted to the facility on [DATE] with pertinent diagnoses which included memory deficit and dementia. Review of a current fall Care Plan intervention for Resident #5, initiated 5/2/2019, directed staff to place the resident's call light in reach and encourage her to use it for assistance as needed. In an observation and interview on 7/23/2024 at 8:51 AM in Resident #5's room, Resident #5's call light was clipped to the bed sheet under the edge of her pillow and not visible to the resident. When asked if she knew where her call light was located, Resident #5 looked around and reported she could not find it. In an interview on 7/23/2024 at 8:55 AM, Certified Nursing Assistant (CNA) F reported Resident #5 was able to use her call light to request assistance. In an observation and interview on 7/24/2023 at 9:44 AM in Resident #5's room, Resident #5's call light was clipped next to her pillow on the right side, out of sight and reach of the resident. When asked where her call light was, Resident #5 stated Oh, I don't know, down here somewhere. Resident #5 reached down beside her left hand and was unable to find the call light. Resident #8 Review of an Admission Record revealed Resident #8 admitted to the facility on [DATE] with pertinent diagnoses which included mild cognitive impairment and dementia. Review of a current fall Care Plan intervention for Resident #8, initiated 12/11/2023, directed staff to place the resident's call light in reach and encourage her to use it for assistance as needed. In an observation and interview on 7/23/2024 at 9:06 AM in Resident #8's room, Resident #8's call light was coiled up on a small organizer next to her bed and against the wall, out of reach of Resident #8. Resident #8 was in her wheelchair and her bedside table was between her and the call light. When asked where her call light was located, Resident #8 reported she did not know and was unable to find the call light. In an observation and interview on 7/23/2024 at 12:47 PM in Resident #8's room, Resident #8's call light was coiled up on a small organizer next to her bed and against the wall, out of reach of Resident #8. Resident #8 was in her wheelchair and her bedside table was between her and the call light. When asked where her call light was located, Resident #8 stated, I don't know where it is. Resident #68 Review of an Admission Record revealed Resident #68 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke) and depression. Review of a current fall Care Plan intervention for Resident #68, initiated 7/20/2023, directed staff to place the resident's call light in reach and encourage her to use it for assistance as needed. In an observation and interview on 7/23/2024 at 10:13 AM in Resident #68's room, Resident #68 was in her geriatric chair and her call light was in the middle of her bed and out of reach of the resident. Resident #68 reported staff often left her call light out of reach. Resident #68 reported she had to yell to get the attention of staff when her call light was not in reach. In an observation on 7/24/2024 at 9:19 AM in Resident #68's room, Resident #68 was resting in bed and her call light was below her feet in the bed and out of reach of the resident. In an observation and interview on 7/24/2024 at 9:27 AM, CNA G reported Resident #68 was unable to use her call light because of her contractures. CNA G entered Resident #68's room and observed Resident #68's call light lying at the foot of her bed. CNA G asked Resident #68 if she was able to press the call light if it were near her hands and Resident #68 stated Yes. CNA G placed the call light near Resident #68's right hand and she was able to immediately activate the call light purposefully by moving her hand over the pressure activated call light. In an interview on 7/24/2024 at 9:27 AM, CNA G reported Resident #8 and Resident #5 were also able to use their call lights to request staff assistance.

Based on interview and record review, the facility failed to ensure a Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification Level II Screening (DCH-3878) was completed for 1 resident (Resident #43) of 1 resident reviewed for PASARR assessments, resulting in the potential for unmet mental health needs. Findings include: Resident #43 Review of an Admission Record revealed Resident #43 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, bipolar disorder, depression, and anxiety. Review of Resident #43's Annual Resident Review (ARR), form (DCH-3877), dated 2/20/2024, revealed section II was checked yes for lines 1, 2, 3, and 4 related to diagnoses of anxiety disorder, mood disorder, bipolar disorder, depression, and dementia and prescriptions for Depakote and Zyprexa. Further review of DCH-3877 revealed .If any answer to items 1-6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program . with a copy of form DCH-3878 if an exemption is requested . Further review reviewed no documentation that the Level II Screening (DCH-3878) was completed. In an interview on 7/24/2024 at 2:00 PM, Social Services Supervisor B reported Resident #43's Level II Screening (DCH-3878) was not completed as it should have been when the last ARR was completed 2/20/2024 and they were past due for a Level II Screening. Social Services Supervisor B was not sure why this was missed but was working on a plan of correction. In an interview on 7/23/2024 at 1:19 PM, the Director of Nursing (DON) reviewed Resident #43's PASARR history and reported the Level II Screening had not been completed since their admission to the facility in October of 2020. The DON reported Resident #43 required a Level II Screening. The DON reported the Social Services Director was working on a plan of correction for this oversight.

This intake pertains to intakes: MI00134885, MI00136472, MI00137258. Based on interview and record review, the facility failed to provide adequate supervision to prevent resident to resident altercations for 6 residents (R21, R22, R26, R33, R35 and R36), resulting the potential for injury. Findings include: R22 Review of R22's face sheet, dated 6/1/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Senile degeneration of brain, vascular dementia, anxiety disorder, seizures, and weakness. R22 was not her own responsible party. Review of R22's care plan created on 8/10/22, revealed, R22 is at risk for decline in cognition and has impaired cognitive function or impaired thought process R/T (related to): dx (diagnosis) of cognitive communication deficit, metabolic encephalopathy (problem in the brain) and dementia, resident will stop off and lay down in beds at times when she is propelling herself around the facility in her wheelchair. There were not interventions listed to supervise R22 or prevent this known behavior. Review of R22's care plan created on 8/4/22, revealed, R22 has an ADL (activities of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to) impaired mobility, Afib (irregular heartbeat), CHF (congestive heart failure) seizures, arthritis, impaired mobility. Guest will become combative with care, hitting, pinching, kicking towards staff. Has been observed defecating in inappropriate behaviors. No interventions were located to ensure R22 was supervised to avoid combative behaviors when around other residents. Review of the facility timeline for R22's incident reports revealed R22 was in 7 resident to resident altercations from 10/24/22 to 5/28/22. R22 wandered into other residents' room on 10/24/22, 1/13/22, 2/8/23, 4/25/23 and 5/28/23. These incidents involved R21, R26, R33, and R35. Each of these events resulting in physical and verbal confrontation with residents. R21 Review of R21's face sheet dated, 6/1/23 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: memory deficit, vascular dementia, muscle weakness, anxiety and major depressive disorder. R21 was not her own responsible party. Review of R21's progress note dated 2/8/23 at 2:55 PM revealed, Resident was resting in her own bed, had a resident who is known wonderer and alert to person only, crawled into her bed. Resident was upset and a physical altercation took place. Review of the facility incident and accident report for R21, dated 2/8/23 at 1:30 PM revealed R22 got into R21's bed and a physical altercation took place with R22. There was no indication R22 was being supervised when the incident occurred. R26 Review of R26's face sheet dated 6/1/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: muscle weakness, difficulty in walking, chronic pain, and Schizophrenia. R26 was not his own responsible party. Review of the facility incident and accident report for R22, dated 1/13/23 at 2:36 PM revealed, R22 was in another resident's room. When R26 asked R22 to leave R22 hit R26 on his hand. R26 then turned, yelled, and hit R22 on her left arm. There was no indication R22 was being supervised when she entered R26's room. R33 Review of R33's face sheet dated 6/1/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: chronic pain syndrome, major depressive disorder, and chronic obstructive pulmonary disease. R33 was her own responsible party. Review of R33's incident report for R33 dated, 4/25/23 at 2:05 PM revealed, Another resident was observed near the doorway of this resident's room, back (sp) strap across doorway was between them at this time. This writer heard this resident yelling at other resident to get out and leave her alone. Other resident had this resident's O2 tubing in her hands. That's when this resident was observed slapping other resident several times, attempting to remove 02 tubing from her hands, other resident then began slapping his resident as well. Residents were separated. Resident was tearful about incident, stated that other resident actually went under the black strap and into her room, yelling at her to get out of the bed that this was her room. This resident moved toward other resident and was able to her out of the room, back under the strap. Review of the facility timeline revealed R22 was the resident that was involved in the resident-to-resident altercation with R33 on 4/25/23. There was no indication in the timeline or in the incident report that R22 was being supervised when this event occurred. R35 Review of R35's face sheet dated 6/1/23, revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses that included, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (brain bleed causing weakness of the left side), chronic pain, and muscle spasms. Review of R22's progress note dated 5/28/23 at 10:19 PM revealed R22 was found in R35's room with her right hand holding R35's right arm and her left hand over R35's mouth. Staff heard screams for help and entered R35's room and redirected R22 out of the room. R22 was last observed at 8:50 PM and the incident occurred at 9:00 PM. During an interview with Certified Nurse Aide (CNA) E on 6/1/23 at 12:09 PM, CNA E confirmed she was working on 5/28/23 and was assigned to care of R22. CNA E' recalled seeing R22 just prior going into a room to do care. CNA E said the resident she was caring for required her to put on a complete set of personal protective equipment (PPE) which takes time to put on and take off. When CNA E had removed the PPE, R22 was nowhere near where she had seen her last. CNA E said R22 was found by other staff in R35's room. CNA E was asked how she was to supervise R22 when she was assigned to her care and CNA E said she just does her best to redirect her. CNA E said there was no location where R22 could be supervised as all staff scheduled were assigned to do care which requires them to go in and out of resident rooms. R36 Review of R36's face sheet, dated 6/1/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: cognitive social or emotional deficit following cerebral infarction (stroke), dementia, muscle weakness, difficulty in walking, and traumatic brain injury. Review of R36's progress note dated 5/17/23 at 6:02 PM revealed, Resident was attacked by another resident in the dining room. Attack was unprovoked and witnessed by other residents. Review of the facility timeline of incidents revealed R22 was the resident that attacked R36 in the dinning room on 5/17/23. During an interview with Unit Manager (UM) C and facility Social Worker (SW) D on 6/1/23 at 1:00 PM, the facility timeline of the resident-to-resident altercations for R22 was reviewed. They confirmed they were aware of R22's aggressive behaviors and all the incidents with other residents. They denied implementation of any supervision for R22 when she was around other residents. They said normally staff just try to redirect R22.

Based on observation, interview and record review, the facility failed to implement measures to improve/prevent the development of pressure ulcers and follow best infection control practices for 1 (Resident #10), resulting in the development and worsening of pressure ulcers and infections. Findings include: Review of a Face Sheet revealed R10 is a [AGE] year-old male who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] revealed R10 is moderately cognitively impaired and requires extensive assistance of two staff for bed mobility and totally dependent on two staff for transfers. He had limited range of motion on bilateral lower extremities, an indwelling foley catheter, a [CONDITION(S)], a stage 4 pressure ulcer present upon admission and 2 unstageable pressure ulcers, and a [CONDITION(S)]. During an observation and an interview on 6/13/22 at 11:58 AM, R10 was observed lying in bed on his back with his eyes closed. Registered Nurse (RN) G reported the resident went to the wound clinic this morning and a wound vac was ordered for his pressure ulcer on his left leg. During an observation and an interview on 6/13/22 at 3:50 PM, resident observed on his back with his legs elevated and rated his pain at a 10/10 scale. He was in the same position as observed earlier this day. It took a minute for him to answer questions. Pressure relieving mattress noted. Review of the Electronic Medical Records (EMR) for R10 revealed no progress notes from the Wound Clinic since admission. During an observation on 6/14/22 at 8:06 AM, R10 was in bed laying on his back with his eyes opened but would not answer questions at this time. No specialty boots or positioning wedges noted in place or in the room. During an observation on 6/14/22 at 9:14 AM, R10 observed in bed on his back in the same position as previous observation. No specialty boots or positioning wedges noted. During an observation on 6/14/22 at 10:00 AM, RN G was in his room to provide [CONDITION(S)] care and the resident was in bed on his back with the head of the bed at 20-30 degrees. After [CONDITION(S)] care was completed, the resident was on his back with the head of the bed elevated at approximately 30 degrees. No specialty boots or positioning wedges noted. During an observation and an interview on 6/14/22 at 12:06 PM, the Wound Care Nurse, RN H preparing for dressing changes reported the facility was waiting for the wound vac to arrive for his left leg pressure ulcer and is not going to change that dressing this day. R10 was observed on his back in the same position as earlier observations. RN H proceeded to change the dressing on his right heel and observed adjusting her face mask with her clean gloved hands and proceeded to change his dressing. RN H irrigated the wound with a wound cleanser and patted the wound dry with a gauze and applied a hydrofoam dressing using the same gloves to remove the old dressing, and then covered it with an [MEDICATION(S)] dressing. Appropriate hand hygiene was done before starting the wound care to his sacrum. RN H irrigated the wound on his sacrum with a wound cleanser and then patted the area dry with gauze, then wiped the area with gauze in a stroking motion across the wound. When asked if that was considered [MEDICATION(S)] the wound, RN H reported no because there was slough. RN H then performed hand hygiene and proceeded to open the 4 packages of hydrofoam dressing with gloves on and applied the hydrofoam dressing to the wound and covered them with a large [MEDICATION(S)] dressing. The unused dressing was brought out of the room and placed in the treatment cart. When queried about the dressing changes done, RN H acknowledged she should not have touched her mask without appropriate hand hygiene during the dressing change and should have had the dressing supplies already opened so she could apply the dressings without breaching best infection control practices. RN H did not see any concern with bringing unused dressing supplies out of the residents' room and placing them in the treatment cart since they were placed in a plastic bag and then wrote the residents name on it. RN H reported this was a new dressing change order for R10 and she needed to get more familiar with it. RN H reported R10 refuses dressing changes frequently. During an observation and on 6/15/22 at 8:11 AM, R10 was observed laying on his back with 1 pillow under his legs. No specialty boots or wedges noted. During an observation and an interview on 6/15/22 at 8:20 AM, Certified Nursing Assistant (CNA) J and CNA K reported they last repositioned R10 around 5:45 AM and will try again around lunch time. Said they try to reposition him at least twice during their shifts. Both CNAs reported R10 refuses to be repositioned frequently and said they report it to the nurse when he refuses. When both CNAs were informed this surveyor had not seen this resident repositioned since the survey began 2 days ago, they had no comment. The resident was observed on his back, no specialty boots or positioning wedges noted. During an interview on 6/15/22 at 8:30 AM, Unit Manager, RN L reported R10 was on another unit when he received the pressure ulcer on his left calf and right heel. Therapy was working with him to try special boots and he is also on a rotating mattress to assist with repositioning. RN L reported she thinks he got the pressure ulcer on his left calf is from a heels up device. R10 is to be repositioned every 2 hours, and when RN L was informed the resident had been in the same position since the surveyors entered the building, she had no comment. When queried about Wound Clinic Progress notes not in the EMR, RN L reported she will request them from the wound clinic. When queried about why the wound vac that was ordered on Monday was still not in place for R10, she reported the kit (supplies) were sent without the machine and was working on it. When asked about how often the skills checks for staff were done, she reported she thinks annually but could not confirm. Requested Wound Clinic Notes dated from January 2022 to current/last visit on 6/13/22. The facility provided Wound Clinic Notes dated 1/28/22 through 4/22/22 prior to the exit of this survey. Review of a Report of Consultation handwritten document regarding the Wound Clinic signed 12/1/21 for R10 revealed he had a positive wound culture on his stage IV coccyx pressure ulcer and antibiotics were ordered. Review of the Wound Clinic Notes for R10 dated 1/28/22 revealed he had 5 pressure ulcers. Wound #1 was an unstageable pressure ulcer to the right calcaneus. Wound #2 was a stage III pressure ulcer to the left calcaneus. Wound #3 was a stage IV pressure ulcer to the left lateral lower leg. Wound #4 was a stage IV pressure ulcer to the coccyx and wound #5 was a stage II pressure ulcer to the right medial lower leg. The plan was to offload and keep pressure off wounds at all times. Utilize a felt/foam/ortho wedge/surgical shoe-air or foam suspension boots, a group 