Every finding on record at The Manor of Novi

This citation pertains to intake 3134842Based on interview and record review the facility failed to initiate and complete a thorough investigation of an alleged allegation of physical abuse by staff for one (R700) of three reviewed for abuse. Findings include:The State Agency received a complaint alleging the facility failed to protect the residents' right to be free from physical abuse by staff.Clinical record review revealed R700 was admitted to the facility on [DATE] with a medical history of epilepsy (chronic brain disorder characterized by seizures), diabetes, heart disease, and dementia. R700 could make their basic needs known and had impaired cognitive and thought processes related to dementia and was unable to participate in a Brief Interview of Mental Status.On 8/6/26 at 11:40 AM, an interview was conducted with R700's spouse who said on Saturday 8/1/26 while visiting, R700 reported that the staff were beating them up. Per the spouse, R700's legs had wounds like a knife went down them, their buttocks were black and blue and had a bruise around their left eye. Per the spouse, the facility made them aware of an unwitnessed fall R700 had about a month prior, saying they fell out of bed, but these wounds could not be from that fall. Per the spouse, R700 would tell them they fell, but were being slapped around by the staff and confided, they are beating me. The spouse acknowledged they called the police and referenced a female officer was involved. The spouse confirmed they contacted Social Services (SS) A on 8/4/26 about the abuse allegation, said they had called the police, and on 8/4/26, R700 was brought home.On 8/6/26 at 10:53 AM, an interview with SS A was conducted and said R700 was at the facility for rehabilitation from a history of falls, was alert and orientated at times, could let their needs be known but baseline was primarily confused. Per SS A the original discharge plan was for R700 to go back home with their spouse, and they were engaged in many conversations with the spouse then out of the blue called SS A on 8/4/26 around 1:30 PM and said R700 was going to be picked up and taken home because they believed the bruising and injuries on R700 was from us. SS A then informed Social Services Director (SSD) B and the Nursing Home Administrator (NHA) of the spouse's allegation of abuse.On 8/6/26 at approximately 11:00 AM, SSD B and the NHA attended the interview with SS A and acknowledged they were informed R700 was going to be discharged on 8/4/26 because the spouse thought they were being abused. They further acknowledged the police were at the facility on the evening of 8/3/26 for the allegation of abuse from the spouse. The NHA who also served as the abuse coordinator was questioned if an abuse investigation commenced and they said they had not.On 8/6/26 at 1:47 PM, the NHA was recalled for a second interview and acknowledged they were contacted via text messaging by the DON on the evening of 8/3/26. Per the NHA, they too were informed the police were at the facility. When asked if there was any follow up in contacting the police, the NHA said they didn't request any information and that typically the police would not release the information to them because they were not the one initiating the complaint. When questioned if they knew the police were called to alleging physical abuse, why wasn't an investigation conducted. The NHA said they were informed by the DON that the injuries were from R700's falls specifically the one that occurred on 7/16/26. When asked how this was determined, the NHA said all communication was done via text messaging with the DON. When asked if anyone did a physical assessment on R700, the NHA said they did not. When asked how they validated the injuries were old versus new, the NHA said there was no assessment, it was just assumed as informed by the DON's text messaging. When asked if the allegation of abuse for R700 should have been investigated, the NHA nodded yes and had no further comment.Record review of the facility policy titled Abuse Prohibition Policy dated 9/2022 documented; .Allegations of guest/resident abuse.shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies.Allegations by anyone who becomes aware of verbal, physical.abuse and mistreatment.must immediately report it to his/her Administrator.The Director of Nursing or designee will complete an assessment of .resident(s) and document findings in the medical record.

This citation pertains to intake 3134842Based on interview and record review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act against one resident (R700) of three reviewed for abuse. Findings include:The State Agency received a complaint alleging the facility failed to protect the residents' right to be free from physical abuse by staff.Clinical record review revealed R700 was admitted to the facility on [DATE] with a medical history of epilepsy (chronic brain disorder characterized by seizures), diabetes, heart disease, and dementia. R700 could make their basic needs known and had impaired cognitive and thought processes related to dementia and was unable to participate in a Brief Interview of Mental Status assessment.On 8/6/26 at 11:40 AM, an interview was conducted with R700's spouse who said on Saturday 8/1/26 while visiting, R700 reported that the staff were beating them up. Per the spouse, R700's legs had wounds like a knife went down them, their buttocks were black and blue and had a bruise around their left eye. Per the spouse, the facility made them aware of an unwitnessed fall R700 had about a month prior, saying they fell out of bed, but these wounds could not be from that fall. Per the spouse, R700 would tell them they fell, but were being slapped around by the staff and confided, they are beating me. The spouse acknowledged they called the police and referenced a female officer was involved. The spouse confirmed they contacted Social Services (SS) A on 8/4/26 about the abuse allegation, said they had called the police, and on 8/4/26, R700 was brought home.On 8/6/26 at 12:07 PM, Licensed Practical Nurse (LPN) C was interviewed and acknowledged on 8/3/26 they were the assigned nurse to R700 and had another nurse assigned to them for one-to-one supervision. When asked why they required one-to-one, LPN C said they had a history of trying to elope from the facility. When asked if they were aware of the police being contacted, LPN C said they were present when the police arrived and said they heard the spouse called because they thought we were mistreating R700. LPN C said they were interviewed by the police and were asked general questions about R700's medical history and if they were confused. LPN C, recommended contacting LPN D who was the assigned one-to-one nurse as they might have more specific information about the police involvement. LPN C denied they had obtained a name or contact information from the police who interviewed them and did not contact the Director of Nursing (DON).On 8/6/26 at 12:15 PM, an interview with LPN D, the assigned one to one nurse for R700 acknowledged on 8/3/26 they cared for R700. Per LPN D R700 wanted to call their spouse, both were sitting in a general activity area, and instead of going back to R700's room to call, LPN D said they called R700's spouse from their personal phone on 8/3/26 at 3:37 PM. LPN D overheard over the speaker phone the spouse telling R700 they had called the police, and when they arrived to be sure to tell them everything that had been happening about them being abused, and R700 replied Okay. LPN D said around the time their shift ended around 6:50 PM. The police said they were called because the spouse allegedly reported R700 was being physically abused by the staff. LPN D denied they had obtained a name or contact information from the police officer who interviewed them, and only referenced it was a female officer. LPN D said they had contacted the DON and informed police involvement and abuse allegation.On 8/6/26 at 12:55 PM, a telephone interview was conducted with the DON and confirmed on the evening of 8/3/26 they were contacted by LPN D, who said the police were called by R700's spouse alleging physical abuse. Per the DON, they notified the NHA via text message on 8/3/26 at 7:19 PM.A record review authored by SS A documented on 8/4/26 at 2:06 PM, they received a call from R700's spouse at 1:30 PM and stated they would be picking up R700 at 4:00 PM and taking them home.On 8/6/26 at 10:53 AM, an interview with SS A was conducted and said R700 was at the facility for rehabilitation from a history of falls, was alert and orientated at times, could let their needs be known but baseline was primarily confused. Per SS A the original discharge plan was for R700 to go back home with their spouse, and they were engaged in many conversations with the spouse then out of the blue called SS A on 8/4/26 around 1:30 PM and said R700 was going to be picked up and taken home because they believed the bruising and injuries on R700 was from us. SS A then informed Social Services Director (SSD) B and the Nursing Home Administrator (NHA) of the spouse's allegation of abuse.On 8/6/26 at 1:47 PM, the NHA who also served as the facility abuse coordinator, was interviewed and acknowledged they were contacted via text messaging by the DON on the evening of 8/3/26. Per the NHA, they too were informed the police were at the facility. When asked if there was any follow up in contacting the police, the NHA said they didn't request any information and that typically the police would not release the information to them because they were not the one initiating the complaint. When questioned if they knew the police were called to alleging physical abuse, why wasn't an investigation conducted. The NHA said they were informed by the DON that the injuries were from R700's falls specifically the one that occurred on 7/16/26. When asked how this was determined, the NHA said all communication was done via text messaging with the DON. When asked if anyone did a physical assessment on R700, the NHA said they did not. When asked how they validated the injuries were old versus new, the NHA said there was no assessment, it was just assumed as informed by the DON's text messaging. The NHA was asked when LPN D overheard the spouse telling R700 at 3:37 PM, they had called the police regarding physical abuse, should they had been notified at that time, the NHA said yes. This allegation of alleged physical abuse by staff was not reported to the State Agency.Record review of the facility policy titled Abuse Prohibition Policy dated 9/22 documented; .Allegations of guest/resident abuse.Allegations by anyone who becomes aware of verbal, physical.abuse and mistreatment.must immediately report it to his/her Administrator.The Administrator or designee will notify the guest's/resident's representative. Also, any State of Federal agencies of per state guidelines (2 hours if abuse allegation or serios injury.