2 or ideally a group 3 mattress and reposition every 2 hours. Cultures obtained from the coccyx and R10 was started on [MEDICATION(S)] for 10 days. Review of the Wound Clinic Notes for R10 dated 2/18/22 revealed the resident had the following wounds: #1 (Right heel) acquired 11/8/21 an unstageable pressure ulcer with a large amount of necrotic tissue within the wound bed including eschar and adherent slough. Measures 4.7 cm (centimeters) X 3.8 cm X 0.1 cm. Wound #2: (Left heel) acquired 11/8/21 and currently classified as a stage III pressure ulcer and measures 1.9 cm X 1 cm X 0.1 cm. has large amounts of necrotic tissue within the wound bed including adherent slough. Wound #3 (Left lateral lower leg) acquired 10/28/21. Wound measures 10.8 cm X 2 cm X 0.3 cm with muscle and fat layer exposed and small amount of necrotic tissue within the wound bed including adherent slough. Wound #4 (coccyx) acquired 2/2/21 and currently classified as a stage IV pressure ulcer and measures 12.9 cm X 8.1 cm X 0.9 cm. There is bone and fat layer exposed. There is tunneling at 6:00 with a maximum distance of 1.9 cm. There is a medium amount of sanguineous drainage noted. There is large (67-100%) red granulation within the wound bed. There is a small (1-33%) necrotic tissue within the wound bed including Adherent slough. Wound #5 (right medial lower leg) acquired 1/28/22 and was classified as a stage II pressure ulcer and is healed. Plan: Off-Loading: Keep weight off area of wound at all times. Felt/Foam/Ortho-wedges/Surgical shoe- Air or foam heel suspension boots. Other: group 2 or ideally a group 3 mattress. Turn and reposition every 2 hours. Review of a Report of Consultation handwritten document regarding the Wound Clinic signed 4/22/22 for R10 revealed: Stage 4 coccyx- cleanse with acetic acid 5% daily. Apply Mesalt to the wound bed, cover with foam daily. (Right) calcaneus (heel) Stage 3- cleanse with (normal saline), apply [MEDICATION(S)] (treatment infused dressing), Vaseline gauze and cover with foam daily. Left lateral lower leg Stage 4 - cleanse with normal saline, prism to the wound bed, cover with foam daily. Turn (every) 1-2 hours. Limit pressure to left lateral leg and coccyx. Review of the Wound Clinic Progress Notes for R10 dated 4/22/22 revealed: returns with multiple stage 3 and 4 ulcers. The coccyx is stage 4 with bone exposed, there is increased granular tissue and large amount of epithelial fill at the margins. There is increased drainage this week with a foul odor. The left calcaneus has a large amount of epithelial fill at the margins, granular wound bed with some scattered slough throughout. The left posterior calf with large amount of epithelial fill at the margins, tendon is no longer exposed, undermining has resolved. Will change to acetic acid cleansing and mesalt and mextra daily. The right posterior calf, lateral leg, and right calcaneus with [MEDICATION(S)] and foam. He will need to be turned Q (every) 2 hours and limit sitting no less than 2 hours and will need heel floating foam or air boots. He will return in 2 weeks. Plan: Off-loading: Keep weight off area of wound at all times. Felt/Foam/Ortho-wedge/Surgical Shoe-Air or foam heel suspension boots. Other: group 2 or ideally a group 3 mattress. Turn and reposition every 2 hours. Wound #1: Calcaneus-Wound Laterally Right: Primary Dressing: [MEDICATION(S)] 4.34 (in) Other: change as needed. Discharge instructions: Moisten with normal saline or sterile water. Cover wounds as directed. Do not remove from wound bed. Primary dressing: ALLEVYN Gentle Border Heel, 9 x 9 (in), change as needed. Wound #3: Left Lower Leg: Cleanse with normal saline, Primary Dressing: [MEDICATION(S)]. Discharge instructions: Moisten with normal saline or sterile water, cover wound as directed. Do not remove from wound bed. Secondary dressing: ABD pad, fold in half-length wise. Wound #4 Coccyx: Cleanser: Acetic Acid irrigation USP 0.25% 3 times per week. Primary dressing: [MEDICATION(S)] 4.34 (in) 3 times per week. Primary Dressing: Mesalt Impregnated Dressing 8X8 (in) 3 times per week. Secondary dressing: Maxtra Superabsorbent 3 times per week. Secure with tape 3 in 3 times per week. Will change to Acetic Acid and mesalt and maxtra daily. The right posterior calf, lateral leg, and right calcaneus with [MEDICATION(S)] and foam. He will need to be turned Q (every) w hours and limit sitting to less than 2 hours and will need heel floating foam or air boots. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A 7 has been documented indicating the resident was sleeping. There are several blank/undocumented days indicating treatment was not done. The nursing notes do not reflect when or why the resident refused, if the resident was reapproached another time, another shift, by another staff, physician notification, or even social services/behavioral health care. Review of Nursing Progress Notes dated from 3/17/22 to 6/13/22 revealed R10 refused care on 3/27/22 and the Guardian and physician was notified. On 4/7/22 the resident refused all cares, and no notifications or interventions were documented. Review of a Dietary Progress Note dated 3/28/22 for R10 revealed while he is on a tube feed for nutrition, he continues to gain weight and had a good [MEDICATION(S)] level, but it recently dropped and will recommend Protstat (a dietary supplement). Weight in December 2021 was 170.4 pounds and March 2022 weight was 172.4 pounds. Review of a Nursing Progress Note dated 4/20/22 for R10 revealed: addendum to wound eval completed on 4/19/22 there is no debridement, using mesaly for wound bed, have spoken to guardian regarding wounds and residents occasionl refusal of treatment, will continue to encourage resident to allow treatments as ordered, resident continues to be seen by wound clinic as well. (sic) Review of a Dietary Progress Note dated 4/22/22 for R10 revealed his weight was 173.6 pounds and needed high calorie intake for his wounds and labs showed good levels for protein at 6.0 and mild low [MEDICATION(S)]. Review of a Resident At Risk Progress Note for R10 dated 5/13/22 revealed the resident was reviewed for tube feedings and wounds. Continues with daily wound care, wounds showing improvement each week. Stable weights/slow gain . tolerating well. Guest historically refuses lab draws. Continues with air mattress and heels up device or pillows for offloading which he is compliant with. Response to Previous Actions Taken: No other changes at this time. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He does try to comply with repositioning, however, he is bed bound which raises his risk. He admitted with wounds and has developed new wounds despite aggressive wound regimen. Review of a Nursing Progress Note dated 5/18/22 for R10 revealed he was up in a Broda chair in the morning and walked in the facility assisted by staff. Review of a Nursing Progress Note dated 5/27/22 for R10 revealed his [MEDICATION(S)] (antipsychotic medication) levels were greater than 2000 (normal is 200 - 700). Review of a Resident At Risk Progress Note dated 6/3/22 for R10 revealed the resident was reviewed for pressure ulcers and tube feedings suggesting he had mildly high glucose which could slow his heeling, abnormal liver enzymes, and low protein levels. Continues with pressure injuries to left calf, right heel, and buttocks. Guest has been getting up more in broad chair and has been enjoying that. Review of a Nursing Progress Note dated 6/9/22 for R10 revealed: new wound to right heel, culture taken, (antibiotics) ordered, will continue to observe. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of a Report of Consultation handwritten document regarding the Wound Clinic signed 6/13/22 for R10 revealed: Report of Consulting Physician: Buttock ulcer- bone debrided from both deeper spots - Start [MEDICATION(S)] to deep spots. [MEDICATION(S)] blue over all. ABD (abdominal dressing pad) and tape daily. Right calc (aneous) (heel) with purulent drainage. Continue [MEDICATION(S)], culture obtained. Start [MEDICATION(S)] blue daily, ABD and tape. Left leg with increased depth, a small ridge of bone exposed. Start (negative pressure unit (NPUT)) at -125 with black foam. Start [MEDICATION(S)] blue daily until NPUT available. Check CRP, CMP, CBC (all different lab types) and left leg Xray. Off load all wounds. Optimize nutrition for wound healing. Continue protein supplement. Follow up 1 week. Review of a Social Services Progress Note dated 6/13/22 for R10 revealed he has impaired processing skills and memory deficits related to [CONDITION(S)] and [CONDITION(S)] disorder. He is severely cognitively impaired and his PHQ9 indicated he has mild depression. He also receives Trazadone (antidepressant) and [MEDICATION(S)] for seizures and indicated it may cross over for mood. He refuses care and treatment at times. The resident cut his feeding tube and needed it replaced and suggesting to the family to place on comfort care because he cut his feeding tube. Review of R10 blood laboratory results collected 5/26/22 revealed his white blood cell count was 15.91 (normal is 4.0 - 10.5), hemoglobin is 10.2 (normal is 13 - 18.2), [MEDICATION(S)] >2000 (normal is 200 - 700), [MEDICATION(S)] 2.7 (normal is 3.8-4.9), total protein 8.9 (normal is 6.2 -8.2), glucose 111 (normal is 70 - 110). Review of once-a-week blood sugar checks in April 2022 for R10 revealed they were maintained between 92 - 101. Review of the Pressure Ulcer Care Plan for R10 revealed on 8/15/22 he is to be repositioned every 2 hours and to follow the facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No interventions from the Wound Clinic were implemented. On 6/13/22 (day of this survey), an intervention to reapproach the resident if he refuses dressing changes was added. In an interview on 6/15/22 at 10:00 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reported R10 refuses care sometimes and expects the resident to be reapproached later or by another staff. There was no expectation for the staff to notify they physician unless he refused care several days in a row but that depended on if they physician was aware of his refusals. Their expectations for dressing changes were to create a clean barrier and dressing supplies should be opened and hand hygiene and gloving done prior to starting the dressing change and when going from dirty to clean which would also include touching a face mask and removing of old dressings. The DON reported dressing supplies should not go back out to the treatment cart once they have already been in the resident's room. The DON considered wiping the wound to be [MEDICATION(S)] but not padding the wound. The DON and ADON reported R10 admitted with his coccyx pressure ulcer and the pressure ulcer on his left calf was a result of using a heels up device. They reported the resident is very non-compliant and capable of repositioning himself. In an interview on 6/15/22 at 11:40 AM, the Physician Assistant (PA) reported R10 overall needed hospice because he is bed bound, non-compliant and is compromised. The PA reported he is not notified every time R10 refuses care Review of a policy titled Clean Dressing Change last revised 10/14/21 revealed the process for a clean dressing change which includes establishing a clean field and opening supplies before the procedure and hand hygiene before and after removal of old dressing. It also says on step 9 to cleanse the wound gently with the solution ordered and wash from the center of the wound to the periphery. It does not say to use gauze to pat the wound dry or to rub it with the gauze. Review of a Skin Management policy last revised 7/14/22 revealed: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. The policy explains how the Interdisciplinary Team (IDT) will consider whether the resident exhibits conditions that places them at a higher risk of developing pressure injuries such as cognitive impairments, impaired/decreased mobility, diabetes, incontinence, and resident refusals. A Guest/Resident at Risk meeting is to be conducted at least monthly by the IDT to evaluate resident skin changes, review treatment modalities, interventions and will make recommendations as needed. This policy also included a quarterly system audit of the Skin Management Guideline to ensure ongoing compliance in all areas and report to the QAPI committee for trending, analyzing and recommendations.

Based on observation, and interview, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services out of the facility's total census of 74 residents. Findings include: 1. On 6/13/22 at 11:09 AM, the kitchen's steam table was observed leaking onto the floor from its lower rear right-hand corner creating a puddle approximately seven inches wide and 15 inches in length. On 6/13/22 at 11:10 AM, upon interview with the Dietary aide, staff B, on the current state of the steam table they stated, it's older, but I didn't know it was leaking. Maintenance is coming in tomorrow to replace a part on one of our ovens, I will ask them to look at it then. At this time, the surveyor observed staff B placing a caution wet floor sign next the puddle. Review of the U.S. Public Health Service 2013 Food Code, Chapter 4-501.11 Good Repair and Proper Adjustment directs that: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 2. On 6/13/22 at 11:18 AM, Cook, staff A, was observed taking food temperatures of multiple thin cuts of pork lion stacked on top of one another with an analog bimetal thermometer. At this time, the surveyor inquired with staff A why they were stacking the pork lion slices on top of one another to take temperatures of the product to which they stated, If I don't have enough product my thermometer to can't read it. On 6/13/22 at 11:19 AM, the surveyor asked staff A if that was the only type of thermometer they had available to use to which they stated, yes, this is what we have for everything. We have a few of them to share. At this time Dietary aide, staff B, entered the conversation and commented, If we have a digital one somewhere I haven't seen it. I wish we did. Review of the U.S. Public Health Service 2013 Food Code, Chapter 4-302.12 Food Temperature Measuring Devices directs that: (B) A TEMPERATURE MEASURING DEVICE with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin FOODS such as MEAT patties and FISH filets. Pf Further review of the 2013 Food Code Annex 3 states: The presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded. When determining the temperature of thin foods, those having a thickness less than 13 mm (1/2 inch), it is particularly important to use a temperature sensing probe designed for that purpose. Bimetal, bayonet style thermometers are not suitable for accurately measuring the temperature of thin foods such as hamburger patties because of the large diameter of the probe and the inability to accurately sense the temperature at the tip of the probe. However, temperature measurements in thin foods can be accurately determined using a small-diameter probe 1.5 mm (0.059 inch), or less, connected to a device such as thermocouple thermometer. 3. On 6/13/22 at 11:30 AM, 11:44 AM, and at 12:12 PM, Cook, staff A, was observed was observed taking off gloves, adjusting their face mask, and putting on a new pair of gloves without washing their hands while assembling meal trays and plating meals for lunch service. On 6/13/22, at 12:23 PM, and at 12:28 PM, Cook, staff C, was observed donning gloves prior to washing their hands after touching refrigerator door handles, prep counters, the floor, a cutting board and soiled dishes prior to preparing a grilled cheese and BLT sandwiches. On 1/26/22 at 11:59 AM, Dietary aide, staff B, was observed removing and donning new pairs of gloves during the assembly, plating, and loading of meals into hall carts for lunch service. On 1/26/22 at 1:19 PM, the surveyor inquired with staff B on the hand hygiene expectations for staff when they choose to use gloves as a hand barrier to which they replied, wash their hands before they put them on. At this time the surveyor requested the facility's hand hygiene policy to review to which staff B replied, let me see what I can find. At the time the survey team exited the facility, no hand hygiene policy was received by the surveyor to review. Review of 2013 U.S. Public Health Service Food Code, Chapter 2-301.14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands

Based on observation, interview, and record review, the facility failed to provide quality care and notify the physician of blood glucose readings outside of parameters, failed to provide appropriate [CONDITION(S)] care, tube feeding tube care, and address the psychosocial wellbeing for 2 (Resident #10 and Resident #60), resulting in the potential for complications from [CONDITION(S)]. aspiration, infections and underlying psychosocial behaviors to not be addressed and affect resident wellbeing. Findings include: Resident #10 (R10) Review of a Face Sheet revealed R10 is a [AGE] year-old male who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] revealed R10 is moderately cognitively impaired and requires extensive assistance of two staff for bed mobility and totally dependent on two staff for transfers. He had limited range of motion on bilateral lower extremities, an indwelling foley catheter, a [CONDITION(S)], a stage 4 pressure ulcer present upon admission and 2 unstageable pressure ulcers, and a [CONDITION(S)]. During an observation on 6/13/22 at 3:50 PM, R10 was in bed and a blue humidifying tube was on the floor next to his bed and not connected to anything. During an observation on 6/14/22 at 8:06 AM, R10 was lying in bed and his blue humidifying tube was noted on the floor next to the bed not in use or connected to any device. During an observation and an interview on 6/14/22 at 10:00 AM, R10 was in bed with his tube feeding infusing at 90 ml/hr (milliliters/hour). Registered Nurse (RN) G prepared R10 for [CONDITION(S)] care by lowering the head of his bed to an almost flat position with the tube feed still running. RN G removed the inner canula replaced the inner canula with a new one when the resident started to gag, then coughed up phlegm and a large amount of tube feeding came out through his inner cannula. The nurse handed him a trash bag then raised the head of the bed. The trash bag had about 200-300 mls of fluid in it. The resident did not want the nurse to suction his [CONDITION(S)] and wanted to clear it out himself. When asked, RN G did not see any concerns with doing [CONDITION(S)] care with the head of the bed lowered and the tube feeding continuing at 90 mls/hr. No respiratory assessment done. The nurse said she does do respiratory assessments on the resident but does not always chart them in the computer. Review of a Nursing Progress Note dated 6/14/22 at 10:26 AM for R10 revealed: Temp 97.1. Resident vomited up yellowish sputum during [CONDITION(S)] care. He refused to be suctioned and was able to cough it up. SPO2-92% (oxygen saturation) on (room air). Lung sounds clear. Breathing even and non-labored at rest. (Physician Assistant) notified. During an observation and an interview on 6/14/22 at approximately 12:06 PM, RN G reported she did not change R10's PEG (percutaneous endoscopic gastrostomy) tube dressing yet and went to his room to change it. A yellowish purulent drainage noted at the exit site. When queried if R10 had an infection at his PEG tube site, RN G denied it and reported she did not remember what his exit site looked like the day before when she took care of him. During an observation and an interview on 6/15/22 at 8:11 AM, R10 was in bed, tube feeding infusing at 90mls/hr, and the head of the bed was less than 30 degrees. The blue humidifying tubing was in the same position on the floor next to the bed not connected to anything. RN I walked into his room and when pointed out the tubing was on the floor, the nurse reported it should not be there and picked it up and threw it away. She reported it was for humidity if the resident needed it for his [CONDITION(S)]. When queried about the HOB being lower than 30 degrees, RN I did not see anything wrong with it and then said he does not always like to sit up and refuses at times. RN I then said he has rights. During an interview on 6/15/22 at 8:30 AM, Unit Manager, RN L reported R10 should be sitting upward when changing out the inner cannula. If the resident is sitting upward, then it would not matter if the tube feeding were infusing. When informed of the observation made, she had no comment. When asked how often they do a skills check/education for their staff, RN L reported she thinks they do them annually but was not certain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . He is documented as refusing several treatments, some treatments are not documented as done, and some are documented to hold/see nurse notes but no nursing progress notes correlate with the missed treatments. No documentation to show the resident was reapproached later that day or by another staff member. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Several refusals documented with no documentation to show the resident was reapproached later that day or by another staff member. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another Order of [MEDICATION(S)] (antipsychotic) 100 mg twice a day starting 3/11/22 and discontinued on 5/27/22. [MEDICATION(S)] Solution s750 mg three times a day for seizures started on 3/11/22 for seizures. Trazadone (antidepressant) 150 mg ordered 3/11/22 once a day at bedtime for [CONDITION(S)]. Review of a laboratory result for R10 collected 5/26/22 revealed a [MEDICATION(S)] level greater than 2000 NG/ML (normal is 200-700). Review of the MAR for March 2022 revealed R10 was on [MEDICATION(S)] (antibiotic) for 10 days for pneumonia. Review of the MAR for April 2022 revealed R10 was on [MEDICATION(S)] for 10 days for a respiratory infection. Review of a Behavioral Health Document dated 11/12/21 for R10 revealed he was seen for an initial psychiatric assessment who the resident reported he was depressed. There was no documentation in the EMR indicating the resident has been seen since then. Review of a Social Services Progress Note dated 3/11/22 for R10 revealed this was a quarterly note. Stating R10 can understand and is understood using verbal communication. He has processing deficits related to [CONDITION(S)], [CONDITION(S)] disorder, and a history of cerebral infarction. He is moderately cognitively impaired and minimally depressed and did not appear to be having any well-being concerns at this time. Behaviors are stable this quarter. Family would like him closer to the Grand Rapids area so they can visit more. Discharge plan is to remain in the facility unless a facility closer to the family accepts him. No documentation indicating the facility is pursuing to find another facility closer to his family. No behavior documentation noted in EMR or follow up to potential refusals of nursing care. Review of Hospital Discharge Instructions dated 6/7/22 for R10 revealed he went to the hospital because he cut his own feeding tube. The hospital replaced the feeding tube and hand wrote on the instructions that R10 needs to follow up with his psychiatrist. His final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation showing a psychiatrist was contacted or any follow-up to the discharge instructions. Review of a Social Services Progress Note dated 6/13/22 (date of survey entry) for R10 revealed a Quarterly note stating he has impaired processing skills and memory deficits related to [CONDITION(S)] and [CONDITION(S)] disorder. He is severely cognitively impaired and his PHQ9 indicated he has mild depression. He also receives Trazadone (antidepressant) and [MEDICATION(S)] for seizures and indicated it may cross over for mood. He refuses care and treatment at times. The resident cut his feeding tube and needed it replaced and suggesting to the family to place on comfort care because he cut his feeding tube and refuses care at times. Social Services monitoring changes in mood, behavior, and psychiatric medication. Discharge plan is to be long term care resident but look at option in Grand Rapids to be closer to family. The last Social Services Progress Note was 3/11/22. No behavior documentation noted in EMR and no documentation indicating the search for a new facility closer to family has been initiated. No documentation indicating the resident is being followed up regarding potential refusals of nursing care. Review of a Feeding Tube Care Plan last revised on 6/10/22 for R10 revealed he will be free of aspiration through the review date. The HOB is to be elevated at 45 degrees during and thirty minutes after the tube feeding that was last revised on 9/3/21. Review of a Care Plan addressing R10s psychosocial status/medications last revised on 9/9/21 revealed the resident will show decreased episodes of anxiety. The interventions included but not limited to offer food/drink, offer activity, offer bathroom, reposition, redirect to quiet area, approach 1:1, if possible, approach by different care giver, maintain ambulation or offer wheelchair ride, provide reassurance. Not all interventions are person centered for R10. Psych consult as needed on 9/3/21. Review of the Care Plan revealed no plan/interventions for R10 refusing nursing cares and services. Review of the Care Plan revealed no plan/interventions for R10 to discharge to a facility closer to his family. Review of a standards of practice document for [CONDITION(S)] cannula and stoma care provided by the facility revealed: Implementation: . Elevate the head of the bed to 30-45 degrees (unless contraindicated) to decrease abdominal pressure on the diaphragm, promote lung expansion, and reduce the risk of aspiration. Documentation: Record the date and time of the procedure; type of procedure performed; amount, consistency, color, and odor of secretions; stoma and skin condition; and patient's respiratory status and tolerance of the treatment. Note any complications, the name of the practitioner notified, the date and time of notification, any prescribed interventions, and the patient's response to them. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. Review of a policy titled Enteral Nutrition last reviewed 10/1/19 revealed the resident should be in a semi fowler's position (HOB at approximately 30 degrees) during administration and for 30 minutes to one hour after to prevent aspiration. The skin surrounding a . gastrostomy . is kept clean and free from irritation and/or infection. Review of a policy titled Behavior Management last revised 7/9/21 revealed The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors. Individualized approaches . Care that is individualized by being tailored to all relevant considerations for that individual, including physical, functional, and psychological aspects. To aid with cause identification, the IDT will attempt to determine . A Behavior Management meeting will be conducted monthly and (as needed) or at the Guest/Resident at Risk at least monthly . Resident #60 (R60) Review of an Admission Record reflected R60 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan initiated on 11/10/2021 reflected R60 was at risk for fluctuations in blood sugar related to diabetes with the goal of being free from signs of complications from fluctuations in blood sugars such as mental status changes, tremors/shakiness, dizziness, weakness, and appetite loss. Interventions included: Observe and document signs and symptoms of complications from fluctuating blood sugar, report abnormal findings to physician; obtain labs/diagnostics per physician orders, report abnormal finding to physician. Review of R60's May and June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record reflected No in every entry for the months of May and June 2022, indicating the physician was never notified of a blood sugar reading less than 70 or greater than 400. Review of a Blood Sugar Summary from 4/14/2022-6/15/2022 reflected R60's blood sugar was greater than 400 on 20 occasions. Review of the R60's Progress Notes did not reflect any mention of blood sugar readings greater than 400 or notification to the physician of the blood sugar readings outside of parameters. During an interview on 06/15/22 at 8:28 AM, the Director of Nursing (DON) said her expectation was for staff to notify the physician of blood sugar readings outside of parameters and follow physician orders. The Assistant Director of Nursing (ADON) said her perception of the order for monitoring was that there were no signs or symptoms of blood sugar readings outside of parameters but then agreed that a blood sugar reading would be a symptom of [CONDITION(S)]. According to the Cleveland Clinic, [CONDITION(S)] (high blood glucose) means there is too much sugar in the blood because the body lacks enough insulin. Associated with diabetes, [CONDITION(S)] can cause vomiting, excessive hunger and thirst, rapid heartbeat, vision problems and other symptoms. Untreated [CONDITION(S)] can lead to serious health problems. Early symptoms of [CONDITION(S)] include high blood sugar, increased thirst and/or hunger, blurred vision, frequent urination and headache. (Accessed from clevelandclinic.org on 6/21/2022)

This citation pertains to intake number MI 325. Based on interview and record review the facility failed to prevent falls for 1 Resident (R1) of 3 resident reviewed for falls, resulting in R1 having a fall resulting in a laceration and ongoing falls. Findings included: Review of R1's face sheet dated, 5/17/22 revealed she was an [AGE] year-old female and was last admitted to the facility on [DATE]. R1 had diagnoses that included: unspecified dementia without behavioral disturbance, muscle weakness, difficulty in walking, and unspecified fall, subsequent encounter. Review of R1's Minimum Data Set (MDS), a nursing assessment tool, dated 4/20/22 revealed she had a Brief Interview of Mental Status (BIMS) score of 6/15 (severely impaired cognition). R1 required supervision assistance of one person for bed mobility, transfers, walking, and eating. She required limited supervision assistance of one person for moving around the facility, toilet use and hygiene. Review of R1's physician progress note dated effective 4/15/22 at 00:00 (midnight) revealed, Patient admitted currently for dementia. Having increased confusion, agitation, behavioral changes, difficulty with ADL's (Activities of daily living), personality changes, restlessness and gait disturbance. Review of R1's incident report dated 4/28/22 revealed R1 fell at 7:10 am in her room. There was no indication that there was staff in the room (unsupervised) at the time of the fall. R1 was noted to have a 4 cm (centimeter) laceration above her right eye when she was found on the floor. The box on the incident report for attempting to self-transfer was marked. In the post fall evaluation, she was noted to be very impulsive and that she self-transfers. Under initial interventions noted, Assessment, pressure held to res (resident) head, sent to [name of hospital]. Under new interventions noted, Therapy Services, Tx (treat) to area til (until) healed. There was no indication the facility increased R1's supervision or assistance related to her unmet needs. Review of R1's incident report dated 5/2/22 at 23:15 (11:15 PM) revealed R1 fell in her room and the fall was unwitnessed (no supervision). Review of the Immediate interventions revealed R1 was placed on frequent checks. Under Re-Creation of Last 3 hours before fall noted, Resident with chronic impulsive transfers, not asking for assist or using call light to summon staff. Under new intervention note check every 20 minutes for 24 hours. No long-term intervention for increased supervision or assistance was noted. During an interview with the Director of Nursing (DON) on 5/17/22 at 10:28 AM, R1's fall incident reports and fall care plan were reviewed. The DON confirmed R1 was known to be impulse and self-transfer prior to the falls on 4/28/22 and 5/2/22. The DON confirmed the facility did not implement any increased supervision or assistance for R1 after both falls. The DON confirmed they were unable to determine times R1 required assistance with toileting needs as the bowel and bladder documentation did not reflect the times staff had been assisting R1 to the toilet. The DON said the facility does not do wake and sleep assessments. During an interview with Certified Nurse Aide (CNA) E on 5/17/22 at 11:25 AM, CNA E confirmed that she was assigned to care for R1 on 4/28/22 at 7:10 AM when R1 fell and required emergency care after a fall with a laceration. CNA E said she cared for R1 several times prior to the fall. CNA E said her shift starts at 5:00 AM. CNA E said R1 was generally sleeping at 5:00 AM. CNA E said she would assist R1 with her morning care when she woke up which was generally before 7:30 AM. CNA E would walk R1 to the dining room after AM (morning) care. R1 would get assistance walking back to her room after breakfast to assist her with toilet needs. After toilet needs were meet R1 would go to exercise class and return to her room to use the toilet. R1 would be assisted to the dining room for lunch and CNA E's shift ended at 1:00 PM. CNA E said the few times R1 did self-transfer (that she was aware of prior to her fall) was early in the shift prior to AM care. CNA E was asked if the facility had a program to supervise residents prior to breakfast and CNA E said No. CNA E was not aware what time R1 woke up on 4/28/22 and CNA E said she did not provide any AM care for R1 the day she fell and had a laceration to her head. CNA E said the facility did not interview her about R1's fall on 4/28/22 or anytime after that fall. Review of R1's fall investigation for 4/28/22 revealed no indication CNA E was interviewed about R1's fall. Review of R1's fall care plan date created on 4/14/22 revealed, History of falls, PNU (unknown), [CONDITION(S)] (urinary tract infection), weakness and impaired mobility. An intervention anticipate and meet needs. PRN (as needed) was located for 4/15/22. There were no new interventions located to increase supervision or assistance after R1 fell on [DATE] or 5/2/22.

This citation pertains to intake number MI 325. Based on interview and record review the facility failed to implement interventions to increase supervision and assistance to prevent falls for 1 Resident (R1) of 3 resident reviewed for falls, resulting in R1 having a fall resulting in a laceration and ongoing falls. Findings included: Review of R1's face sheet dated, 5/17/22 revealed she was an [AGE] year-old female and was last admitted to the facility on [DATE]. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's Minimum Data Set (MDS), a nursing assessment tool, dated 4/20/22 revealed she had a Brief Interview of Mental Status (BIMS) score of 6/15 (severely impaired cognition). R1 required supervision assistance of one person for bed mobility, transfers, walking, and eating. She required limited supervision assistance of one person for moving around the facility, toilet use and hygiene. Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Having increased confusion, agitation, behavioral changes, difficulty with ADL's (Activities of daily living), personality changes, restlessness and gait disturbance. Review of R1's incident report dated 4/28/22 revealed R1 fell at 7:10 am in her room. There was no indication that there was staff in the room (unsupervised) at the time of the fall. R1 was noted to have a 4 cm (centimeter) laceration above her right eye when she was found on the floor. The box on the incident report for attempting to self-transfer was marked. In the post fall evaluation, she was noted to be very impulsive and that she self-transfers. Under initial interventions noted, Assessment, pressure held to res (resident) head, sent to [name of hospital]. Under new interventions noted, Therapy Services, Tx (treat) to area til (until) healed. There was no indication the facility increased R1's supervision or assistance related to her unmet needs. Review of R1's incident report dated 5/2/22 at 23:15 (11:15 PM) revealed R1 fell in her room and the fall was unwitnessed (no supervision). Review of the Immediate interventions revealed R1 was placed on frequent checks. Under Re-Creation of Last 3 hours before fall noted, Resident with chronic impulsive transfers, not asking for assist or using call light to summon staff. Under new intervention note check every 20 minutes for 24 hours. No long-term intervention for increased supervision or assistance was noted. During an interview with the Director of Nursing (DON) on 5/17/22 at 10:28 AM, R1's fall incident reports and fall care plan were reviewed. The DON confirmed R1 was known to be impulse and self-transfer prior to the falls on 4/28/22 and 5/2/22. The DON confirmed the facility did not implement any increased supervision or assistance for R1 after both falls. The DON confirmed they were unable to determine times R1 required assistance with toileting needs as the bowel and bladder documentation did not reflect the times staff had been assisting R1 to the toilet. The DON said the facility does not do wake and sleep assessments. During an interview with Certified Nurse Aide (CNA) E on 5/17/22 at 11:25 AM, CNA E confirmed that she was assigned to care for R1 on 4/28/22 at 7:10 AM when R1 fell and required emergency care after a fall with a laceration. CNA E said she cared for R1 several times prior to the fall. CNA E said her shift starts at 5:00 AM. CNA E said R1 was generally sleeping at 5:00 AM. CNA E said she would assist R1 with her morning care when she woke up which was generally before 7:30 AM. CNA E would walk R1 to the dining room after AM (morning) care. R1 would get assistance walking back to her room after breakfast to assist her with toilet needs. After toilet needs were meet R1 would go to exercise class and return to her room to use the toilet. R1 would be assisted to the dining room for lunch and CNA E's shift ended at 1:00 PM. CNA E said the few times R1 did self-transfer (that she was aware of prior to her fall) was early in the shift prior to AM care. CNA E was asked if the facility had a program to supervise residents prior to breakfast and CNA E said No. CNA E was not aware what time R1 woke up on 4/28/22 and CNA E said she did not provide any AM care for R1 the day she fell and had a laceration to her head. CNA E said the facility did not interview her about R1's fall on 4/28/22 or anytime after that fall. Review of R1's fall investigation for 4/28/22 revealed no indication CNA E was interviewed about R1's fall. Review of R1's fall care plan date created on 4/14/22 revealed, History of falls, PNU (unknown), [CONDITION(S)] (urinary tract infection), weakness and impaired mobility. An intervention anticipate and meet needs. PRN (as needed) was located for 4/15/22. There were no new interventions located to increase supervision or assistance after R1 fell on [DATE] or 5/2/22.