Based on observation, interview, and record review, the facility failed to prevent avoidable falls for three residents (R#'s 5, 60, and 50) of five residents reviewed for falls resulting in R5 sustaining a fracture to their left shoulder causing pain and hospital care, and provide supervision for wandering residents for two residents (R#'s 18 and 81) of two residents reviewed for supervision. Findings include: On 4/6/26 at approximately 12:19 PM, R5 was observed lying in bed. Their left arm was in a sling and assist bars were observed on both sides of the bed. R5 was alert and able to answer all questions asked. R5 reported that they were admitted to the facility on [DATE], primarily to receive in-house Dialysis care. They noted that on day two of their stay, they needed to take a bowel movement and needed assistance as they are immobile. At that time, they did not have assist bar(s) in place and further their needed their mattress changed. They noted that the needed mattress was in the room but had not yet been placed on their bed. R5 further explained that in the evening of 3/4/26 the CNA turned them on their side and placed a bedpan on the bed. The CNA left the room and when they were done, they pushed their call light on and continued to remain on their left side. As they were waiting for assistance, R5 started to slip, could not hold on to anything and rolled off the bed and landed on the floor. R5 further stated that as they rolled their call light got tangled underneath them. They noted while lying on the floor they started to yell for help and finally a nurse came to their room. After the fall they had significant pain in their left shoulder and arm. Following the fall R5 noted they were transferred to the hospital and told they had a fractured shoulder. A review of R5's hospital records revealed, in part: .3/4/26.(R5) lives at (facility) brought in to the emergency department via EMS (emergency medical services) with a chief complaint of left arm pain.Patient states that she is bed ridden.earlier today she rolled over to use the commode, however fell.notes she is non-ambulatory.Radiology Impressions: XR (x-ray)Shoulder – comminuted minimally displaced humeral head fracture (top of arm). A review of R5's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: acute kidney failure, morbid obesity, and dependence on dialysis. A review of R5's Minimum Data Set (MDS) noted the resident was cognitively intact. R5's initial comprehensive evaluation (dated 3/3/260 noted the following: .new admission.recent weight: 432.7 lbs.obtained mechanical lift.bowel.continent.Adl (activities of daily living).Transfers: Total assist.Bed Mobility: [NAME] assist.Ambulation: bedrest.non-ambulatory .Functional Ability Deficit Care Plan.Focus: has a functional ability deficit and requires assistance with self-care/mobility.positioning bars: No.History of falls: Yes.Does the resident take medications that may increase falls.Yes.Focus: is at risk for fall related injury. A review of the facility Incident/Accident (IA) Report revealed the following: .Alleged Incident.Date: 3/4/26.Resident (R5).Brief Description: Nurse was alerted to resident's room. (R5) was observed lying on the floor. She complained of left shoulder pain. Was transported to the hospital for evaluation. Upon return facility was notified of a left shoulder fracture.Summary of Resident Interview.Guest (R5).Said that she needed to have a bowel movement. CNA came to the room, rolled her on her side.left out of the room. She felt a lump in the mattress.could not move her leg and she fell out of bed.Staff Member Interview (RN MM).heard yelling. Went to (R5's) room and observed her lying on the floor. Called for assistance and 911.Staff Member Interview (CNA NN).resident's call light was on.resident said she needed to have a bowel movement.the resident asked her to roll her on her side.left out of the room to give privacy.was out of the room for about 15 minutes when heard a page for assistance. On 4/7/26 at approximately 1:13 PM, an attempt to interview CNA NN via phone was made. A voice mail could not be left. The facility was asked to have CNA NN contact the Surveyor. No contact was received by the end of the survey. On 4/8/26 at approximately 8:29 AM, a phone interview was conducted with RN MM. RN MM reported they had been employed by the facility for a little over a year and generally worked the 7 PM to 7 AM shift. RN MM was asked about the incident involving R5 on 3/4/26. RN MM reported that they were working that evening and while in the hall they could hear someone yelling loudly. RN MM noted that it took a bit of time, but they were able to figure out that the screaming was coming from R5's room. They entered the room and could initially hear the resident but could not see them. They were able to locate them on the floor closest to the wall near the window. They immediately assessed the resident, determined that they were in significant pain and called 911 and EMS (Emergency Medical Services) to have the resident transferred to the hospital. RN MM was asked if they were aware of how R5 fell. They reported that CNA NN turned R5 on their side and placed a bedpan/commode on the bed, they then left the room. RN MM noted that CNA NN should never have left the resident alone as they were bedbound, obese and had nothing to hold on to while on their side. RN MM reported that following in the incident they provided 1:1 training with CNA NN. The Administrator was asked to provide CNA NNs personnel file. The file indicated the resident was hired as a CNA on or about 1/20/26. There were no documents in the file that indicated CNA NN had received either initial training upon hire or 1:1 training regarding R5's fall. On 4/8/26 at approximately 11:58 AM, an interview with the DON (Director of Nursing) was conducted. The DON was asked about the education provided to CNA NN. The DON noted that they believed they were educated not to leave the resident alone on their side based on their mobility status. The DON noted that they did not have a copy of the CNA's training. The Administrator was interviewed on 4/8/26 at approximately 4;45 PM and reported that they could not locate any documents related CNA MM education training. The Administrator was also asked about the incident involving R5 and noted that they were aware that CNA NN should not have left R5 on their side. R60 On 4/6/26 at 2:05 PM, a review of a progress note entered into the record on 3/30/26 at 8:06 PM by the DON was reviewed and read, .IDT (interdisciplinary team) met to discuss the fall (on 3/25/26) The resident was in the room for 6minutes [sic] when the nurse walked pass [sic] and saw her sliding from the wheelchair. She didn't make it to the floor on her own, the nurse guided her down to the when [sic] she couldn't get her back up into the wheelchair . It was observed that her seatbelt wasn't fastened. Intervention Education provided to the cna [sic]. On 4/7/26 at 11:57 AM, an interview was conducted with the facility's DON regarding R60's fall. At that time, the DON confirmed R60 was supposed to have their seatbelt buckled and the CNA did not ensure it was secured. R50 On 4/7/26 at 10:58 AM, a review of R50's progress notes was conducted and revealed a note dated 1/13/26 at 10:11 PM entered into the record by the facility's DON that read, IDT (interdisciplinary team) met to discuss the fall. The resident was observed on the floor in her room bedside her bed. It was noted that the HOB (head of bed) was elevated too [sic] r/t (related to) the resident having seizures and a jerking motion that she sometimes does while in bed. The resident did have anewer [sic] cna [sic] that was taking care of her .Intervention CNA educated on ensuring residents bed is in proper position. On 4/7/26 at 11:59 AM, an interview was conducted with the facility's DON regarding R50's fall. They explained the fall occurred at night and while the bed was in the lowest position, the head of the bed should have been flat, not elevated in order for R50 to sleep. They further explained that due to the elevated head of the bed and R50's positioning it caused them to fall out of the bed. R18 and R81 On 4/6/26 at 1:16 PM, R18 was observed in their Merry [NAME] (a specialized framed four-wheeled walking aid designed to surround a user. It acts as a combination walker and seat, featuring a built-in rear seat for resting, a bar across the front, and a safety belt that is fastened in between the legs) on the B-unit. R18 was observed to enter R81's room at the end of the hall. CNA (Certified Nurse Aide) 'F' was overheard to call up the hall to R18 in an attempt to redirect them from entering R81's room, however; R18 proceeded to enter R81's room. CNA 'F' did not proceed to R81's room to re-direct R18, rather they entered another room further down the hall. After R18 entered R81's room, R81 was overheard to call out, Help me, I have an unwanted person in here. Staff did not respond to R81's calls for help and R18 exited R81's room on their own without staff re-direction. On 4/7/26 at 12:02 PM, the Director of Nursing (DON) was made aware of the observation of CNA 'F' not going and re-directing R18 and said they should have went to her and redirected her away from R81's room.

This citation pertains to Intake 2588311.Based on observation, interview and record review, the facility failed to identify upon admission and provide treatment and services for a Stage Three pressure ulcer (having full-thickness skin loss, not involving underlying fibrous tissue) for one resident (R4) of four residents reviewed for pressure wounds resulting in a delay of treatment, pain and worsening of a sacral pressure wound. Findings include: Clinical record review revealed R4 was admitted to the facility on [DATE] for osteomyelitis (infection in the bone) of the left foot requiring amputation of the toes and required administration of intravenous (IV) antibiotics via PICC (Peripheral Inserted Central Catheter) line, had Acute Kidney Injury (AKI) due to kidney failure and required hemodialysis. R4 was alert, orientated, and capable of making their needs known.On 4/6/26 around 10:30 AM, during initial introductions, R4 voiced a concern that their dressing on their bottom was missed being changed over the weekend. R4 said the open wound on their backside was present before they were admitted to the facility and the other hospital they were transferred from were putting ointment on it. When asked if they have pain in the sacral area, R4 replied they can feel pain around the opening of the wound, and it becomes more intense when they are in a sitting position. The dressing helps cushion the area, but they still need to get it healed up.Record Review of facility documentation identified R4 had a Facility Acquired Unstageable Pressure Ulcer.Record review of the hospital discharge paperwork documented on 3/9/26 at 2:53 PM wound/ulcer assessment midline center sacral injury Stage Three Pressure Ulcer, with wound management to include cleanse, apply enzymatic debriding agent, gauze, and a silicone dressing.On 4/7/26 at 10:58 AM, the Director of Nursing (DON) was interviewed and questioned about the Nursing Progress Note they authored on 3/17/26 at 2:09 PM .New skin Issue. Location: Coccyx.New: new wound. Pressure ulcer staging: Unstageable pressure .It is unknown how long the wound has been present .The DON was questioned how this concern came to their attention as documented on 3/17/26, five days after admission, (3/12/26) the DON responded they received a referral from a centralized admission coordinator and communicated the sacral wound was present prior to their admission to the facility.A record review was conducted with the DON (of the hospital discharge paperwork) which documented on 3/9/26 at 2:53 PM wound/ulcer assessment midline center sacral injury Stage Three with wound management dressing changes to be cleansed, apply enzymatic debriding agent, gauze, and silicone dressing.The DON confirmed Nursing responsibilities regarding new resident skin assessments said they must look at every inch of their skin, place a wound consult, and implement a treatment plan until the wound consultation is completed. The DON recognized the admission Licensed Practical Nurse (LPN) X did not do a thorough skin assessment upon admission and missed the sacral wound.Clinical record review of the Nursing Comprehensive Evaluation dated 3/13/26 at 1:10 AM performed by Licensed Practical Nurse (LPN) X documented R4's skin having right toe amputated, left toe amputated, and a chest wall dialysis port.On 4/7/26 at 1:04 PM, a telephone interview was conducted with LPN X and when asked if they recalled performing the skin assessment for R4, they recalled the toes were amputated, had a port for dialysis and a small area on their coccyx. When asked why the coccyx was not documented on the skin assessment, they sounded surprised that it was not documented and then replied that I must have forgot to document it. Further review revealed LPN X placed a wound consult order and responded that all new admits get wound consults, they automatically trigger under the admission nurse, but only residents that have a paper placed in the wound binder are seen. There is no electronic notification to Providers.On 4/7/26 at 1:45 PM, a telephone interview with Wound Care Specialist JJ confirmed they are notified of wound consults when they come on site by LPN M and they inform them who to see. When questioned when they were notified that R4 needed to be seen, Wound Care JJ replied they were not formally consulted. R4 overheard them tending to the roommate and said they had an open wound on their backside and amputated toes. JJ stated. [R4] overheard I was with wound care and asked if I could take a look (at their wounds). It was at that time we observed [R4] had an unstageable pressure ulcer, and I then initiated a treatment plan. If it wasn't for [R4] self-reporting, I would have never assessed them.Treatment Order was initiated on 3/17/26 to cleanse coccyx topically every day shift, pat dry, apply moist Dakins (antiseptic) gauze with Santyl (medication removes dead skin tissue, promotes wound healing) and cover with Allevyn (foam) dressing every day shift and as needed.On 4/8/26 11:30 AM, a pressure ulcer dressing observation with LPN Q was conducted. R4 was observed lying in bed alert and orientated. An incontinent brief was removed, and R4's coccyx area was observed with no dressing exposing an unstageable coccyx pressure ulcer open split horizontal wound with yellow colored slough. When inquired why there was no dressing, R4 stated they had a made a mess around three/four this morning and no one ever put a dressing back on.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service and hydration areas resulting in the potential to spread foodborne illness to all residents. Findings Include:On 04/06/2026 at 8:55 AM during an initial kitchen tour observed in the upright cooler: opened container of hummus with facility marked use by dates of 3/27-4/4 and an opened package of sliced cooked turkey breast with facility marked use dates of 3/31-4/5. Dietary staff member 'LL' discarded upon observation. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A) .On 04/06/2026 at 9:32 AM observed (2) of the nursing hydration carts getting prepared for use on the units. Each cart had an attached mesh bag for storage of the ice scoop. On both carts the storage bags were soiled/discolored on the bottom interior and not removable for routine cleaning. The mesh bags were also observed not covered, with the stored ice scoop exposed to potential contamination when in the unit hallways. One of the storage bags was observed frayed and torn. During this observation, dietary staff member 'LL' confirmed seeing the soiled/discoloration on the storage bags and indicated that dietary staff does clean and sanitize the food contact equipment (coolers and ice scoops), but the hydration cart unit and ice scoop storage would be a nursing staff responsibility. According to the 2022 FDA Food Code section 4-202.16 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination On 04/06/2026 at 9:47 AM in the dining room, observed the ice machine bin drain line soiled with a black substance. At the time of observation, Dietary Manager (DM) 'KK' cleaned the exterior surface, but the interior was unable to be cleaned. DM 'KK' indicated they would follow up with maintenance. According to the 2022 FDA Food Code section 6-501.18 Cleaning of Plumbing Fixtures. PLUMBING FIXTURES such as HANDWASHING SINKS, toilets, and urinals shall be cleaned as often as necessary to keep them clean. On 04/06/2026 at 12:25 PM observed several kitchen ceiling tiles adjacent to the ceiling vent soiled with dust build up. When mentioned following this observation, DM 'KK' indicated they would put in a maintenance request for cleaning of this area. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation, interview and record review the facility failed to ensure sufficient nurse staffing to meet the needs of multiple residents, including, but not limited to (R101, 55, 79, 44, 58, 17) and 11 anonymous residents that participated in the resident council meeting, resulting in the potential for delayed care for activities of daily living, medication administration and treatments to all residents residing in the facility. Findings include: On 4/6/26 at 9:28 AM, R58 was observed lying in bed. R58 was asked about care in the facility. R58 explained frequently it took staff approximately one hour to answer the call light. R58 was asked what time of day was usually the longer wait. R58 explained at night and on the weekends were the longest waiting time. On 4/6/26 at 9:30 AM, R101 was heard crying from the hallway. At that time, R101 was interviewed about the care in the facility. R101 stated, I just want to go home and explained the last time their incontinence brief was changed was around 11:00 PM the previous night (4/5/26). R101 reported when she was sleeping, she did not like to be woken up but typically woke up early enough to be changed at the end of the midnight shift. R101 reported at that time she had not been changed. R101 was tearful during the interview and reported the facility did not have enough staff to care for the residents. R101 reported they were supposed to take her to the toilet to use the bathroom, but at times there were not enough staff to assist, and