This citation pertains intake #MI 657 Based on observation, interview, and record review, the facility failed to provide adequate assessment and treatment of [REDACTED].#2, #3, #13 and #14), of 4 Residents reviewed for pain, resulting in Resident #13 shaking in uncontrolled pain for an hour, Resident #3 not having adequate pain relief and Residents #2 and #14 having uncontrolled pain when their pain medication was not provided as requested. Findings include: Resident #13 Review of Resident #13's face sheet dated 9/9/19 revealed he was a [AGE] year old male admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #13 was his own responsible party. Review of Resident #13's Brief Interview of Mental Status (BIMS) score dated 9/10/19 revealed he scored 15/15 (normal cognition). Review of Resident #13's Brief Interview of Mental Status (BIMS) score dated 8/25/19 revealed he scored 14/15 (normal cognition). On 9/9/19 at 9:00AM, Resident #13 was in bed under his blankets shaking/tremoring with his eyes closed. Resident #13 responded to his name and when asked if he was cold said, no, I am in pain. The Surveyor asked Resident #13 when he had received his pain medication and he said an hour ago but over the weekend they changed my [MEDICATION NAME] (narcotic pain medication) to every 12 hours from every 6 hours. Resident #13 said he has been on narcotic pain medication for [AGE] years because of a back injury. The Surveyor asked Resident #13 who told him his pain medication had been changed, he said he did not want to get staff in trouble, but it was a nurse on day shift Sunday 9/7/19. Resident #13 said he asked for his pain medication last night, but they told him it had changed to every 12 hours and again he would not say which nurse told him that because he did not want to get them in trouble. Resident #13 said his pain has been a 7 all morning and it had not lowered even though it had been an hour since he received his [MEDICATION NAME]. During an interview with Registered Nurse (RN) Y at 9:04 AM, RN Y said she was still in training as this was the 4th day she was working in this facility. Y said she gave Resident #13 his pain medication around 8:00 AM and he said his pain was a 3 at that time. Y had a nurse with her LPN P, LPN P said she was Y's preceptor (instructor). P told Y she would go assess Resident #13 as Y was still passing medications. LPN P went to Resident #13's room and Resident #13 said his pain had been a 7 all morning and Resident 13 said he was told he would see the doctor today and explained he could not handle pain medication change to every 12 hours. LPN P went to check the medical record and Resident #13 did not have a change in his pain medication order. LPN P discovered Resident #13 had gone 15 hours since his last prn (as needed) pain medication. LPN P and RN Y said they did not get any report on Resident #13 at shift change. RN Y was asked if her preceptor was with her at 8:00 AM when she gave Resident #13 his pain medication and RN Y said, no she did not come in until 9:00 AM today. On 9/9/19 at 9:14 AM, the Director of Nursing (DON) was informed of Resident #13's condition and concern that he had gone 15 hours without his prn pain medication and was in severe pain. The DON instructed the Unit Manager, RN S to check on Resident #13. Resident #13 was still shaking in pain when RN S arrived. Resident #13 told RN S about staff telling him the doctor changed his pain medication orders and refused to give him medication last night because of the order change. Resident #13 again refused to give RN S any names as he did not want to get anyone in trouble. RN S said she would contact Resident #13's doctor. Review of Resident #13's progress note dated 9/9/19 at 8:07 AM revealed RN DD gave Resident #13 [MEDICATION NAME] HCL, 5 mg and at 8:05 AM gave Tylenol Extra Strength 500 mg. RN DD recorded Resident #13's pain was 3 at 8:07 AM. There was no indication RN Y provided his pain medication or pain assessment. Review of Resident #13's pain assessment dated [DATE] signed by Unit Manager, RN S revealed Resident #13 had vocal complaints of pain, facial expression of pain and was shaking. Guest state medication is effective when given, unable to go 12 hours between doses, but states he's never been able to go 12hr. Review of Resident #13's pain assessment dated [DATE] at 13:12 revealed Unit Manager, RN S documented, his pain was a 7, the worst his pain gets is a 10, the best pain gets is a 4 and his goal for managing his pain is a 3. During an interview with RN S on 9/10/19 at 2:18 PM, RN S said this assessment was done because Resident #13 started on a pain medication rub. The Surveyor asked RN S asked what she did about Resident #13's pain at the time of the assessment at he had reported it was a 7. RN S reviewed Resident #13's electronic medical record and could not see any information that would indicate she did anything at that time to decrease Resident #13's pain. Review of Resident #13 progress note dated 9/9/19 at 9:33 AM revealed Unit Manager, RN S documented, Guest with c/o (complaint of) increased pain this am. Medicated as ordered, states some relief since administration. Does state urine was more cloudy yesterday than normal, some increased confusion observed as guest is more forgetful today than norm. Dr. name aware with new orders for UA and C&S if needed. There was not indication that he did not receive his [MEDICATION NAME] every 6 hours as was his normal pattern and no indication he reported staff had told him he could not have his pain medication as ordered. Review of Resident #13's Medication Administration Record [REDACTED]. RN DD provided a dose at 17:26 (5:26 PM) on 9/8/19 RN DD provided the next dose on 9/9/19 at 8:07 AM (almost 15 hours between doses and same nurse working). Review of Resident #13's progress note dated 9/10/19 at 10:28 AM revealed, late entry for 9/9/19 1700 urine sample obtained, urine dip performed dip was negative, resident denies pain with urination denies frequency, will continue to monitor for changes and needs. Review of Resident #13's (MONTH) MAR for [MEDICATION NAME] HCL, 5 mgs revealed he had one dose on 9/1/19, 4 doses on 9/2/19, 3 doses on 9/3.19 and 9/4/19, 2 doses on 9/5/19, one dose on 9/6/19, 3 doses on 9/7/19 and 9/8/19. During an interview with the Pharmacy Representative (PR) DD (State Agent CC and the DON also witness to interview) on 9/6/19 at 4:13 PM, PR DD said he was not working for the facility in (MONTH) 2019 when the facility reported LPN L to the police for possible narcotic diversion. PR DD said the Pharmacist that was working for the facility at that time is no longer with the company. PR DD said he was not aware of any narcotic documentation or diversion concerns until this week. PR DD had asked his general manger for any documentation that showed the former Pharmacist, or the pharmacy company was aware of any narcotic concern in the facility prior to 9/6/19. They were not able to find any documentation to provide for review. PR DD was asked if during the monthly reviews, they look for documentation errors and PR DD said they do but he was not able to find any records that the former Pharmacist had discovered any documentation concerns related to narcotics. DD said he did a complete review of all narcotic documentation today for all Residents currently in the facility and he his review discovered approximately 60 documentation errors for the 13 residents currently on prn narcotics for the month of (MONTH) 2019. PR DD said the Pharmacy was not aware of the narcotic documentation/discrepancies and therefore did not notify the Drug Enforcement Agency (DEA) of the problem. There were no disciplinary notes or audits prior to 9/6/19 located for the errors that PR DD found. Resident #3 Review of Resident #3's face sheet dated 9/9//19 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and that [DIAGNOSES REDACTED]. Resident #3 was his own responsible party. Resident #3 Brief Interview of Mental Status (BIMS) score dated 1/24/19 (last BIMS in the system) was 15/15 (normal cognition). On 9/9/19 at 2:00 PM, Resident #3 was in his room in a recliner with compression equipment on both legs. Resident #3 said he goes out to [MEDICAL TREATMENT] 6 days a week and has ulcers on his feet that go to the bone. Resident #3 said his pain gets out of control at least once a week. Resident #3 said if he does not wake up for over 4 hours he wakes up in severe pain. He said he has been on the same dose of [MEDICATION NAME] for a long time and should be able to get it every 4 hours but has had to wait longer. Resident #3 said when he gets to a pain level of 7, he is crying and did not understand why he could not have other pain medication like [MEDICATION NAME] since he is dying. He reported his pain is currently a 5. On 9/9/19 at approximately 2:30 PM, the Director of Nursing was informed of Resident #3's pain concerns. The DON reported she was going to have his prn [MEDICATION NAME] changed to schedule every 4 hours to avoid the need to wake up for pain medication. On 9/10/19 at 1:00 PM, the DON said the doctor did not change Resident #3's pain medications orders yesterday but he would evaluate his medications today. The DON said Resident #3 is out of the facility 6 days a week for [MEDICAL TREATMENT] and he is gone for at least 5 hours. The DON said she would check into having Resident #3 take his pain medication with him, so he did not get a late dose on those days. Resident #3's pain evaluation dated 6/4/19 at 11:54 revealed his pain at that time was a 5, the worst pain gets is a 7 and his goal was 2. The last physician assessment the DON could locate in Resident #3's medical record was dated 6/17/19 and documented, just seems to be doing ok with pain. Review of Resident #3's pain level assessments located on the MAR indicated [REDACTED]. Resident #3 stated pain goal on the pain assessment dated [DATE] was a 2. On the (MONTH) 2019 MAR from 9/1/19 to 9/9/19 Resident #3 received a score that showed he was meeting his pain goal 8 times out of 31 scores of his pain level. The DON was not able to locate any documentation in Resident #3's medical record that indicated the Resident #3's physician was made aware of Resident #3's pain concerns and was addressing why his pain goal was not able to be met. Resident #2 Review of Resident #2's face sheet dated 9/9/19 revealed she was [AGE] year-old female admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #2 was her own responsible party. Review of Resident #2's Brief Interview of Mental Status (BIMS) score dated 7/10/19 revealed she was 14/15 (normal cognition). During an interview with Resident #2 on 9/9/19 at 9:47 AM, Resident #2 said she had been on narcotic pain medication for 5 years. Resident #2 said she has a timer on her pill bottle at home and takes her narcotic pain medication around the clock every 4 hours and that never gets her pain below a level of 4. Resident #2 said the facility does not have enough nursing staff so she is not able to get her narcotic pain medication every 4 hours. Resident #2 said she asked for her pill at 8:00 AM today but there is a new nurse in training, and she did not have time to get me my pill until 9:00 AM. By 9:00 AM her pain level reached a 7 and it is difficult to get my pain back in control when they are late. Resident #2 said she has had to wait up to 8 hours to get her narcotic pain medication because nurses frequently work 16-hour days and do not have enough help. On 9/10/19 at 1:00 PM, Resident #2's electronic medical record was reviewed with the DON. The DON said Resident #2 has been on [MEDICATION NAME] 5/325 since admission on 4/3/19. Resident #2's pain assessment dated [DATE] was reviewed and her pain was 6 at that time and her goal was a 2. Resident #2's [MEDICATION NAME] was increased from 100 mg to 200 mg on 4/8/19. The next pain assessment was 6/21/19 and her pain was 9 at that time. The DON could not locate any ongoing assessments or documentation that showed Resident #2's pain was monitored after the increase in [MEDICATION NAME] or any indication that anything was done when Resident #2 reported her pain was a 9 on 6/21/19. Review of Resident #2's MAR for (MONTH) 2019 (9/1/19 to 9/9/19) revealed [MEDICATION NAME] 3/325 was ordered every 4 hours as needed for pain. Resident #2 pain was documented 35 times. Resident #2 pain was rated at 2 or below 13 of the 35 times (Residents goal documented on 4/9/19 was 2. (There was no indication the facility was working on meeting Resident #2 pain goal or why that pain goal could not be met). Resident #14 Review of Resident #14's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #14 was her own responsible party. Resident #2's Brief Interview of Mental Status (BIMS) score dated 9/10/19 was 15/15 (normal cognition). On 9/9/19 at 9:55 AM, Resident #14 was in bed and feeling very tired and not well because she was awake all night by a Resident yelling. Resident #14 complained of poor pain control due to staff not always being able to get her pain medication to her on time. On 9/10/19 at 1:00 PM, the DON reviewed Resident #14's electronic medical record and said Resident #14 had orders for [MEDICATION NAME] every 6 hours. The MAR for scheduled pain medication does not include pain level assessment and it does not include that time the pain medication is actually given. The DON was not able to print a report of the times [MEDICATION NAME] was actually given to verify if Resident #14 had ever waited 8 hours for [MEDICATION NAME] verses 6 hours. On 9/10/19 at 1:00 PM, the DON reviewed Resident #14's initial pain assessment dated [DATE] and her pain was 7 at that time and her goal was 0. Resident #14's pain was assessed on 6/4/19 at 17:48 by LPN FF assessed her pain to be 10/10. The DON could not find any documentation that LPN FF did anything about Resident #14's pain on 6/4/19 at 17:48 when he documented her pain was 10/10. The Surveyor asked the DON about LPN FF and the DON said LPN FF was been let go but did not indicate it was related to this assessment. The Surveyor asked the DON what her expectation was if a Resident complained of pain being 10/10 and she said, call the physician. The DON reviewed Resident #14's record and did not any documentation that the physician had been notified that Resident #14 pain was 10/10. The DON said Resident #14's last physician assessment was on 7/5/19 and indicated she was on a high dose of [MEDICATION NAME]. Resident #14's [MEDICATION NAME] was increased to 7.5/325 on 7/5/19. Review of Resident #14's MAR for (MONTH) 2019 for [MEDICATION NAME] 7.5-325 mg every six hours for pain revealed she scheduled to get it at midnight, 6:00 AM, noon and 6:00 PM. The first pain level documented was on 9/6/19 at 6:00 PM and Resident #14 rated her pain at 2. Resident #14's pain was rated 10 more times. Resident #14 rated her pain at a 5, five times, at a 4 one time and a 3 one time. Resident #14's pain goal of 2 or lower was only met 6 times of the 12 times it was assessed. The DON was not able to locate any documentation that Resident #14 Physician was aware she not meeting her pain goal and she was last seen on 7/5/19 and was provided an increase in her pain medication.