she had to wet my pants. At that time, R101's roommate nodded her head to indicate nobody had been in to change R101 since the previous night. R101 and the roommate were observed with Styrofoam cups dated 4/5/26 7:00 AM to 7:00 PM. Both residents indicated water was passed on the morning of 4/5/26 and not passed since. On 4/6/26 at approximately 9:41 AM, R55 was observed lying in bed. The resident reported that they are often left wet in bed and on the previous evening (4/5/26) there was only one person working on their hall. On 4/6/26 at 10:04 AM, R79 was observed with a Styrofoam water cup dated 4/5/26 7:00 AM to 7:00 PM. When queried about whether she had fresh water, R79 shook the cup which was empty and said nobody passed fresh water since Sunday morning (4/5/26). On 4/6/26 at 12:01 PM, R17 was observed sitting in a wheelchair in their room. R17 was asked about care at the facility. R17 explained only the CNAs would ever change him or get water, the nurses would not help, they were too busy. R17 was asked about the food at the facility. R17 explained he needed assistance to eat, and by the time someone got around to assist him, the food was cold and he did not want to eat it. On 4/6/26 at 12:20 PM, R101 reported she had not yet been changed and said they would do it when she received a shower after lunch. On 4/7/26 at 10:00 AM, an interview was conducted with 11 residents who wished to remain anonymous. Four of 11 residents reported they felt there was not enough staff to care for the residents. One resident said they changed CNAs to work 12-hour shifts instead of eight hours, but they got burned out and then they quit, which leaves the facility short staffed. The same resident reported on the evening of Easter Sunday that a nurse did not come in, and another nurse had to cover the whole C unit. Another resident said nurses often have to cover multiple units. Three residents reported issues with other residents wandering into their rooms and said there were not enough staff to supervise them. One resident said the wandering resident sometimes take their belongings. When it was short staffed, the residents reported the CNAs would tell them they have to do other things before they can assist them and often times, they do not come back. One resident reported they were not provided incontinence care in a timely manner, most recently on Easter Sunday. They reported their brief was changed at 11:30 PM on 4/5/26, but not again until 4/6/26 at 3:00 PM when they were given a shower. Another resident said the staff do not return after answering the call light. Nine of 11 residents reported they did not receive fresh water every day. One resident said it was a chronic problem. Another resident said they went a whole day without water. Multiple residents said they ask a CNA for water and because they split the room with another CNA (one CNA is assigned to a resident in the room and another CNA is assigned to their roommate), if they asked for water, the roommate's CNA said they were not their CNA and did not get them water. One resident said they are not given fresh water at night and if they ask the CNA, they said they would bring it but never came back. The resident reported that it happens often, but most recently on Easter Sunday (4/5/26). The residents reported they thought this was due to the facility being short staffed. The facility was asked to provide their weekend staffing schedule for 4/5/26. A review of the schedule indicated several WNBI (will not be in) nursing staff. Punch cards were reviewed and it was determined that on the 7 PM to 7 AM shift (4/5/26) there were two CNAs (herein after CNA OO and CNA PP) working the C and D hall and no nurse was assigned to the D hall and further no nurse started working the C hall until approximately 8:15 PM when Nurse MM punched in. On 4/7/26 at 2:01 PM, CNA 'EE' was interviewed by phone and asked about staffing at the facility. CNA 'EE' explained there was usually not enough staff, she would have 16 or 17 residents. there were a lot of residents that required mechanical lifts, or feeding assistance and several that needed to be supervised due to wandering. CNA 'EE' was asked if the nurses would help the CNAs. CNA 'EE' explained some of the nurses would help pass meal trays if they felt like it, but do not do anything else, they would leave the call light on and tell the CNA that the resident wanted water. CNA 'EE' was asked if the dining room was open on weekends. CNA 'EE' explained it was sometimes open and sometimes not due to staffing, either no nurse or not enough kitchen staff. On 4/7/26 at approximately 2:27 PM, a phone interview was conducted with CNA PP. They reported working for the facility for over 35 years and generally works the evening shift. When asked about staffing on 4/5/26 they reported that there were so many call ins that day and they had to work both the C and D halls with CNA OO. They further noted that it was hard to get all their work completed but tried to ensure care the best they could. On 4/7/26 at approximately 2:31 PM, a phone interview was conducted with CNA OO. CNA OO reported they have worked at the facility for approximately 25 years. When asked about staffing, specifically on 4/5/26, they reported that there were several call-ins and they were assigned to care for staff in both the C and D hall with one other CNA. They noted that there was not a specific nurse assigned at the start of the shift. On 4/7/26 at 3:30 PM, an interview was conducted with CNA 'W' via the telephone. CNA 'W' confirmed they worked second shift (7:00 PM to 7:00 AM) on 4/5/26. CNA 'W' reported it was short staffed on the A Hall that night. CNA 'W' reported the staff work together the best they can when it's short, but it was often short. CNA 'W' reported they were assigned to approximately 17 residents. On 4/7/26 at approximately 4:09 PM, a phone interview was conducted with Nurse QQ. Nurse QQ was asked about staffing on 4/5/26. They reported they started working at the facility about 3 weeks ago and noted that on 4/5/26 they worked the 7AM to 7 PM shift on the D hall. They indicated that at the end of the shift, there was not a nurse in the building to replace them. They noted that they contacted the Director of Nursing (DON) who instructed them to sign off with another day nurse (Nurse CC) and leave the keys to the cart in the DON's office. Nurse QQ further reported that staffing has been very low since they started at the facility, and many times have asked them to cover two halls at a time. They noted at times it is hard to cover all the needs of the residents. On 4/8/26 at approximately 8:49 AM, a phone interview was conducted with Nurse MM. Nurse MM reported that they have been employed by the facility for over a year and generally work the 7 PM to 7 AM shift. When asked about scheduling on 4/5/26 Nurse MM reported that they were not scheduled to work on that day and received a call from the DON. The DON asked them to cover the 7PM shift to 7 AM shift and agreed to work that evening however, they told the DON they could not start at 7 PM. The DON noted that the keys to the medication cart on the D hall would be found in their office. Nurse MM reported they started on the floor with the residents at about 9:30 PM. On 4/8/26 at approximately 1:43 PM, the Administrator was interviewed about staffing in general and the schedule for 4/5/26. The Administrator reported that they changed the scheduling for both CNAs and Nurses to 12-hour shifts and have noticed many call-ins. With respect to 4/5/26, the Administrator confirmed that there were several call-ins and no nurse showed up for the evening shift. On 4/8/26 at approximately 2:33 PM, a visitor to the facility (herein after visitor RR) reported that the facility was always short staffed and was told by the DON not to report concerns to the Administrator regarding staffing. Visitor RR further noted that the resident they were visiting did not get up and out of bed until 11:30 AM on 4/5/26 and generally likes to get up at 9 AM. On 4/8/26 at approximately 3:44 PM, an interview was conducted with the DON. The DON was asked about staffing concerns generally and what occurred on 4/5/26. The DON confirmed that there were several call-ins and on the 7 PM to 7 AM shift on 4/5/26 a nurse called in sick and another did not show up. They stated that they did not work that day but contacted Nurse MM who was not scheduled to work but did show up later that evening. The facility policy titled, Nursing Staffing (revised 9/14/23) was reviewed and documented in part: .Policy: The nursing service department provides 24 hours nursing services.The facility ensure sufficient nursing staff with the appropriate competencies and skills set to provide nursing services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident evaluations and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population. On 4/6/26 at 9:28 AM, R58 was observed lying in bed. R58 was asked about care in the facility. R58 explained frequently it took staff approximately one hour to answer the call light. R58 was asked what time of day was usually the longer wait. R58 explained at night and on the weekends were the longest waiting time. On 4/6/26 at 10:03 AM, R44 was observed lying in bed. R44 was asked about call light response times. R44 explained at night and on the weekend the wait was an hour or longer. R44 was asked if he thought the long wait time was due to staffing levels. R44 explained sometimes it was because there was not enough staff and sometimes it was because the staff on midnights were sleeping. On 4/6/26 at 12:01 PM, R17 was observed sitting in a wheelchair in their room. R17 was asked about care at the facility. R17 explained only the CNA's would ever change him or get water, the nurses would not help, they were too busy. R17 was asked about the food at the facility. R17 explained he needed assistance to eat, and by the time someone got around to assist him, the food was cold and he did not want to eat it. On 4/7/26 at 2:01 PM, CNA 'EE' was interviewed by phone and asked about staffing at the facility. CNA 'EE' explained there was usually not enough staff, she would have 16 or 17 residents. there were a lot of residents that required mechanical lifts, or feeding assistance and several that needed to be supervised due to wandering. CNA 'EE' was asked if the nurses would help the CNA's. CNA 'EE' explained some of the nurses would help pass meal trays if they felt like it, but do not do anything else, they would leave the call light on and tell the CNA that the resident wanted water. CNA 'EE' was asked if the dining room was open on weekends. CNA 'EE' explained it was sometimes open and sometimes not due to staffing, either no nurse or not enough kitchen staff. On 4/6/26 at 9:30 AM, R101 was heard crying from the hallway. At that time, R101 was interviewed about the care in the facility. R101 stated, I just want to go home and explained the last time their incontinence brief was changed was around 11:00 PM the previous night (4/5/26). R101 reported when she was sleeping, she did not like to be woken up but typically woke up early enough to be changed at the end of the midnight shift. R101 reported at that time she had not been changed. R101 was tearful during the interview and reported the facility did not have enough staff to care for the residents. R101 reported they were supposed to take her to the toilet to use the bathroom, but at times there was not enough staff to assist, and she had to wet my pants. At that time, R101's roommate, R22 nodded her head to indicate nobody had been in to change R101 since the previous night. R101 and R22 were observed with Styrofoam cups dated 4/5/26 7:00 AM to 7:00 PM. Both residents indicated water was passed on the morning of 4/5/26 and not passed since. On 4/6/26 at 10:04 AM, R79 was observed with a Styrofoam water cup dated 4/5/26 7:00 AM to 7:00 PM. When queried about whether she had fresh water, R79 shook the cup which was empty and said nobody passed fresh water since Sunday morning (4/5/26). On 4/6/26 at 12:20 PM, R101 reported she had not yet been changed and said they would do it when she received a shower after lunch. On 4/7/26 at 10:00 AM, an interview was conducted with 11 residents who wished to remain anonymous. Four of 11 residents reported they felt there was not enough staff to care for the residents. One resident said they changed CNAs to work 12-hour shifts instead of eight hours, but they got burned out and then they quit which leaves the facility short staffed. The same resident reported on the evening of Easter Sunday a nurse did not come in and another nurse had to cover the whole C unit. Another resident said nurses often have to cover multiple units. Three residents reported issues with other residents wandering into their rooms and said there was not enough staff to supervise them. One resident said the wandering resident sometimes take their belongings. When it was short staffed, the residents reported the CNAs will tell them they have to do other things before they can assist them and often times, they do not come back. One resident reported they were not provided incontinence care in a timely manner, most recently on Easter Sunday. They reported their brief was changed at 11:30 PM on 4/5/26, but not again until 4/6/26 at 3:00 PM when they were given a shower. Another resident said the staff do not return after answering the call light. Nine of 11 residents reported they did not receive fresh water every day. One resident said it was a chronic problem. Another resident said they went a whole day without water. Multiple residents said they ask a CNA for water and because they split the room with another CNA (one CNA is assigned to a resident in the room and another CNA is assigned to their roommate), if they asked for water, the roommate's CNA said they were not their CNA and did not get them water. One resident said they are not given fresh water at night and if they ask the CNA, they said they would bring it but never came back. The resident reported that happened often, but most recently on Easter Sunday (4/5/26). The residents reported they thought this was due to the facility being short staffed. On 4/7/26 at 3:30 PM, an interview was conducted with CNA 'W' via the telephone. CNA 'W' confirmed they worked second shift (7:00 PM to 7:00 AM) on 4/5/26. CNA 'W' reported it was short staffed on the A Hall that night. CNA 'W' reported the staff work together the best they can when it's short, but it was often short. CNA 'W' reported they were assigned to approximately 17 residents.

Based on observation, interview, and record review, the facility failed to ensure fresh water was passed and available to residents consistently and upon request for four (R4, R22, R79, R101) of four residents reviewed for hydration. Findings include: On 4/6/26 at 9:30 AM, R101 and R22 (who were roommates) were observed with Styrofoam cups dated 4/5/26 7:00 AM to 7:00 PM. Both residents indicated water was last passed on the morning of 4/5/26 and not passed since then (24 hours later). On 4/6/26 at 10:04 AM, R79 was observed with a Styrofoam water cup dated 4/5/26 7:00 AM to 7:00 PM. When queried about whether she had fresh water, R79 shook the cup which was empty and said nobody passed fresh water since Sunday morning (4/5/26). On 4/7/26 at 10:00 AM, an interview was conducted with 11 residents who wished to remain anonymous. Nine of 11 residents reported they did not receive fresh water every day. One resident said it was a chronic problem. Another resident said they went a whole day without water. Multiple residents said they ask a CNA for water and because they split the room with another CNA (one CNA is assigned to a resident in the room and another CNA is assigned to their roommate), if they asked for water, the roommate's CNA said they were not their CNA and did not get them water. One resident said they are not given fresh water at night and if they ask the CNA, they said they would bring it but never came back. The resident reported that happened often, but most recently on Easter Sunday (4/5/26). A review of Resident Council Meeting Minutes from October 2025 through March 2026 revealed the following: On 3/25/26, 2/27/26, 1/30/26, and 11/20/25, it was documented in the minutes that residents had a concern with not receiving fresh water every day. On 4/7/26 at 12:15 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's protocol to ensure residents were provided with enough fresh water throughout the day and per their request, the DON reported water is passed each 12 hour shift with no specific time during that shift that it was required to be passed by. When queried about whether one water pass a day provided sufficient fluid for residents, the DON reported staff should provide water upon request or if they noticed the cups were empty. The DON was not aware of water not being passed on 4/5/26 after the first shift on the A Hall. A review of R101's clinical record revealed R101 was admitted into the facility on 7/14/23 with diagnoses that included: history of a stroke and diabetes. A review of a MDS assessment dated [DATE] revealed R101 had intact cognition. A review of R79's clinical record revealed R79 was admitted into the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease. A review of a MDS assessment dated [DATE] revealed R79 had moderately impaired cognition. R4 Clinical record review revealed R4 was admitted to facility on 3/12/26 for osteomyelitis (infection in the bone) of the left foot requiring amputation of the toes and required administration of intravenous (IV) antibiotics via PICC (Peripheral Inserted Central Catheter) line, had Acute Kidney Injury (AKI) due to kidney failure and required hemodialysis. R4 was alert, orientated, and capable of making their needs known. Minimum Data Set, dated [DATE] documented .Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Set up or clean-up assistance and no impairment with upper range of motion. On 4/6/26 around 10:30 AM, during initial introductions, R4 voiced concern on Easter Sunday 4/5/26, they had requested a glass of water four to five times and never received anything to drink until today 4/6//26. R4 was concerned because they were having concerns with urinating, knew they had to drink more, and was never provided water.