This citation pertains to intake MI 361. Based on observation, interview and record review, the facility failed to 1) provide supervision to prevent the elopement of 2 residents (Residents #1 and #2), 2) complete an Incident/Accident report after the elopement of 2 residents (Residents #1 and #2) per facility policy and 3) complete a nursing assessment for 2 residents (Residents #1 and #2) after an elopement from the facility of 9 sampled residents reviewed for elopement, incident report completion and nursing assessment of a total sample of 16 residents, resulting in Immediate Jeopardy for Residents #1 and #2, who were put at risk for physical harm, injury and/or death and placing 13 other residents assessed by the facility to be at risk for elopement, at high risk for serious harm, injury and/or death. Findings Include: Resident #1: Review of the Minimum Data Set ((MDS) dated [DATE], Admission Assessment (dated 12/1/16), Falls (dated 12/29/16) and Cognitive (dated 12/19/16) care plans, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a BIMS of 8 (cognitive assessment score indicating cognitive impairment), at risk for falls due to stroke, Alzheimer's dementia, poor safety awareness, impulsivity, short term memory loss and who had a guardian in place to make health care decisions. Resident #1 was assessed upon admission to the facility as a fall risk of 7 (at risk for falls) and per review of her admission care plan (dated 12/1/16), was assessed to be at risk for elopement, unsafe with poor safety awareness and given an electronic ankle bracelet to prevent elopement. Review of Occupational Therapy (dated 12/2/16), Physical Therapy (dated 12/1/16) and Speech Therapy (dated 12/7/16) note's, revealed Resident #1 had reduced cognition, altered mental status and was at risk for falls. Review of Resident #1's clinical record revealed her [DIAGNOSES REDACTED]. Resident #1 was not living at the facility at the time of the investigation 10/2/17, she was discharged on [DATE], to another Long Term Care to be on the supervised locked unit. Review of Resident #1's facility Admission Care Plan dated 12/1/16, revealed she was assessed to be an elopement risk and was given a wander guard bracelet. Review of Resident #1's facility Quarterly Fall Risk dated 9/13/17 and Falls care plan dated 12/29/16, (prior to elopement on 9/16/17) revealed the resident was risk for falls due to dementia with a history of stroke and she had intermitted confusion and had 1-2 falls in the previous 3 months. Review of Resident #1's Occupational Therapy (dated 12/2/16), Physical Therapy (dated 12/1/16) and Speech Therapy (dated 12/7/17) note's, revealed she was a fall risk related to her decreased cognition, impaired safety awareness, documented physical impairments and associated functional deficits and had a cognitive assessment score of 13/30 (13 out of a possible 30, revealing she had impaired cognition). Resident #2: Review of the MDS dated [DATE], Admission Assessment (dated 12/1/16), Falls (dated 9/14/17) and Cognitive (dated 12/19/16) care plans, revealed Resident #2 was an [AGE] year-old male admitted to the facility on [DATE] with a BIMS of 12 (mild cognitive impairment) and per review of his admission care plan (dated 12/1/16), was assessed to be at risk for elopement, unsafe with poor safety awareness and given an electronic ankle bracelet to prevent elopement. Review of Occupational Therapy (dated 12/2/16), Physical Therapy (dated 12/1/16) and Speech Therapy (dated 12/7/16) note's, revealed Resident #2 had cognitive impairment and decreased safety awareness, decrease in strength and functional mobility, reduced ability to safely ambulate, weakness, unsteadiness and was at risk for falls. The resident's Admission Care Plan (dated 12/1/16) stated, (electronic ankle bracelet)-elopement risk, poor safety awareness, cast to L (left) forearm FX (fracture) post fall prior to admission. Review of Resident #2's clinical record revealed his [DIAGNOSES REDACTED]. Resident #2 was not living at the facility at the time of the investigation 10/2/17, he was discharged on [DATE], to another Long Term Care to be on the supervised locked unit. Review of Resident #2's facility Admission nurses assessment and admission care plan dated 12/1/16, revealed he was assessed to be an elopement risk and was given a wander guard bracelet. Review of Resident #2's facility Admission Care Plan dated 12/1/16, revealed he was assessed and given a fall risk score of 8 (at risk for falls), and he was an elopement risk due to, poor safety awareness, HX (history) of falls prior to admission in which he was given a wander guard bracelet. Review of Resident #2's Fall Care Plan dated 9/14/17 (prior to elopement on 9/16/17), revealed he was at risk for falls due to his poor safety awareness, unsafe self transfers, dementia, unsteadiness on feet, history of falling with a fracture of right wrist and hand, altered mental status, muscle weakness with wander: exit seeking R/T (related to) impaired cognition. Review of Resident #2's Cognitive Care Plan dated 12/19/16, revealed he had poor safety awareness, short term memory loss and had a history of [REDACTED].#1). Review of Resident #1's Occupational Therapy (dated 12/2/16), Physical Therapy (dated 12/1/16) and Speech Therapy (dated 12/7/17) note's, revealed he was a high fall risk related to significant weakness, unsteadiness, dizziness, decrease in strength, decrease in functional mobility, reduced ability to safely ambulate and requires Min Ax1 (minimum assist of 1 person) with all standing and ambulatory activities as well as having decreased cognitive abilities. Review of Residents #1 and #2's facility's Letters of Guardianship dated 5/9/17, revealed both residents had a Guardian in place at the time of their elopement on 9/16/17. Review of Resident's #1 and #2's nurses note's dated 9/16/17, stated Resident went to restaurant and did not sign out. Came back and notified nurse upon arrival. Review of Residents #1 and #2's facility Release of Responsiblity for Leave of Absence sheets dated 12/5/16 to 8/10/17, revealed no documentation of either resident being signed out on the date they eloped from the facility, 9/16/17. During an interview done on 10/2/17 at 2:15 p.m., staff member H (Nursing Assistant/CNA) stated, we did not see them (Residents #1 and #2 on 9/16/17) for 2 maybe 3 hours, the last time we saw them is when they came back from Darby's, they had a bag (a bag of food), they came through the front door. I found their (electronic ankle bracelets) cut off on their side table and we found the scissors in their room, we have the same kind of scissors at the nurse's station. We didn't look for them because we did not know they were gone. Observation was done on 10/2/17 at 1:30 p.m., of the distance and terrain the residents took from the facility to the fast food restaurant when they both eloped on 9/16/17. It was a total of 2.6 miles to and back from the restaurant, with no less than 14 street crossings noted. During a phone interview done on 10/2/17 at 3:56 p.m., staff member J (Charge Nurse, LPN) stated, she (Resident #1) came to me around 5:15 p.m. to 5:30 p.m. (on 9/16/17) and said we are back, we are supposed to look at all our residents (at the start of shift), I didn't, I was making sure the 5:00 p.m. meds were passed. Review of staff members J (Charge Nurse, LPN) orientation records dated 6/29/17, revealed she had been educated by the facility during orientation regarding residents rights, abuse, elder justice act and missing persons. During an interview done on 10/3/17 at 1:20 p.m., staff member K (Charge Nurse, LPN) stated A CNA (staff member H, Nursing Assistant/CNA) brought the wander guards to me and I put them on the desk, the scissors they were found, the CNA (staff member H) brought the scissors up with the wander guards, I locked them up in a cart (medication cart), I don't know who took them. I didn't document any assessments, I thought someone else would. During an interview done on 10/2/17 at 1:56 p.m., staff member I (Charge Nurse, LPN) stated they (Residents #1 and #2) cut their wander guards off and went to a restaurant. During an interview done on 10/2/17 at 2:40 p.m., staff member M (CNA) stated they (Residents #1 and #2) were taking butter knifes in their pockets to their room. I did not trust them, I would take knifes away from them (prior to the elopement on 9/16/17). During an interview done on 10/4/17 at 10:20 a.m., staff member R (Nursing Assistant/CNA) stated, I heard after it happened, the (Residents #1 and #2) somehow made it to Darby's and made it to Darby's and they were sitting on someone's porch and they were no longer here (at the facility). During observation and interview done on 10/3/17 at 10:05 a.m., Resident #1 and Resident #2 were in another Long Term Care Facility in a supervised locked unit, both were clean, neat and well groomed. Both residents were interviewed by this surveyor. Resident #2 stated, I had the opportunity to get out the door. We took 2 rests (on the way to Darby's restaurant on 9/16/17). We started in the driveway, I cut them (wander bracelets) off. I parked my walker in the bushes. I love Darby's but we never get to go there. It was pretty warm that day, we sat down on the curb once, about half way there was a man who had 2 plastic chairs, we sat down in them. A good Samaritan that had the plastic chairs, he gave us a ride, the Spanish guy and his wife and 2 kids. He said were are you going and he gave me a ride, I ordered 2 beef sandwiches. When we got back, (staff member A, Administrator) chewed us out. We left (the facility) because there was no freedom. Resident #1 was not able to be interviewed due to decreased cognitive abilities (a BIMS score of 8). Resident #2 said they did not get anything to drink at the restaurant, they waited until they got back to the facility. Residents #1 and #2 had nothing to drink and it was very hot out in MT Pleasant on 9/16/17. The actual temperature in MT. Pleasant MI on 9/16/17, between the times of 3:00 p.m. and 5:00 p.m. was, 85 degrees Fahrenheit. www.wunderaround.com Review of the facility physician orders [REDACTED].#2 dated 12/1/16, stated Wander bracelet to guest: Check placement Freq Ck (frequently) every shift (day, eve, night). Review of Resident #1 and Resident #2's TAR dated 9/17, revealed documentation that both residents wander bracelets were checked for placement per physician orders [REDACTED]. No documentation was found that the residents wander bracelets were checked for placement was found on 12/16/17, for the second or third shifts. Review of the facility physician orders [REDACTED].#2 dated 12/1/16, stated Wander bracelet to guest: Check function Freq Ck (frequently) daily night (on night shift). Review of Resident #1 and Resident #2's Treatment Administration Record (TAR) dated 9/17, revealed on 9/16/17, no documentation was found that the residents wander bracelets function was checked per physician orders [REDACTED]. Review of the facility Wander Guard/Secure Care Device Assessment policy dated 0305, stated once a day, obtain a bracelet testing device from the medication cart, Testing should be performed during a light medication pass. Placement of the wander guard/secure care device will be monitored every shift and the device will be tested daily to ensure that the device is functioning properly. During an interview done on 10/2/17 at 4:05 p.m., staff member B (Director of Nursing/DON) stated, we did not do an incident report, I don't know why we didn't, prior to leaving (elopement of both residents on 9/16/17), the facility had assessed both of them to be unsafe to leave the facility on their own. Upon request done on 10/2/17 at 3:00 p.m., by this surveyor made to staff members A (Administrator) and B (Director of Nursing/DON) for the facility Accident/Incident (I & A) report regarding the elopement on 9/16/17, no I & A was given to this surveyor at the time the request was made on 10/2/17. Staff member A revealed he had done an investigation regarding the elopement of Residents 1 and #2, however he did not do an Incident report and did not report the elopement to the state agency because we (the facility) didn't think it was an elopement. On 10/4/17 at 7:55 a.m., staff member A (Administrator) gave this surveyor his investigation of the elopement that took place on 9/16/17, involving Residents #1 and #2 and stated, Here's my report even though I didn't report it (to the state agency). During a phone interview done on 10/2/17 at 2:50 p.m., N (Guardian #1) stated they (resident's #1 and #2) cut their theaters (wander bracelets) off and they got out the door. He (Resident #2) ditched his walker in the weeds and went to Darby's. He is in the (another Long Term Care facility's locked unit), they (Residents #1 and #2) are not happy with that. Their room (at the facility) was right around the corner, near the exit door, no one knew they were gone until they got back (on 9/16/17), I asked them (the facility) to move them (the residents) closer to the nurses station. During a phone interview done on 10/4/17 at 3:35 p.m., Family Member #2 was asked by this surveyor if she had been informed that Residents #1 and #2 had eloped from the facility on 9/16/17 and she stated, they (the facility) actually didn't. I had gone the day after and (Residents #1 and #2) told me they had gotten out, I was a bit up-set. That was a scary thought having them out alone. I talked to (staff member A, Administrator), he said they left and (Resident #2) did not want to take his walker and he got a ride to Darby's. During a phone interview done on 10/3/17 at 12:53 p.m., staff member AA' (Medical Director/Primary Physician, MD) revealed he was not informed of the elopement incident regarding Residents #1 and #2 until sometime last week (9/25/17 to 9/29/17, approximately 1 week after the elopement had occurred). Review of the facility Physician Notification policy dated 11/16, stated The licensed nurse will report changes in the guest's condition due to illness, exacerbation of existing condition, or accidents and incidents to the physician, nurse practitioner, or physician assistant. Review of Residents #1 and #2's clinical records, revealed no documentation that staff member AA (Physician), N Guardian #1 nor Family Member #2 were ever called regarding the residents elopement on 9/16/17. Review of the facility Documentation policy dated 03/11, stated Documentation in a guest's medical record is done to reflect a guest's status as well as address acute episodes. Interventions taken, the guest's response to interventions, and any unusual occurrences should be recorded. Be complete when documenting, making certain that everything significant to be the guest's condition and course of treatment is recorded (including elopement on a very hot day). During an interview done on 10/4/17 at 10:00 a.m., staff member Q (Charge Nurse, LPN) said if an elopement takes place he would, do a complete assessment and a incident report During an interview done on 10/2/17 at 3:05 p.m., staff member P (Social Service) was asked by this surveyor if she had follow-up with both residents after they eloped on 9/16/17, and she stated, I did not met with them until the meeting (meeting held 6 days after the elopement to transfer the residents to a locked unit), ya sure, I should of talked with them, (staff member A, Administrator) was handling it. I would call it an elopement. They stock pilled things to cut their wander guards off, it was in their room after they left. Review of the facility Missing Guest policy dated 0303, stated Required notification, designated family or legal represented, attending physician, complete a physical assessment that includes vital signs, range of motion, and skin assessment, notify QA (quality assessment) Risk Manager per notification policy. Guidelines for documentation: time the guest was discovered, time the guest was last seen, time the Administrator and Director of Nursing were notified, time the family or legal representative was notified, time physician was notified, up-date care plan with approaches. Review of the facility Incident Reporting policy dated 06/17, stated An incident is an unexpected occurrence which is not consistent with the routine operation of the facility or the routine care of a particular guest. A licensed nurse will assess the guest including taking all vital signs, after the nurse's assessment, if no injury is present, the physician may be notified by fax, office notification, or voice mail. Families are to be notified as soon as possible. All attempts to contact the legal representative and physician are to be documented in the nurse's notes. The nurse is responsible to completing the Incident Report in objective terms. The incident report is to be completed as soon as possible, but no later than the end of the nurse's shift. The Administrator will oversee the investigation of the incident. Review of the facility Philosophy (un-dated) stated, Specifically, the company will focus on the following areas that it believes will represent the basic components of quality care, clean, safe, pleasant environment. On 10/3/17 at 11:30 a.m., notification of Immediate Jeopardy was given to the Administrator (staff member A) that began on 9/16/17 at 3:30 p.m., as a result of the facility's failure to prevent the elopement and ensure the safety of two residents, Resident #1 and Resident #2, who were both assessed as elopement risks and who had wander bracelets put on them by the facility, the facilities failure to complete incident reports per their policy for the residents as a result of their elopement and the failure to do nursing assessments on the residents upon return to the facility after eloping on 9/16/17, a hot day with the temperature being in the 80's. On 10/4/17, the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1. As of 9/27/17 Resident #1 and #2 no longer lived at the facility. 2. On 9/16/17 at 11:59 p.m., a head count of in-house residents was completed by facility staff nurses. 93 of a census of 93 residents were accounted for. 3. On 9/21/17, Nurse Managers re-assessed the 17 facility residents who had a wander guard device. As of 10/3/17, 13 of 17 residents remained at risk for elopement and a wander guard device remained in place. 4. On 9/21/17, the Director of Nursing (staff member B) and Unit Managers audited the 13 resident's with wander guards to ensure placement and proper functioning were documented in each residents Treatment Administration Record (TAR). Residents with wander guards in place will have them checked for placement every shift and functionality daily by licensed nurses or designee and documented on the TAR per facility policy. 5. On 9/21/17, the Administrator (staff member A) reviewed the facility Missing Guest policy and it was deemed appropriate. 6. On 9/18/17 and on 9/17/17, the Environmental Service Director and designee validated all 6 facility alarmed and wander guard equipped exit doors were functioning properly. The Environmental Service Director or designee will continue checking all alarmed and wander guard equipped exit doors for proper functioning on a daily basis per facility policy and document findings daily. 7. On 9/18/17, Social Service (staff member and Unit Nurse Managers reviewed the elopement books and they were found to be up-to-date. Social Service (staff member P) will update each book with any changes as needed per facility policy. 8. On 10/3/17, Staff Development Director educated 105 of 143 facility staff members regarding resident abuse and missing guest policy. The remaining staff members will be educated by the Staff Development Director and Nurse Managers prior to the start of their next scheduled shift. 9. On 10/4/17, the Director of Nursing (staff member B) reviewed the facility Guest General Policy and deemed it was appropriate. 10. New employee orientation will include elopement process education. 11. The Director of Nursing (staff member B) will conduct random wander guard audits to ensure residents are re-assessed when no longer an elopement risk and ensure licensed nurses are documenting wander guard placement and functionality on the TAR. This will occur weekly for 4 weeks and then monthly for 3 months. Concerns will be addressed immediately by the Director of Nursing or designee and reported to the QAPI (quality assurance) Committee for further recommendations. 12. The Administrator (staff member A) will report any elopement concerns to the state regulatory agency by completing the BHS-362 and BHS-363 in accordance with state regulations and guidelines beginning 10/3/17 and I accordance with facility Incident Reporting policy. 13. The Administrator is responsible for the implementation of the above enumerated abatement plan. Although the Immediate Jeopardy was removed 10/3/17, the facility remained out of compliance at a scope of Isolated and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy, due to sustained compliance had not been verified by the state agency.