Based on observation, interview, and record review, the facility failed to identify, assess, implement treatment, and follow physician's orders for treatment and preventative care for one (R32) of two residents reviewed for non-pressure skin conditions, resulting in the development of 10 open areas to the resident's left lower leg and a delay in treatment. Findings include: On 4/6/26 at 10:01 AM, R32 was observed seated in a geriatric positioning recliner (geri-chair). R32 was awake but did not make eye contact or engage in conversation. R32 was observed kicking their left leg straight up into the air and then forcefully back down onto the footrest of the geri-chair repeatedly. Five pink colored open areas were observed on the top of R32's left lower leg with no dressing applied. A review of R32's clinical record revealed an active physician's order to clean left shin with NS (normal saline), pat dry, cover with border gauze and Tubi grip (elastic bandage) to bilateral legs, remove tubi grip and check skin integrity q shift. On 4/6/26 at approximately 2:20 PM, a dressing was observed on R32's left lower leg dated 4/6/26. R32 was observed kicking their left leg up and down. No elastic bandage was observed on R32's legs. A review of R32's progress notes revealed the following: A Skin Check progress note dated 3/28/26 indicated no new skin issues for R32. A Nurses Notes progress note dated 3/30/26 noted, writer observed skin tear on res (resident) left shin .hospice nurse rounded, cleaned, covered, and placed orders for skin tear. DON (Director of Nursing), hospice nurse and responsible party notified. A Nurses Notes progress note dated 4/1/26 noted, IDT (Interdisciplinary Team) met to discuss the skin tear. The resident was observed with a skin tear to her left shin. The resident was sitting in her wheelchair when the area was observed. The area was cleansed and dressed. Intervention apply (elastic bandage) to bilateral legs. On 4/6/26 at 1:00 PM, a further review of R32's progress notes revealed no documented assessment of R32's skin tear to the left lower leg. There was no documentation of any additional open areas to R32's left lower leg. A review of assessments in R32's clinical record revealed no assessment form that documented R32's skin tear or any other open areas. On 4/7/26 at 1:04 PM, the DON was asked to provide a staff member who was able to assess wounds to conduct an observation of R32. An observation of R32's left lower leg was conducted with Unit Manager, Licensed Practical Nurse (LPN) 'N'. R32's left lower leg was observed with a large adhesive dressing dated 4/6/26. LPN 'N' reported she was not wound care certified. LPN 'N' brought wound care supplies into R32's room, including split gauze (typically used for tube feeding sites) and smaller adhesive dressings. LPN 'N' reported she thought the dressing that was applied to R32's left lower leg was too much for a skin tear. No elastic bandages were observed on R32's bilateral legs. LPN 'N' removed the adhesive dressing. Multiple areas of dried brown drainage were observed on the dressing with one area that had medicated gauze dressing stuck to it. LPN 'N' said the dried drained looked like dried blood. After the dressing was removed, multiple open areas were observed on the top and back of R32's left lower leg. When LPN 'N' was asked about the multiple open areas, LPN 'N' stated, I thought there was just a skin tear. At that time, LPN 'N' left the room to obtain a nurse to assess wounds. On 4/7/26, an observation of R32's left lower leg was conducted with Infection Control Preventionist, Registered Nurse (RN) 'R'. RN 'R' was asked to assess (including measurements) all open areas to R32's left lower leg. RN 'R' stated, Wounds are not really my thing and proceeded with the assessment. The following 10 open areas were observed to R32's left lower leg: Top of R32's left lower [NAME] circular open area with a pink center with grey colored macerated rolled edges that measured (according to RN 'R') 1 centimeter (cm) by (x) 1 cmA circular open area with a pink center with grey colored macerated rolled edges that measured 1 cm x 1 cmAn open area pink in color that measured 0.5 cm x 0.5 cmAn open area pink in color that measured 0.5 cm x 0.3 cmA dry closed areaBack of R32's left lower [NAME] open area that RN 'N' described as a dry area that measured 1 cm x 5 cmA dry area open in the center with discolored surrounding skin as described by RN 'N' that measured 1 cm x 1 cmThree additional open areas that were not described or measuredOn 4/7/26 at 2:01 PM, an interview was conducted with the DON. When queried about the facility's protocol when new skin impairments were identified, the DON reported if a resident had a new skin tear, they would open a risk management (incident report), notify all parties, discuss with the IDT, and put a treatment in place. When queried about who was responsible to assess the wound upon identification, the DON reported the treatment nurse was responsible to take a picture of the wound and the outside wound team would assess the wound the next time they were in the building. When queried about the number of open areas observed on R32's left lower leg and the lack of documented assessment of the initial skin tear and any other open areas, the DON reported a wound consult should have been done on 3/31/26 and the treatment nurse (LPN 'M') should have taken a picture. The DON reported the wound providers evaluated all skin impairments including skin tears. Residents who received hospice services were evaluated by the wound provider for new skin impairments and monthly thereafter. The DON reviewed R32's clinical record at that time and confirmed R32's skin tear was not assessed or evaluated by the wound provider and the additional open areas were not identified or assessed. At that time the DON reviewed the hospice documentation for R32 and revealed a document titled Physicians Order dated 4/6/26. The document noted, Pt (patient) has skin tear to L lower leg, but did not include any assessment of the skin tear or any other open areas. A review of a hospice Visit Log entry dated 3/30/26 revealed, .New skin tear to LLE (left lower extremity) anterior (top) wound care orders and care done . There was no documented assessment of the skin tear or any additional open areas. A review of incident report dated 3/30/26 for Skin Tear revealed, .writer observed ski [sic] tears on res L (left) shin area .Hospice nurse cleaned, and covered area. Treatment orders placed. Tubi grip to bilateral legs . The incident report indicated there were more than one area on the left lower leg as indicated by skin tears (plural). Further review of R32's progress notes on 4/8/26 at approximately 8:30 AM revealed a note from RN 'R' that documented, .Multiple wounds noted to left lower leg. Wound measures approximately 1.0 x 1.0 (cm) with granulation present to wound bed. Surrounding skin is CDI (clean dry and intact), and discoloration is present . The progress note did not indicate which wound was assessed per the documentation, did not include the description of the macerated rolled edges observed on two or the wounds on the top of the leg, or assessments of each open area that was present on R32's leg. On 4/8/26 at approximately 1:13 PM, an interview was conducted with the DON. The observation of R32 not having the elastic bandages applied to their bilateral legs on 4/6/26 and 4/7/26 during all observations, the DON reported the physician's orders should have been followed.Further review of R32's clinical record revealed R32 was admitted into the facility on 3/23/20 and readmitted on [DATE] after a hospitalization. R32's diagnoses included: Alzheimer's disease, protein-calorie malnutrition, unspecified convulsions, and anoxic brain damage. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R32 had severely impaired cognition and was dependent on staff for all activities of daily living. A review of R32's care plans on 4/6/26 at approximately 2:00 PM revealed a care plan initiated on 3/23/20 that read, .at risk for skin integrity .R/T (related to) .vigorously kicks left leg at times . Interventions included: Tubi grip to bilateral legs (initiated on 3/31/26).On 4/8/26 at approximately 3:45 PM, an interview was conducted with LPN 'M', the treatment nurse for the facility. LPN 'M' reported she did rounds with the wound provider and took pictures of wounds when she was notified of new skin impairments. When queried about R32's skin tear and other open areas to the left lower leg, LPN 'M' reported she was told by corporate staff not to take pictures of skin tears. LPN 'M' confirmed she did not look at R32's left lower leg. On 4/8/26 at approximately 3:50 PM, an interview with the DON was conducted. The DON reported LPN 'M' was supposed to take pictures of R32's skin tears which contradicted what LPN 'M' reported. A review of a facility policy titled, Skin Management, last revised 1/28/26, revealed, in part, the following, .Upon occurrence, all skin tears will be reported to the licensed nurse .An Incident and 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 .Photos of skin tears are not required .

Based on observation, interview, and record review, the facility failed to provide treatment and services according to professional standards of practice related to administering medications for two (R22 and R101) of two residents observed; failed to ensure diet orders were clarified and accurate for one (R98) of two resident reviewed for tube feeding; and failed to assess skin under an undated dressing for one (R96) of two residents reviewed for non-pressure skin conditions. Findings include:R22 and R101 On 4/6/26 at 9:42 AM, Licensed Practical Nurse (LPN) 'I' entered the room of R22 and R101 with both residents' medications. LPN 'I' first gave R101 her medications and then R22. On 4/6/26 at 2:20 PM, an interview was conducted with LPN 'I'. When queried about protocols for medication administration and whether multiple residents' medications should be prepared at the same time, LPN 'I' reported they were not supposed to be prepared at the same time, but she was just trying to get them done. On 4/7/26 at 12:15 PM, an interview was conducted with the Director of Nursing (DON). The DON reported nurses should not prepare medications for different residents at the same time. A review of R22's clinical record revealed R22 was admitted into the facility on [DATE] with diagnoses that included: hereditary spastic paraplegia and dementia. A review of R22's Minimum Data Set (MDS) assessment dated [DATE] indicated she had moderately impaired cognition. A review of R101's clinical record revealed R101 was admitted into the facility on 7/14/23 with diagnoses that included: history of a stroke and diabetes. A review of a MDS assessment dated [DATE] revealed R101 had intact cognition. R98 On 4/6/26 at 9:58 AM, R98 was observed lying in bed receiving nutrition through a feeding tube. A cup of orange juice was observed on the resident's over-bed table. A review of R98's clinical record revealed the following active physician's orders: Nothing By Mouth (NPO) diet Nothing By Mouth texture, Nothing By Mouth consistency, for Tube Feeding with a start date of 3/9/26. Regular diet Pureed texture, Thin consistency, 1:1 (one to one) assistance at all meals for Pleasure feeding with a start date of 3/11/26. On 4/7/26 at 8:48 AM, Certified Nursing Assistant (CNA) 'V' delivered a breakfast tray to R98 and placed the food in front of the resident and left the room. A cup of orange juice was also observed in front of the resident. At that time, R98's meal ticket was reviewed and it noted, pleasure tray 1:1 feed. A review of a Progress Note written by Nurse Practitioner (NP) 'II' revealed, .She was seen today to follow up on her eating status. Since returning from a recent hospitalization, the patient has been NPO .I was unable to find a note from the speech pathologist (SLP), and they were not present in the facility today to discuss the patient's condition. We will continue the current feeding regimen until the SLP evaluation and further recommendations are made .npo until further recommendation from SLP. (Speech Language Pathologist) . Review of an Interdisciplinary Therapy Screen dated 3/11/26 revealed R98 was screened for modified diets. The following was documented by SLP 'T': .spoke with PA (Physician Assistant), cleared to return to previous diet (pleasure tray, puree solids/thin liquids) 1:1 assist as needed for all meals . On 4/7/26 at 9:07 AM, an interview was conducted with LPN 'N', (Unit Manager) after they exited R98's room and put a straw in R98's cup of orange juice. LPN 'N' was queried about R98's diet and reported she received tube feeding with a pleasure tray. When queried about why there were active orders for NPO and food by mouth, LPN 'N' reported there should not be two orders. LPN 'N' said if there were two conflicting orders, they should have been clarified prior to serving food to R98. On 4/7/26 at 12:15PM, an interview was conducted with the Director of Nursing (DON). The DON reported the nurse should have contacted the dietician for clarification of R98's diet orders prior to serving her food by mouth. A review of R98's clinical record revealed R98 was admitted into the facility on 8/3/23 and readmitted on [DATE] with diagnoses that included: sarcoidosis and dysphagia (difficulty swallowing). A review of a MDS assessment dated [DATE] revealed R98 had moderately impaired cognition. A review of a facility policy titled, Medication Administration, last revised on 10/17/23, revealed, in part, the following, .Follow safe preparation practices . R96 On 4/6/26 at 10:27 AM, R96 was observed sitting in a wheelchair in the activity room, an undated dressing was observed on R96's right forearm. R96 was asked what the dressing was. R96 explained he did not know but he had another one on his left forearm. R96's left forearm was observed to have an undated dressing that had bruising visible underneath the dressing. Review of the clinical record revealed R96 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: peripheral vascular disease, heart disease and dementia. According to the Minimum Data Set [MDS] assessment dated [DATE], R96 had moderately impaired cognition. Review of R96's physician orders revealed no order for any dressings. On 4/7/26 at 9:55 AM, R96 was observed sitting in a wheelchair in the hallway. Both undated dressings on the right and left forearms appeared to be the same dressing. On 4/7/26 at 11:39 AM, observation of R96's dressings was made with the DON. The DON removed both dressings and explained they both appeared to be from a blood draw. On 4/7/26 at 11:44 AM, the DON was asked when was the last time R96 had blood drawn at the facility. The DON explained the last blood draw was on 12/23/25, but R96 had been readmitted from the hospital on 4/2/26 and the dressings most likely had been put on at the hospital. The DON was asked if R96 should still have any dressing he had gotten at the hospital prior to readmission. The DON explained no, her expectation was for the nurse to remove the dressing to see what was under the dressing and assess the skin. Review of a facility policy titled, Standards of Nursing Practice revised 3/12/25 read in part, .The delivery of nursing care in the facility is based on a thorough evaluation of the resident to identify his or her care needs. The nurse collects data regarding the resident's current health status and potential risk areas. Data is obtained through direct resident evaluation and health history, as well as interaction with family members and other health care providers.