Citation perains to Intake #s MI 590 and MI 133. Based on observation, interview and record review, the facility failed to follow the facility policy Abuse (dated 6/30/17) inappropriate cutting of beard and hair for 1 sampled (Resident #11) resulting in the potential for resident abuse, coercion, intimidation, and humiliation for a census of 82 residents. Findings Include: According to Resident # 11's Significant change Minimum Data Set (MDS) assessment dated [DATE], Resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident's Brief Interview for Mental Status (BIMS) was assessed at 3 which indicated severe impairment. Review of the facility's documentation provided failed to provide an incident report for the incident related to Resident #11's hair and beard being cut by CNA D. Review of Resident #11's facility investigation dated 6/30/17 revealed, Resident's Rights were not considered when CENA D trimmed (Resident's) hair and beard without his permission. Staff that were aware of this hair cut did not report it timely to the NHA. According to the facility report after investigation, it was determined that the incident occurred on 6/19/17 but was brought forward from his roommate on Saturday, 6/24. On 10/2/17 at 1:55 PM, Resident #11 stated, One CNA watched out and 2 were cutting, had my beard since I was 30 since the 70's ([AGE] years), they cut my hair from mid shoulder to at shoulder and beard at least 2-3 inches off, why, why did they do that? Resident #11 pointed to a picture on the wall and stated, see my hair that was how long it was. The picture on the wall next to Resident #11 bed showed Resident's hair midway between shoulder and elbow and beard was approximately 6-7 inches long. Resident #11's hair on 10/2/17 was observed to have been at shoulder level (at least 7-8 inches cut) very uneven and his beard was 3-4 inches long (at least 2-3 inches cut). Resident #11 denied that staff had asked permission at the time to cut his hair or beard. Resident #11 then stated staff were later laughing about how staff had cut off his beard and hair in his bathroom and he and his roommate over heard them. Resident #11 kept repeating why, why did they do that? On 10/5/17 at 10:45 AM, Resident #16 reported he had noticed staff take Resident #11's to a shower and it was not his regular shower day and Resident #11 was very drowsy and he takes [MEDICATION NAME] in the morning so he is always drowsy in the morning. Later in the day Resident #16 noted Resident #11's hair was chopped off. He (Resident #11) would never cut his hair he has had it for years. Resident #16 reported he and Resident #11 later heard the staff in the bathroom laughing/talking about how one CNA held, one CNA distracted and one CNA cut Resident #11's hair and Resident #11 did not know about it. Resident #16 stated, I was worried I was next, look at me. I have long hair and a long beard. Resident #16 was asked You are worried the staff are going to cut your hair and beard, and responded, yes, Resident #16 reported he had notified Social Services staff P of the incident. Resident #16 reported he had the Ombudsman's telephone number and a number of a lawyer in the event that the concerns continued. On 10/3/17 at 2:07 PM, Certified Nurse Aide (CNA) D was asked if she had cut Resident #11's hair and beard and responded, yes, it was a huge rats nest, I tried to get it out with conditioner and could not. CNA D was asked if Resident #11 was asked permission prior to cutting his hair and beard and responded, yes. Did anyone else hear you ask the resident? and responded, 2 others were present but they didn't hear me. CNA D was asked if it was in her job description to cut hair and responded, I didn't think it was a problem, the trim was not that bad. On 10/3/17 at 2:21 PM, CNA S reported to have been present in the shower room with CNA T and CNA D during Resident #11's shower. CNA S stated, I went to wash his glasses, and had my back to staff. I did not hear no request to cut resident's hair. I saw his hair that was cut. CNA S was asked how much was cut and responded, Unsure. I saw scissors in CNA D hands and her cutting. CNA S was asked if it was in the CNA job description to cut hair or beards and responded, Never, only cut facial if they allow it. do what resident wants. Do not cut long beard. Let beautician cut that. Only grooming. CNA S was asked if had received any resident rights or abuse training and stated, yes. CNA S was asked if the incident was reported and responded no. On 10/4/17 at 2:22 PM, CNA T returned a phone call and was asked if she was present in the shower room at the time CNA D Cut Resident #11's hair and beard and responded, I was responsible for him he was on my hall that day, CNA T grabbed scissors out of her pocket and just cut his hair and beard like she knew what she was doing. It happened so fast. CNA T stated that CNA D was reported to have stated, I wanted to clean him up. CNA T then stated, we finished washing him up and got him back to bed. CNA D was asked if CNA T asked Resident #11 permission to cut his hair and beard prior to cutting and responded, No, I don't think he was even aware of it at the time. CNA T was asked if cutting hair was part of the CNA job description at the facility and responded, No. Review of Resident #11's social service notes dated 6/24/17 revealed, (Resident) states 3 girls in blue cut his hair and he did not want it. This writer asked if he wanted to make an appointment with the hairdresser to have it straightened out and he said no This writer called the guardian to see if he had requested the hair cut and he said no. Resident repeated over & over he did not want his hair cut. called to NHA, DON . There was no other documentation noted related to the Power of attorney or how resident was dealing with his hair being cut other than no concerns. On 10/2/17 at 3:15 PM, Social Services (SS) P reported that she was informed on 6/24/17 Resident #11's Roommate (Resident # 17) had reported staff had cut Resident #11's hair and beard. SS P reported following the incident staff were in-serviced and instructed that Only one person at the (facility) was to cut hair and unless you are licensed by the State of Michigan and employed by the (facility) to specifically cut hair you do not cut hair. SS P stated went to talk to Resident #11 he was laughing and would not answer me. I called (Administrator) and started asking questions, nobody really knew at that point. The next day I talked to the nurse who knew one of the girls names and ask one girl, who said one girl cut while one girl washed him, one person said Oh, He got his hair cut like it meant it was ok. I talked to the guardian and was instructed to have him talk and ask if he was upset. SS P stated that Resident #11 was very upset, felt violated and could tell by his stance in his bed when talking about the incident. He went ridged. Social Service P reported that resident had [MEDICAL CONDITION] and would often have trouble finding his words and often stroked his beard in an attempt to give himself time to think of what he wanted to say. Social Service P was asked if Resident #11 was finding it harder to express himself since his beard had been cut and responded, it has taken away his concentration and ability to find words. Social Service P was asked if this was documented and responded, No. SS P was asked of the conversation with the POA was documented and responded, No. On 10/3/17 at 9:20 AM, Social Services (SS) P stated, I spoke with guardian, knew hair and beard got cut and not upset (Resident), no concerns, ok if beautician cuts hair. On 10/4/17 at 5:06 PM, Family Member DD reported he had discussed the hair cut and beard cut with his brother and his brother was extremely upset. Was not very happy and did not intend to get a hair cut. FM DD reported he had spoken with SS P about the incident and how Resident #11 was upset about having his hair and beard cut. FM DD reported this was a loose end that he had wanted taken care of that had not been followed up on. On 10/4/17 at Director of Nursing (DON) B reported CNA D was terminated on 6/19/17 for cutting Resident #11's hair and beard, it was discovered during the investigation there was one other Resident #10 that her hair cut during the same time frame. DON B reported Resident #10 was on the same hall and it was assumed by the same staff therefore considered an isolated incident. DON B was asked if cutting Resident #11 hair and beard was part of a Certified Nurse Aide's job description and responded no Review of facility CNA Job description revised date 2/10, revealed, Major Duties and Responsibilities Administrative Functions: . Report all accidents and incidents observed immediately to the Charge Nurse. Personal Functions: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors. Guest rights: Ensure that you treat all guests, fairly, and with kindness, dignity and respect and Report any allegations or suspected abuse immediately to the facility administrator. CNAD signed a facility Certified Nursing Assistant job description on 8/12/10. Review of the facility staff general orientation checklists dated 2/10/17 revealed CNA D was checked off on 2/10/17 and CNA T was checked off on 5/11/17 for competency with Abuse Policy and procedures including Prohibition, training, Identification, Reporting Screening, Prevention and investigation and Elder Justice. CNA S's general orientation checklist was not provided for review. According to the facility Employee authorization form CNA D's last day worked was 6/20/17 and was terminated effective 6/21/17 abuse charge. (3 days prior to the day incident was reported to the social worker). Employee Disciplinary Record revealed Resident was suspended for investigation on 6/20/17 violation of Resident Rights/ Abuse cut a resident's hair & beard without permission. She stated she had permission. The resident stated she did not. Review of the facility policy Abuse Prohibition, Investigation, and reporting dated 6/30/17, revealed, D. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. E . G. H. Mental abuse is defined as, but not limited to, harassment, threats of punishment, coercion, intimidation, withholding or treatments or services, or humiliation including abuse that is facilitated or caused by facility staff taking or using photographs or recordings in manner that would demean or humiliate a guest . Review of information provided by Administrator A on 10/2/17 revealed, Addendum to Resident Rights education June 2017, 1. Resident's hair including mustache/beards may only be cut by a professional with the approval of the resident and/or responsible party. 2. Remember if something seems not right to you- report to NHA immediately. On 10/4/17 at 2:40 PM, Nursing Home Administrator (NHA) A reported all staff are trained on resident rights annually and cutting hair and trimming beards is not part of the job description for certified nurse aids. NHA A was asked if CNA had the right to cut Resident #11's hair or beard and responded, No.

This citation pertains to MI# 620 and MI# 023 Based on observation, interview and record review, the facility failed to prevent the elopement and ensure the safety of 1 resident (Resident #101) of 4 sampled residents assessed to be at risk for elopement. Resident #101 was assessed by the facility to be severely cognitively impaired with confusion and self-ambulatory. Resident #101 eloped from the facility on two occasions, Sunday 5/1/16 between 12:30 PM and 1:10 PM and Friday 6/10/16 at 4:42 PM. On both occasions, Resident #101 ' s departure and absence from the facility was unbeknownst to facility staff. Review of the 5/1/2016 facility reported investigation of incident report revealed that Resident #101 was observed outside on the sidewalk and her Wander Guard was not on her left ankle. Resident #101 was discovered by a visitor at 1:10 PM on 5/1/2016, as the visitor was driving on Crapo Street. The visitor pulled into the parking lot of the facility, when she saw the resident walking on the sidewalk of Crapo Street alone and unsupervised. The facility found a broken nail care scissors and Wander Guard strap in the bottom drawer of the bedside stand and the Wander Guard device in the waste basket. A new Wander Guard device was applied. Immediate Jeopardy began on 6/10/16 at 4:42 PM, when Resident #101 was found again outside on the sidewalk, alone, un-supervised and next to a busy road with the Wander Guard bracelet (an electronic device for notification of residents going through a Wander Guard alarmed door) in place down the street from the facility, by the Dietary Manager F, who was driving on Crapo street. The Dietary Manager F parked her car and assisted the Resident #101 back to the facility. According to the investigation report, the front door at the parking lot entrance was propped open for another resident, who has was returning and needed assistance. The Wander Guard alarm sounded when Resident #101 re-entered the building. Certified Nurse Assistant (CNA) C and CNA D were noted to state that the door was propped open. CNA C was noted to state that she heard an alarm going off and thought it was because the door was open for so long. Immediate Jeopardy was identified at F-323 on 6/15/16 due to the facility's failure to prevent the elopement and ensure the safety of Resident #101 on two occasions. this deficient practice places 28 residents (including sampled Residents #102, #105 and #106), assessed as being at risk for elopement, at high risk for physical harm, injury and/or death. On 6/16/16 at 9:08 AM the Nursing Home Administrator was notified of the Immediate Jeopardy. Findings include: Record review of Resident #101's Minimum Data Set (MDS), dated [DATE], revealed a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #101's 'Mood' care plan, dated 9/2/15, revealed: At risk for mood issues with history of restlessness, crying, sad facial expressions and [DIAGNOSES REDACTED]. Has wander guard placement due to exit seeking behavior with history of elopement. Removes wander guard, known to cut off. An update, dated 5/2/16, revealed that Resident #101 goes to entrance door and watches for bus. On May 1, 2016: Record review of Resident #101's 'Investigation of Incident', dated 5/1/2016, revealed that on the night shift at approximately 1:30 AM Licensed Practical Nurse (LPN) J noted that the Wander Guard device was not on Resident #101's person. LPN J placed Resident #101 on 15 minute checks. At 6:00 AM on 5/1/2016 the Wander Guard was re-applied. At approximately 1:10 PM on 5/1/2016, staff was notified by a visitor, who came into the facility, that Resident #101 was outside unsupervised. An interview on 6/15/16 at 1:20 PM with Visitor K revealed that she was on Crapo Street and pulled into the facility parking lot and noticed that Resident #101 was out on the sidewalk looking around. Visitor K stated that she parked and went into the building and told the nurses at the desk that Resident #101 was outside by herself. Visitor K stated that Resident #101 was out at the property line heading for Broadway Street. Visitor K stated that she told the nurses that Resident #101 was outside by herself and they (nurses) all jumped up and said she wasn't supposed to be outside alone. Record review of Resident #101's electronic nurse notes, dated 5/1/2016 at 5:01 PM: Resident removed wander guard per self X 2 this shift, resident exited building. Staff assisted resident back into building, full body assessment done, no injuries noted. all VSS (vital signs stable), resident stated she wanted to go for a walk, wander guard put back on, resident placed on 15 minute checks . Record review of Resident #101's physician progress notes [REDACTED]. Plan: She does have psych following and she does seem to be wandering around and does get easily confused. Given her condition these kind of behaviors are expected. I do not see any evidence of active infection or any need for any other active intervention except for ongoing psych follow-up and we will follow. On June 10, 2016: Record review of facility report incident 5-day investigation, dated June 10, 2016 at approximately 4:42 PM, revealed that Resident #101 was found outside on the sidewalk by Dietary Manager F with a Wander Guard bracelet in place. In an interview on 6/15/16 at 8:40 AM, Dietary Manager F revealed that on June 10, 2016 it was a hot day, she estimated around 80 degrees, when she found Resident #101 on the sidewalk down by Illinois street, 6-8 feet from the street. Dietary Manager F stated that she had gone to an appointment and was pulling out of the professional building where her appointment was at 4:42 PM onto Crapo Street when she saw Resident #101. Dietary Manager F stated that she pulled over and assisted Resident #101 back to the facility. Resident #101 told the Dietary Manager that she was hot and her leg hurt. Dietary Manager F stated that the resident told her that she went out through the parking lot door. The Dietary Manager F stated that when resident re-entered the building the Wander Guard alarm sounded. In an interview on 6/15/2016 at 4:00 PM, Certified Nurse Assistant (CNA) C revealed that she went to the parking lot door entrance through the 200 hallway and did not see Resident #101 in the hallway or in the entrance lobby area. CNA C stated that she heard an alarm when she was on her way to the lobby to assist a resident coming back from an outing with a family member. CNA C stated that the lobby door was propped open, when she was outside for approximately 5 minutes. CNA C stated that she did hear an alarm when Resident #101 went back into the building. Record review of the facility 'In-service Program Attendance', dated 5/2/2016 and titled Elopement Policy & Procedure revealed that the facility had policies for 'Wander Guard/Secure Care Device Assessment', dated 3/2005 and a 'Missing Guest' policy, dated 3/2005 attached as presentation material. The state surveyor reviewed the policies and noted that the educational material did not educate staff on the response to door alarms or of expectations to search the immediate area for a cause of the alarm sounding. Record review of facility 'In-service Program Attendance', dated 5/2/2016 and titled Elopement Policy & Procedure revealed that the facility had staff signatures indicating attendance. CNA C signed in on 5/5/2/2016 as receiving elopement education. Observation and interview on 6/15/16 at 8:25 AM at the start of the investigation, of and with Resident #101 revealed the resident was able to self-ambulate hallways throughout the facility. In an interview Resident #101 stated that she had just wanted to walk and they (staff) didn't want her to go. Resident #101 stated, I went out the door and down the sidewalk that was this week. I walked back. I was all wore out, tired from walking. I did it twice, once a while ago and then again. I went through the trees down to that other road. Record review of Resident #101 transfer form, dated 6/17/16, revealed that the resident was transferred to another long-term care facility with a secured locked unit, due to dementia and wandering. Immediate Jeopardy was removed on 6/16/16 at 12:40 PM, when state surveyor confirmed, by observation, interview and record review, that the following had been completed: 1. Beginning on 6/16/16 at 9:30 AM, Resident #101 was placed with 1:1 supervision. 2. Nurse Managers reviewed all 99 residents for elopement risk and updated care plans and care guides as appropriate. 3. Systemic measures- The facility policy on Elopement/Missing Guest was reviewed by the Nursing Home Administrator and facility medical director and deemed appropriate on June 16, 2016. 1. The Environmental Services Director/designee verified all door alarms were in place and checked all exit doors on June 15 & 16, 2016 for functioning of alarms and all were found to be operating appropriately. Environmental Services Director/designee will continue to check all alarmed doors on a daily basis and will report any areas of concern to the Administrator beginning June 16 2016. If any doors are not functioning properly the NHA or designee will assign a facility staff member to monitor the door continually until the necessary repairs have been made beginning June 16, 2016. 2 The code for all alarms were changed on June 10, 2016. 3. The elopement book/binders were updated with new admissions, that are identified as an elopement risks and/or exit seeking residents, who are identified as elopement risks on 6/16/16 by the Director of Nursing or designee. The newly admitted residents will be reviewed regarding their elopement risk status by the IDT team at the morning stand up meeting beginning 6/16/16. 4. The care plans for residents at risk (17 identified) have been reviewed and updated as needed on 6/16/16. Elopement books at the nurse ' s station have been reviewed and updated on 6/16/16. 5. The staff development director educated 105 staff members out of 132 by 6/16/16 on the ' Missing Guest/Elopement ' policy, safety, accidents and hazards, and supervision of residents. The remaining facility staff (those on medical leave (2), personal leave (1), PRN (as needed) (22), and vacation (2) will receive education upon reporting for duty on their next scheduled day beginning June 16, 2016. Newly hired employees will receive education on the policy for ' Missing Guest/Elopement starting June 16, 2016. 6. Resident's using Wander Guard devices will have the device checked daily for placement and functionality and documented in the Treatment Administration Record (TAR) as ordered, by the licensed nurses beginning June 16, 2016. 7. New admissions will be assessed for elopement risk and the elopement book, care plan and care guide will be updated as needed by licensed nurses, beginning June 16, 2016. Residents who are identified with escalating behaviors will be assessed and the physician will be contacted and appropriate interventions will be implemented as ordered. 8. New admission charts will be reviewed daily in the morning stand-up meeting to ensure that residents identified as at risk for elopement have had interventions implemented beginning June 16, 2016. 4. Quality Assessment and Assurance- Environmental services or designee will conduct daily checks of the alarmed doors and findings will be reported to the NHA daily beginning June 16, 2016. Nursing Home Administrator to audit weekly for 4 weeks and then monthly times 3. Elopement audits will be completed weekly for 4 weeks and the monthly for 3 months for residents identified as at risk for elopement to ensure appropriate interventions. The Nursing Home Administrator will report any concerns of elopement to the state agency. Although the Immediate Jeopardy was removed on 6/16/16, the facility remained out of compliance with a scope of isolated and severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy, pending verification by the State Agency (SA) of the facility's ability to demonstrate sustained compliance. #

Based on interview and record review, the facility failed to prevent falls for 2 (#101 and 107) of 8 sampled Residents, from a total sample of 8, resulting in Resident #101 being harmed when found on the floor by staff with a fracture to the nose with laceration requiring emergency room treatment and Resident #108 sustaining a fall from wheelchair resulting in hematoma to the forehead. Findings include: Record review of the facility 'Fall Awareness Program' date 10/2010 which was requested resulted in a single sheet of paper from the facility that revealed that guests at risk for falls will be monitored by staff and the purpose to promptly identify guests at risk for falls. Resident #101 Record review of Resident #101's pre-admission hospital paper work dated 8/4/14 revealed chief complaint; Falls- [AGE] year old gentlemen presented to the emergency room for recurrent falls and unsteady gait he got so debilitated that he was not able to ambulate safely at home. Record review of Resident #101's 'Cumulative [DIAGNOSES REDACTED]. Record review of Resident #101's physician note dated 8/7/14 revealed resident was brought in with frequent falls with unsteadiness. Record review of Resident #101's care plan dated 8/14/14 for 'Falls- at risk for fall related injury was related to impaired mobility, history of falls, recent episodes of dizziness, history of orthostatic hypotension. [DIAGNOSES REDACTED]. Interventions included provide assistive devices, observe for fatigue or unsteadiness, mat to floor next to bed, assist with transfers, and keep bed in low position. Record review of Resident #101's 'Incident Report' dated 10/1/14 at 7:10 AM revealed that Resident #101 was found on floor in resident room with an abrasion to the facial area. Intervention noted on the incident report that was put in place was to place resident at nurse station when out of bed. There were no alarms put in place to alert staff resident is attempting to move or whether there was an assistive device in place to prevent the fall. Record review of Resident #101's 'Inter-Facility Continuity of Care Report'(transfer sheet) dated 10/1/14 revealed reason for transfer: fall from wheelchair to floor with bleeding from facile area, poor safety awareness with non-compliance with transfers, complained of pain to face and neck area. It was unclear how the interventions addressed poor safety awareness with non-compliance. Record review of Resident $101's 'Fall Risk Assessment' dated 11/5/14 identified guest score status/conditions of intermittent confusion (4), chair bound or needs assistance with elimination (2), predisposing conditions hypotension, vertigo, CVA (cardiovascular accident), Parkinson ' s, arthritis, fractures, osteoporosis, neuromuscular disease, dementia, Alzheimer ' s cardiac- 3 or more present (4), takes 3-4 medications from anesthetics, antihistamines, hypoglycemic, narcotics, psychotropic, sedative/hypnotics (4), Gait balance issues of balance problem while standing, balance problem while walking, balance problem while sitting- position, trunk control, or sitting up, decreased muscular coordination, change in gait pattern when walking through doorway, jerking/spasmodic/recent history of seizures. Requires use of assistive devices (7). Total fall risk score of 21 (Total score of 10 or more represents HIGH RISK). Record review of Resident #101's 'Nursing Care Card' (kardex) form (undated) revealed Do not leave up in wheelchair in room, to be at nurse's station when up in chair and Monitor for resident going into room independently. No alarms where noted in use. Record review of Resident #101's 'Incident Report' dated 11/29/14 at 2:15 PM revealed that Resident #101 was found on floor in resident room with a laceration to the facial area. Post fall report dated 11/29/15 revealed that the 'oversight/supervision at the time of incident: Certified Nurse assistant was gathering equipment and personnel to lay resident down'. Resident#101 had no alarms or assistive devices/ restraints at the time of the fall. Incident investigation questionnaire form dated 11/29/14 noted the guest fell forward out of his chair landing on the floor hitting his nose causing a laceration and some deformity .The nursing care card with the intervention , Do not leave up in wheelchair in room was not followed. Record review of Resident #101's 'Inter-Facility Continuity of Care Report'(transfer sheet) dated 11/29/14 revealed reason for transfer: Found on floor, laceration to nose. Record review of Resident #101's hospital CT facial bones without contrast dated 11/29/14 revealed 'Commuted fractures of the nasal bones bilaterally with soft tissue swelling ' Record review of Resident #101's 'Prescriber Telephone Order' form dated 11/29/14 revealed keep sutures to bridge of nose clean and dry- may remove dressing in 1-2 days and remove sutures in 7 days. Resident #107: Record review of Resident #107's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female with brief interview of mental status (BIMs) score of 3 out of 15 sever cognitively impaired. Resident #107 was noted to have had one fall in the prior quarter. Record review of Resident #107's 'Fall Risk Assessment' dated 7/23/15 identified guest score status/conditions of intermittent confusion (0), history of falls of 1 or more falls in past 3 months (10)chair bound or needs assistance with elimination (2), behavior of agitated behavior exhibited less than daily (1) predisposing conditions of dementia and cardiac- 3 or more present (2), takes 1-2 medications from anesthetics, antihistamines, hypoglycemic, narcotics, psychotropic, sedative/hypnotics (2), Gait balance issues of balance problem while standing, balance problem while walking, decreased muscular coordination, requires use of assistive devices (4). Total fall risk score of 21 (Total score of 10 or more represents HIGH RISK). Record review of Resident #107's care plans dated 2/23/15 revealed care plans for extensive assist with transfers, bed mobility and activity of daily living (ADL's), vision related to [DIAGNOSES REDACTED]. Fall care plan dated 2/23/15 revealed Resident #107 was at risk for falls related injury secondary to history of falls and legally blind secondary to macular degeneration. Guest has poor safety awareness and will attempt to get self out of chair. Will frequently fall asleep in chair throughout day. Leans forward while sitting and falls forward, refuses to go to bed when sleepy throughout day and night. Interventions included: Ensure sitting at table when sitting outside, keep items of frequent use within reach. Skilled therapy referral as needed, complete fall risk per protocol, ensure wearing appropriate footwear for transfers and ambulation, if guest falls asleep in wheelchair place recliner back with legs up, extensive assist with transfers, orient to surroundings as needed, keep in mind that guest is legally blind and may require more assist, observe wheelchair position when up assist to sit in upright position is leaning forward, lay down in bed as guest allows, when sleeping in chair or in recliner chair. Bed against wall. Observe for fatigue and/or unsteadiness and encourage rest periods, rear anti tippers to wheelchair. Observation on 9/23/15 at 2:20 PM of room #400 revealed Resident #107 was seated in a wheelchair with her feet resting on wheelchair's foot rest and was leaning forward and appeared asleep. There was a pressure pad alarm in place in the wheelchair at the time of the observation. Resident #107 had a tan plush recliner which was in the up raised position with the seat in the forward tilted position. There was a black coil wired control box located at the right side of the recliner. There were no alarms or motion sensor observed/noted to the tilted recliner. Record review of Resident #107's 'Incident report' form dated 7/23/15 at 2:45 AM indicated the resident was witnessed to fall from the tilted chair in an up position and slide to the floor. Alarm was in use and noted to malfunction. Interventions put in place were- 'Place remote out of reach of resident, education of resident on usage of remote. Review of 'Incident Investigation Questionnaire' form dated 7/23/15 revealed that the resident used the chair remote to tilt it up causing her to slide out. Chair alarm did not sound. It was unclear whether a reassessment was done to prevent resident # 107 sliding out of her recliner chair which she liked to use. Review of Resident #107's fall' care plan had an added intervention dated 7/23/15 monitor for 72 hours for potential late effect and make sure chair is in desired position before leaving the room. Record review of Resident #107's 'Incident report' form dated 8/24/15 at 5:00 AM revealed the resident was found on the floor in guest room with a hematoma to right side of forehead. Review of the incident report form noted that the Resident #107 had a recliner (motorized) and was not working appropriately. Review of the 'Post-Fall report' dated 8/24/15 revealed that circumstance of fall was transferring/ getting out of recliner on her own. Review of 'Incident Investigation Questionnaire' revealed 'Well she has a remote chair, but it's broken. She was trying to stand up and fell '. Intervention put in place to not use recliner until maintenance fixes it. Review of Resident #107's fall' care plan revealed added intervention dated 8/24/15 monitor for 72 hours for potential late effects. Review of Resident #107's electronic nursing notes dated 8/24/15 at 6:39 AM revealed resident was found lying on her left side on floor in front of recliner, alarm sounding call light in reach, full body assessment with full range of motion and hematoma right forehead, neuros started, doctor notified via fax will pass to next nurse to notify family. Review of Resident #107's electronic nursing notes dated 8/24/15 at 1:54 PM revealed resident had a 5.0 X 4.0 cm hematoma on right side of forehead from recent fall. Record review of Resident #107's 'Incident report' form dated 9/18/15 at 1:15 AM revealed resident was found on floor in guest room with large hematoma to right forehead. Intervention put in place to continue to make sure chair alarm is functioning correctly, reposition guest feet to ensure no sliding out of chair. Record review of Resident #107's electronic nurse note dated 9/18/15 at 6:48 AM revealed resident found on floor in room at 1: 15 AM. Large hematoma to right forehead observed, but no other injuries note at this time. Guest denies any pain except that My head hurts a little .This is a reoccurring hematoma from a fall. Record review of Resident #107's 'fall' care plan revealed update on 9/18/15 'Prefers to sleep in her recliner' Interventions included: continue alarm to chair, attempt to lay in bed with bed in lowest position. Continue to offer to toilet every 2 hours and as needed. Therapy to screen. On 9/21/15 mats to floor at recliner side. An interview on 9/23/15 at 3:00 PM with the Director of Nursing (DON) stated that the facility had no 'Alarm' policy for the use of alarms that were being used within the facility. In addition, it was unclear whether the facility reassessed the use of the recliner when the resident acknowledged in their assessment Resident #107 preferred the recliner and at the same time slids off the recliner. There was no past non-compliance received from the facility during the survey process. (# ) (# )

THIS CITATION PERTAINS TO INTAKE MI 273. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY NEGLECTED TO APPROPRIATELY ASSESS, MONITOR AND TREAT THE LACK OF BOWEL MOVEMENTS IN 3 (#103, #108 , #109) OF 6 SAMPLED RESIDENTS FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN: 1) AN IMMEDIATE JEOPARDY FOR RESIDENT #103, WHO HAD NOT HAD A BOWEL MOVEMENT FOR 6 DAYS, SUBSEQUENTLY DEVELOPED A BOWEL OBSTRUCTION WITH POSSIBLE PERFORATION, EXPERIENCED AN ASPIRATION EVENT SECONDARY TO THE BOWEL OBSTRUCTION, WENT INTO [MEDICAL CONDITION] SECONDARY TO THE ABOVE AND SUBSEQUENTLY died , AND 2) IMMEDIATE JEOPARDY FOR RESIDENT #108 AND RESIDENT #109, WHO WERE PLACED AT HIGH RISK FOR BOWEL OBSTRUCTION, PERFORATION AND SEPTIC SHOCK DUE TO A LACK OF TREATMENT FOR NO BOWEL MOVEMENTS FOR 4 DAYS. FINDINGS INCLUDE: RESIDENT #103: REVIEW OF RESIDENT #103'S MEDICAL RECORD REVEALED THAT THE RESIDENT WAS A [AGE] year OLD FEMALE, WHO WAS admitted to the facility on [DATE]. THE FACILITY PHYSICIAN'S PROGRESS NOTE, DATED [DATE], INDICATED SHE WAS TRANSFERRED FROM A HOSPITAL TO THE FACILITY FOR REHABILITATION, AFTER A MOTOR VEHICLE ACCIDENT. THE ASSESSMENT LISTED ON THE PHYSICIAN'S PROGRESS NOTE INCLUDED [DIAGNOSES REDACTED]. THE FACILITY NURSING ADMISSION ASSESSMENT, DATED [DATE], INDICATED THAT UPON ADMISSION TO THE FACILITY, RESIDENT #103 WAS ALERT AND ORIENTED TO PERSON, PLACE AND TIME. RESIDENT #103 REPORTED TO NURSING STAFF THAT HER BOWEL MOVEMENTS OCCURRED AT LEAST EVERY THREE DAYS, WITH HER LAST BOWEL MOVEMENT OCCURRING ON [DATE]. THE FACILITY BOWEL ELIMINATION RECORD FOR RESIDENT #103 FOR [DATE] DID NOT SHOW A DOCUMENTED BOWEL MOVEMENT FROM THE TIME OF HER ADMISSION ON [DATE] UNTIL HER DISCHARGE ON [DATE], WITH THE EXCEPTION OF ONE SMALL BOWEL MOVEMENT ON [DATE] AND ONE SMALL BOWEL MOVEMENT ON [DATE], WHICH SHOWED THAT THE MEDICATIONS ADMINISTERED WERE INEFFECTIVE. FACILITY NURSE'S NOTES, DATED [DATE], INDICATED RESIDENT #103 HAD BEEN GIVEN MEDICATION FOR NAUSEA. FACILITY NURSE'S NOTES, DATED [DATE] AND [DATE], INDICATED RESIDENT #103'S APPETITE WAS POOR AND THAT THE RESIDENT WAS VERY "WHINY". NURSE'S NOTES, DATED [DATE] AND [DATE], INDICATED RESIDENT #103 COMPLAINED OF BACK PAIN AND THAT HER APPETITE WAS POOR. NURSE'S NOTES, DATED [DATE], INDICATED RESIDENT #103 HAD AN INCREASED TEMPERATURE, FELT WARM TO THE TOUCH, HAD DECREASED BOWEL SOUNDS, COMPLAINTS OF CONSTIPATION, A DISTENDED ABDOMEN AND REQUESTED TO SLEEP WITH THE HEAD OF THE BED ELEVATED. NURSE'S NOTES, DATED [DATE], INDICATED RESIDENT #103 COMPLAINED OF ABDOMINAL PAIN, HAD NOT BEEN ABLE TO HAVE A BOWEL MOVEMENT FOR SEVERAL DAYS, HAD THREE DARK BROWN EMESIS (VOMITING), HAD DECREASED BOWEL SOUNDS WITH HER ABDOMEN HARD AND DISTENDED (ENLARGED) AND THAT RESIDENT #103 WAS TRANSFERRED TO THE HOSPITAL. FACILITY SBAR (SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION) FORM (USED TO COMMUNICATE WITH PHYSICIANS), UNDATED, INDICATED RESIDENT #103 HAD VOMITED DARK BROWN LIQUID THREE TIMES, HAD NOT HAD A BOWEL MOVEMENT IN SEVERAL DAYS, HAD ABDOMINAL DISCOMFORT, DECREASED BOWEL SOUNDS, AND A NURSING ASSESSMENT OF "POSSIBLE BOWEL OBSTRUCTION". OCCUPATIONAL THERAPY WEEKLY DOCUMENTATION RECORD FOR RESIDENT #103, DATED [DATE], INDICATED THAT RESIDENT #103 REPORTED TO THERAPY STAFF SHE WAS HAVING PAIN SECONDARY TO THE FACT THAT SHE HADN'T HAD A BOWEL MOVEMENT. THE RECORD INDICATED THAT RESIDENT #103'S ABDOMEN WAS ENLARGED, SHE WAS MOST COMFORTABLE IN A LEFT LYING POSITION, AND WAS LATER TRANSFERRED TO THE HOSPITAL. NUTRITION AT RISK MONITORING RECORD FOR RESIDENT #103, DATED [DATE], INDICATED RESIDENT #103'S FOOD ACCEPTANCE RECORD SHOWED 24 TO 49 PERCENT OF FOOD EATEN AT MOST MEALS DUE TO NAUSEA PROBLEMS. FACILITY Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#103 AT 1:40 AM AND [MEDICATION NAME] WAS DOCUMENTED AS HAVING BEEN GIVEN AT 9:00 AM. FACILITY MAR FOR THE MONTH OF [DATE] FOR RESIDENT #103 INDICATED THAT ON [DATE] AT 1:40 AM, A [MEDICATION NAME] SUPPOSITORY WAS GIVEN TO RESIDENT #103. IN AN INTERVIEW ON [DATE] AT 10:35 AM, LPN #10 STATED SHE REGULARLY CARED FOR RESIDENT #103 AND DID REMEMBER HER. LPN #10 STATED SHE KNEW IT HAD BEEN SEVERAL DAYS SINCE RESIDENT #103 HAD A BOWEL MOVEMENT, BUT "WE WEREN'T THAT CONCERNED". LPN #10 STATED RESIDENT #103 WASN'T EATING GOOD, SHE HAD SO MANY OTHER PROBLEMS, AND WHEN SOMEONE DOESN'T EAT, THEY DON'T GO. IN AN INTERVIEW ON [DATE] AT 1:10 PM, LPN #11 REVIEWED RESIDENT #103'S NURSE'S NOTES IN FRONT OF THE SURVEYOR AND STATED SHE REMEMBERED CARING FOR THE RESIDENT. LPN #11 STATED SHE WAS AWARE THAT RESIDENT #103 HAD NOT HAD A BOWEL MOVEMENT FOR SEVERAL DAYS, BUT SHE DID NOT HAVE ANY CONCERNS ABOUT RESIDENT #103 UNTIL [DATE], WHEN RESIDENT #103 FELT WARM, HAD A FEVER, AND HER ABDOMEN WAS DISTENDED. LPN #11 STATED SHE DID CALL THE DOCTOR AND TOLD THE PHYSICIAN THAT THE RESIDENT WAS COMPLAINING OF CONSTIPATION, BUT DID NOT TELL THE DOCTOR THAT THE RESIDENT HAD NOT HAD A BOWEL MOVEMENT. LPN #11 STATED THE PHYSICIAN GAVE HER AN ORDER TO GIVE RESIDENT #103 A SUPPOSITORY FOR CONSTIPATION, WHICH SHE DID. LPN #11 STATED SHE DID NOT WRITE THE ORDER FOR THE SUPPOSITORY, AND RESIDENT #103 DID NOT HAVE A BOWEL MOVEMENT. IN AN INTERVIEW ON [DATE] AT 1:30 PM, LPN #12 STATED SHE DID PROVIDE REGULAR CARE FOR RESIDENT #103. LPN #12 STATED SHE WAS AWARE THAT RESIDENT #103 HAD GONE SEVERAL DAYS WITH NO BOWEL MOVEMENT, BUT SHE HAD NO CONCERNS. LPN #12 STATED BECAUSE RESIDENT #103 HAD POSITIVE BOWEL SOUNDS NOBODY DID ANYTHING AND SHE (LPN #12) DID NOT CONTACT THE PHYSICIAN FOR RESIDENT #103. IN AN INTERVIEW ON [DATE] AT 2:40 PM, LPN #13 REVIEWED THE NURSE'S NOTES FOR RESIDENT #103 IN FRONT OF THE SURVEYOR AND STATED SHE REMEMBERED PROVIDING REGULAR CARE FOR RESIDENT #103. LPN #13 STATED RESIDENT #103 COMPLAINED OF NAUSEA OFF AND ON, BUT NOTHING REAL SERIOUS. LPN #13 STATED SHE DID NOT RECALL THE CERTIFIED NURSE AIDES (CNA'S) REPORTING RESIDENT #103'S BOWEL STATUS TO HER. LPN #13 STATED EARLY IN THE MORNING ON [DATE], AROUND 7:30 AM, A CNA REPORTED TO HER THAT RESIDENT #103 WAS HAVING ABDOMINAL PAIN, SO SHE (LPN #13) ASSESSED THE RESIDENT. LPN #13 STATED RESIDENT #103 COMPLAINED OF LOWER ABDOMINAL PAIN, DID HAVE A SMALL EMESIS WHICH THE CNA'S HAD DUMPED BEFORE SHE (LPN #13) COULD SEE IT, HER ABDOMEN WAS VERY DISTENDED (ENLARGED) AND HARD, AND HER BOWEL SOUNDS WERE VERY SLOW. LPN #13 STATED SHE LEFT THE ROOM TO CALL THE DOCTOR AND SHORTLY THEREAFTER RESIDENT #103 HAD ANOTHER EMESIS, WHICH WAS BROWN WITH A COFFEE GROUND TEXTURE. LPN #13 STATED IT LOOKED LIKE SOMEONE WHO MIGHT HAVE A BOWEL OBSTRUCTION. LPN #13 STATED RESIDENT #103 HAD ONE MORE EMESIS WHICH LOOKED THE SAME AND THEN THE DOCTOR CALLED BACK AND GAVE AN ORDER TO SEND RESIDENT #103 TO THE HOSPITAL. LPN #13 STATED RESIDENT #103 WAS SENT TO THE HOSPITAL AROUND 1:00 PM BECAUSE SHE HAD TO WAIT FOR THE DOCTOR TO RETURN HER CALL. IN AN INTERVIEW ON [DATE] AT 10:15 AM, THE FACILITY DIRECTOR OF NURSING (DON) STATED THAT HER STAFF DIDN'T DO WHAT THEY SHOULD HAVE DONE FOR RESIDENT #103. THE DON STATED THAT RESIDENT #103 DID GO SIX DAYS WITHOUT HAVING A BOWEL MOVEMENT WHILE RESIDING IN THE FACILITY, AND THAT NOTHING WAS DONE FOR RESIDENT #103 UNTIL [DATE]. THE DON STATED THAT THE FACILITY DID NOT HAVE A BOWEL PROTOCOL UNTIL AFTER [DATE] AND DOES NOT CURRENTLY HAVE A BOWEL MANAGEMENT POLICY OR PROCEDURE. AMBULANCE RECORD, DATED [DATE], INDICATED RESIDENT #103 WAS ALERT AND ORIENTED, COMPLAINED OF ABDOMINAL PAIN TO THE AMBULANCE STAFF, HAD A SEVERELY DISTENDED ABDOMEN AND REPORTED TO THE STAFF THAT SHE HAD NOT HAD A BOWEL MOVEMENT SINCE [DATE]. HOSPITAL PHYSICIAN CONSULT, DATED [DATE], INDICATED RESIDENT #103 HAD A LARGE EMESIS (VOMITING) WITH A FECULENT ASPIRATION (FECAL), REQUIRED CARDIOPULMONARY RESUSCITATION (CPR) AT THAT TIME AND WAS UNRESPONSIVE FOR FIVE TO TEN MINUTES. HOSPITAL DISCHARGE SUMMARY FROM HOSPITAL #1, DATED [DATE], INDICATED RESIDENT #103 WAS TRANSFERRED ON LIFE SUPPORT TO ANOTHER HOSPITAL. THE HOSPITAL DEATH SUMMARY FOR RESIDENT #103 FROM HOSPITAL #2, DATED [DATE], INDICATED ADMISSION [DIAGNOSES REDACTED]. 2) ASPIRATION EVENT SECONDARY TO BOWEL OBSTRUCTION WITH POSSIBLE PERFORATION. 3) [MEDICAL CONDITION] SECONDARY TO ABOVE." THE HOSPITAL DEATH SUMMARY FOR RESIDENT #103 FROM HOSPITAL #2, DATED [DATE], INDICATED DISCHARGE [DIAGNOSES REDACTED]. status [REDACTED]. 2. SEVERE SEPTIC SHOCK. 3. ESCHERICHIA COLI/[DIAGNOSES REDACTED] PERITONITIS WITH POSSIBLE BOWEL PERFORATION"(BACTERIAL INFECTION). THE DEATH CERTIFICATE FOR RESIDENT #103 INDICATED A CAUSE OF DEATH AS "PERITONITIS/SEPTIC SHOCK." RESIDENT #108: REVIEW OF RESIDENT #108'S MEDICAL RECORD REVEALED A [AGE] year OLD MALE admitted to the facility on [DATE], WITH A PRIMARY [DIAGNOSES REDACTED]. physician's orders [REDACTED].#108 WAS TO RECEIVE MILK OF MAGNESIA TWO TABLESPOONFULS BY MOUTH AS NEEDED FOR NO BOWEL MOVEMENT IN TWO DAYS, [MEDICATION NAME] SUPPOSITORY RECTALLY AS NEEDED FOR NO BOWEL MOVEMENT IN 3 DAYS, AND FLEET ENEMA RECTALLY AS NEEDED FOR NO BOWEL MOVEMENT IN 4 DAYS. THE BOWEL CARE PLAN, DATED [DATE], FOR RESIDENT #108, INDICATED THAT RESIDENT #108 HAD BEEN IDENTIFIED TO BE AT RISK FOR CONSTIPATION RELATED TO MEDICATION SIDE EFFECTS, WITH AN INTERVENTION LISTED TO INCLUDE FOLLOWING THE BOWEL PROTOCOL. IN AN INTERVIEW ON [DATE], THE FACILITY DON HANDED A TYPED BOWEL PROTOCOL TO THE SURVEYOR AND STATED IT WAS THE BOWEL PROTOCOL FOR THE FACILITY SINCE [DATE]. THE PROTOCOL WAS NOT ON A FACILITY LETTERHEAD, WAS NOT DATED AND NOT BEEN SIGNED BY ANY FACILITY ADMINISTRATIVE STAFF OR A PHYSICIAN. THE FACILITY BOWEL PROTOCOL LISTED INTERVENTION AS FOLLOWS: MILK OF MAGNESIA (MOM) 30 MILLILITERS IF NO BOWEL MOVEMENT (BM)IN 2 DAYS. [MEDICATION NAME] 30 MILLILITERS FOR [MEDICAL TREATMENT] GUESTS. [MEDICATION NAME] SUPPOSITORY TO BE ADMINISTERED IF NO BM 24 HOURS AFTER MOM OR [MEDICATION NAME]. FLEETS ENEMA IF NO BM 24 HOURS AFTER SUPPOSITORY. CONTACT PHYSICIAN IF GUEST CONTINUES TO HAVE NO BM AFTER LAST INTERVENTION. FACILITY BOWEL ELIMINATION RECORD FOR RESIDENT #108 FOR THE MONTH OF [DATE] INDICATED RESIDENT #108 DID NOT HAVE A BOWEL MOVEMENT [DATE], [DATE], [DATE], OR [DATE]. REVIEW OF FACILITY MEDICATION ADMINISTRATION RECORDS FOR THE MONTH OF [DATE] INDICATED THAT RESIDENT #108 WAS NOT GIVEN ANY "AS NEEDED" MEDICATION FOR CONSTIPATION UNTIL [DATE] WHEN IT WAS DOCUMENTED RESIDENT #108 WAS GIVEN A DOCULAX SUPPOSITORY. REVIEW OF NURSE'S NOTES FOR RESIDENT #108 FOR [DATE] THROUGH [DATE] DID NOT REVEAL ANY DOCUMENTATION OF A BOWEL ASSESSMENT FOR RESIDENT #108 OR ANY DOCUMENTATION OF RESIDENT #108 REFUSING ANY TREATMENT FOR CONSTIPATION. RESIDENT #109: REVIEW OF RESIDENT #109'S MEDICAL RECORD REVEALED A [AGE] year OLD MALE admitted to the facility on [DATE], WITH A PRIMARY [DIAGNOSES REDACTED]. physician's orders [REDACTED].#109 WAS TO RECEIVE MILK OF MAGNESIA- TWO TABLESPOONFULS BY MOUTH AS NEEDED- FOR NO BOWEL MOVEMENT IN 48 HOURS, [MEDICATION NAME] SUPPOSITORY RECTALLY AS NEEDED FOR NO BOWEL MOVEMENT 24 HOURS AFTER MILK OF MAGNESIA, AND FLEET ENEMA RECTALLY AS NEEDED FOR NO BOWEL MOVEMENT 24 HOURS AFTER SUPPOSITORY. THE BOWEL CARE PLAN- DATED [DATE], FOR RESIDENT #109, INDICATED THAT RESIDENT #109 HAD BEEN IDENTIFIED TO BE AT RISK FOR CONSTIPATION RELATED TO PAIN MEDICATION AND IMMOBILITY, WITH INTERVENTIONS LISTED TO INCLUDE ADMINISTER MEDICATIONS AS ORDERED AND FOLLOW THE BOWEL PROTOCOL. IN AN INTERVIEW ON [DATE], THE FACILITY DON HANDED A TYPED BOWEL PROTOCOL TO THE SURVEYOR AND STATED IT WAS THE BOWEL PROTOCOL FOR THE FACILITY SINCE [DATE]. THE PROTOCOL WAS NOT ON A FACILITY LETTERHEAD, WAS NOT DATED AND NOT BEEN SIGNED BY ANY FACILITY ADMINISTRATIVE STAFF OR A PHYSICIAN. THE FACILITY BOWEL PROTOCOL LISTED INTERVENTION AS FOLLOWS: MILK OF MAGNESIA (MOM) 30 MILLILITERS IF NO BOWEL MOVEMENT (BM)IN 2 DAYS. [MEDICATION NAME] 30 MILLILITERS FOR [MEDICAL TREATMENT] GUESTS. [MEDICATION NAME] SUPPOSITORY TO BE ADMINISTERED IF NO BM 24 HOURS AFTER MOM OR [MEDICATION NAME]. FLEETS ENEMA IF NO BM 24 HOURS AFTER SUPPOSITORY. CONTACT PHYSICIAN IF GUEST CONTINUES TO HAVE NO BM AFTER LAST INTERVENTION. FACILITY BOWEL ELIMINATION RECORD FOR RESIDENT #109 FOR THE MONTH OF [DATE] INDICATED THAT RESIDENT #109 DID NOT HAVE A BOWEL MOVEMENT ON [DATE], [DATE], [DATE], OR [DATE]. AND DID NOT HAVE A BOWEL MOVEMENT ON [DATE], [DATE], [DATE] OR [DATE]. REVIEW OF THE MEDICATION ADMINISTRATION RECORDS FOR THE MONTH OF [DATE] FOR RESIDENT #109, REVEALED THAT DURING THE 4 DAYS WITH NO BOWEL MOVEMENT FROM [DATE] THROUGH [DATE], RESIDENT #109 WAS NOT GIVEN ANY TREATMENT FOR CONSTIPATION. DURING THE 4 DAYS WITH NO BOWEL MOVEMENT FROM [DATE] THROUGH [DATE], THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE FACILITY BOWEL ELIMINATION RECORD FOR [DATE] FOR RESIDENT #109 INDICATED RESIDENT #109 DID NOT HAVE A BOWEL MOVEMENT ON [DATE]. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. NO SUPPOSITORY WAS ADMINISTERED TO RESIDENT #109 ON [DATE]. THE BOWEL ELIMINATION RECORD FOR [DATE] SHOWED THAT RESIDENT #109 HAD A BOWEL MOVEMENT ON [DATE]. IN AN INTERVIEW ON [DATE] AT 8:50 AM, THE FACILITY DIRECTOR OF NURSING STATED THAT ALL RESIDENT BOWEL ELIMINATION RECORDS WERE REMOVED FROM THE CERTIFIED NURSE AIDES CHARTING BOOKS AND PLACED IN THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE FACILITY DIRECTOR OF NURSING STATED, "WE HAD TO CHANGE THE PROCESS AGAIN BECAUSE IT STILL WASN'T WORKING". ON [DATE] AT 3:00 PM, THE FACILITY ADMINISTRATOR, THE DIRECTOR OF NURSING, AND THE CORPORATE DIRECTOR OF QUALITY ASSURANCE WERE NOTIFIED OF THE IMMEDIATE JEOPARDY WHICH BEGAN ON [DATE] AND WAS IDENTIFIED ON [DATE], WHEN RESIDENT #103's LACK OF BOWEL MOVEMENTS WENT UNTREATED BY THE FACILITY STAFF FOR SIX DAYS, FROM [DATE] TO [DATE], RESULTING IN A BOWEL OBSTRUCTION REQUIRING hospitalization AND THE SUBSEQUENT DEATH OF RESIDENT #103 AND WHEN RESIDENTS #108's AND #109's LACK OF BOWEL MOVEMENTS WENT UNTREATED FOR 4 DAYS. ON [DATE] AT 3:00 PM, THE SURVEYOR WAS ABLE TO CONFIRM THE FACILITY INITIATED THE FOLLOWING PLAN AND THE IMMEDIATE JEOPARDY WAS REMOVED AS OF [DATE]: 1. RESIDENT #103 WAS discharged TO ACUTE CARE ON [DATE]. 2. ON [DATE], THE BOWEL MOVEMENT (BM) RECORDS OF ALL RESIDENTS IN THE FACILITY WERE REVIEWED TO ASSURE THEY HAD HAD A BOWEL MOVEMENT WITHIN THREE DAYS. NO RESIDENTS WERE IDENTIFIED AS NOT HAVING HAD A BOWEL MOVEMENT WITHIN THREE DAYS. 3. ON [DATE] OR PRIOR TO THE NEXT SHIFT WORKED, ALL LICENSED NURSING STAFF (24 OF 24 NURSES) WERE INSERVICED IN PERSON ON FOLLOWING THE BOWEL PROTOCOL. 4. THE FACILITY BOWEL PROTOCOL WAS PUT IN WRITING ON [DATE] AND IS AS FOLLOWS: MOM (MILK OF MAGNESIA) 30 MILLILITERS (ML), IF NO BM 24 HOURS AFTER MOM OR LACTOLOSE 30 ML FOR [MEDICAL TREATMENT] GUESTS. [MEDICATION NAME] SUPPOSITORY TO ADMINISTERED IF NO BM 24 HOURS AFTER MOM OR LACTOLOSE. FLEETS ENEMA IF NO BM 24 HOURS AFTER SUPPOSITORY. CONTACT PHYSICIAN IF GUEST CONTINUES TO HAVE NO BM AFTER LAST INTERVENTION. 5. PHYSICIAN ORDERS [REDACTED]. 6. UNIT MANAGERS AUDITED BM RECORDS DAILY FOR THREE WEEKS BEGINNING [DATE], THEN WEEKLY, TO ASSURE BOWEL MOVEMENTS ARE DOCUMENTED AND THE BOWEL PROTOCOL IS BEING ADHERED TO BY THE LICENSED NURSING STAFF. IMMEDIATE INTERVENTION IS INITIATED WHERE A NEED IS IDENTIFIED. UNIT MANAGER BM RECORD AUDIT RESULTS ARE REPORTED TO THE DIRECTOR OF NURSING. 7. CHARGE NURSES REVIEW THE BM RECORDS DAILY AND INITIATE THE BOWEL PROTOCOL AS NEEDED BEGINNING [DATE]. 8. THE UNIT MANAGERS REVIEW BM LISTS DAILY IN THE CLINICAL MEETING SINCE [DATE]. 9. BEGINNING ON [DATE], THE BOWEL ELIMINATION RECORDS FOR ALL RESIDENTS WERE MOVED FROM THE CERTIFIED NURSES' AIDE'S CHARTING BOOKS AND PLACED IN THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] THE FACILITY REMAINS OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND A SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" DUE TO THE FACT THAT SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. #