This citation pertains to Intake Number: 2563496. Based on observation, interview, and record review, the facility failed to promptly act on grievances expressed by resident council members affecting nine of 11 residents who attended the confidential resident council interview, resulting in ongoing, unresolved concerns. Findings include: A review of Resident Council Meeting Minutes from October 2025 through March 2026 revealed the following: On 3/25/26, 2/27/26, 1/30/26, and 11/20/25, it was documented in the minutes that residents had a concern with not receiving fresh water every day. On 3/25/26, it was documented in the minutes that residents had concerns with Certified Nursing Assistants (CNAs) splitting rooms, using phones during care, and telling residents they would be right back but did not come back.On 4/7/26 at 10:00 AM, an interview was conducted with 11 residents, all who frequently or sometimes attended the resident council meetings in the facility. When queried about how they expressed concerns to the facility in resident council and if the facility took steps to promptly resolve their concerns, nine of 11 residents in attendance indicated they had ongoing concerns that were not resolved. When queried about the unresolved concerns, the following was expressed: Nine of 11 residents reported they did not receive fresh water every day. One resident said it was a chronic problem. Another resident said they went a whole day without water. Another resident said when the nurses passed medications, at times they did not even have water to take their medications with other than the small cup the nurse brought. Multiple residents said they ask a CNA for water and because they split the room with another CNA (one CNA is assigned to a resident in the room and another CNA is assigned to their roommate), if they asked for water, the roommate's CNA said they were not their CNA and did not get them water. One resident said they are not given fresh water at night and if they ask the CNA, they said they would bring it but never came back. The resident reported that happened often, but most recently on Easter Sunday (4/5/26). Four of 11 residents reported they felt there was not enough staff to care for the residents. One resident said they changed CNAs to work 12-hour shifts instead of eight hours, but they got burned out and then they quit which leaves the facility short staffed. The same resident reported on the evening of Easter Sunday a nurse did not come in and another nurse had to cover the whole C unit. Another resident said nurses often have to cover multiple units. Three residents reported issues with other residents wandering into their rooms and said there was not enough staff to supervise them. One resident said the wandering resident sometimes take their belongings. When it was short staffed, the residents reported the CNAs will tell them they have to do other things before they can assist them and often times, they do not come back. One resident reported they were not provided incontinence care in a timely manner, most recently on Easter Sunday. They reported their brief was changed at 11:30 PM on 4/5/26, but not again until 4/6/26 at 3:00 PM when they were given a shower. Another resident said the staff do not return after answering the call light. Four residents reported staff talk on the phone while providing care to the residents. It was reported the staff wear ear buds and have personal phone conversations while providing care. Another resident reported staff have personal conversations loudly in the hallway. Multiple residents reported they had concerns with the cleanliness of their rooms and bathrooms. One resident said some housekeepers are better than others. Another resident said their bathroom was always dirty and they ended up cleaning it on their own. Another resident reported when they brought up housekeeping issues to the department head, they got angry and told them they were wrong. They said they did not bother going to the Administrator because issues were not resolved. On 4/8/26 at 8:53 AM, an interview was conducted with Activities Director (AD) 'S'. When queried about how concerns brought up in resident council were addressed, AD 'S' reported she wrote all concerns down, completed concern forms for each issue, and the concern forms went to the appropriate department head to address. The Administrator maintained a file with the concern forms and follow up. On 4/8/26 at 9:05 AM, an interview was conducted with the Administrator. When queried about how concerns expressed by the resident council members were addressed and resolved, the Administrator reported she attended the resident council meetings. All concerns were documented on a concern form and given to the appropriate department head or manager to follow up. When queried about ongoing complaints such as not receiving fresh water daily, the Administrator reported she had to follow up with the DON. At that time, all concern forms associated with the resident council meeting minutes were requested. A review of Resident, Family, Employee, and Visitor Assistance Forms generated from the resident council concerns from meetings held October 2025 through March 2026 revealed:On 3/25/26, residents had concerns with Nurses - CNAs using phone/earbuds when giving care - all shifts - all units .Staff will answer call light and tell resident they will be right back and never return . It did not document when this occurred, whether it was an ongoing problem .No signature of who completed the form. Facility response was left blank. Action to be taken was left blank. Facility follow-up was left blank.An undated form indicated multiple residents had concerns with .Not giving ice water/continually. Need to ask - Some CNA will reply 'you are not my resident' . Don't understand split rooms/CNAs. It was documented the problems continually occurred and the Administrator, Activities Director, and DON knew about the problems. It was documented they were ongoing problems for months and the DON, Administrator, and Activities Director were contacted in the past. The Facility Response and Action Take was to educate the staff. The follow-up section was left blank. On 11/24/25, resident had the following concern, Residents stated they continue to have to ask for fresh ice water, afternoon midnights are majority of time/shift. It was documented it was a continual problem that was ongoing for couple months, and the DON, Administrator, and Activity Director were contacted in the past. The Facility Response section indicated the residents were asked if they were telling anyone at the time they were not getting water or waiting until the resident council meeting. The Action Taken section indicated staff were sent a message regarding fresh ice water and residents were asked to mention to the nurse if they did not receive water instead of waiting until the resident council meeting. The form was signed off by the Administrator on 12/5/25. A Sign-in sheet dated 10/25 indicated an in-service was provided Re: fresh water .Staff is to provide all residents excluding NPO (nothing by mouth) with fresh ice water daily q (every) shift. A new cup with shift and date must be given daily.No concern forms or documented action taken for concerns expressed during the January and February 2026 resident council meetings were received. During the survey, deficiencies were identified with not providing water daily, not having sufficient nursing staff, and not maintaining a clean environment. On 4/8/26 at 3:49 PM, an interview was conducted with the facility's Administrator regarding their QA (Quality Assurance) program. They were asked if they consistently documented resident and or family complaints and said they tried to handle them right at the time of occurrence but could probably do a better job with documenting the complaint, resolution, and satisfaction with the outcome. A review of a facility policy titled, Resident Council, last revised 12/23/2025, revealed, in part, the following, .The Resident Council grievances and recommendations will be documented on the Resident Assistance Form .The Completed forms are brought to the attention of the Administrator .and kept with the Resident Council minutes .Action taken and/or considerations given to issues will be reported back to the Resident Council at the following meeting and documented within the minutes . Cross-reference: F584, F725, F807

Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for seven residents (R#'s 45, 50, 21, 32, 8, 18, and 60) of seven residents reviewed for dignity, resulting in verbalized complaints from the anonymous group interview and the potential for embarrassment. Findings include: 4/6/26 at 10:19 AM, CNA 'F' was observed transporting R45 to the shower room on the B-Wing via a shower chair. CNA 'F' was observed pulling the chair in a forward motion with R45 facing rearward. On 4/6/26 at 12:06 PM, an observation of the lunch meal in the Meadowbrook dining room was conducted. There were numerous residents seated at tables awaiting their meals to be served. At that time, it was also observed three staff, CNA 'C', CNA 'E', and Nurse 'G' were present in the room. The staff members were talking across the dining room amongst themselves about the resident's physical abilities to feed themselves and were repeatedly overheard to refer to some of the residents as, feeders. On 4/6/26 at 12:39 PM, CNA 'D' was in the dining room assisting with the lunch meal and was overheard to ask if a resident was a feeder. On 4/7/26 at 8:28 AM, an observation of the breakfast meal was conducted in the Meadowbrook dining room. At that time, CNA 'H' was observed providing one-to-one feeding assistance to R50. In between feeding R50 bites of food, CNA 'H' was observed to have a cell phone in their lap and was scrolling through the phone while providing the one-to-one feeding assistance. On 4/7/26 at 8:34 AM, R21 and R32 were observed in the dining room seated at an adjustable table. It was observed the table was in the lowest position with the height only reaching their knees. On 4/7/26 at 8:41 AM, Nurse 'I' was observed standing over R8 assisting them with their breakfast meal by guiding R8's hands from their plate to their mouth with their eating utensils. Nurse 'I' was overheard to say, There are no chairs in here. Nurse 'I' did not leave the room in an attempt to locate a chair, rather they continued to stand over R8 while they guided R8's hands to bring the food to their mouth for the duration of the meal. On 4/8/26 at 12:50 PM, an observation of the lunch meal was conducted. R18 and R60 were observed seated at an adjustable table. The table was at the lowest level and the height reached their knees. R18 was observed to be hunched over as they fed themselves their food from the table at their knee level. On 4/8/26 at 3:50 PM, an interview was conducted with the facility's Administrator regarding concerns with dignity. They indicated it was not appropriate to refer to residents as feeders and acknowledged the dignity concerns. A review of a facility provided policy titled, Resident Dignity & Personal Privacy revised 3/2024 was conducted and read, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy . On 4/7/26 at 1:11 PM, during an observation of the A Hall unit. An unknown staff member was walking up and down the hall talking on their cellular phone having a personal conversation. The person hung up the phone and then began talking about personal business in the hallway while transporting a resident in a wheelchair to CNA 'V'. They were talking about another staff member who quit because she just couldn't take it anymore. Licensed Practical Nurse (LPN) 'N' was asked who the staff member on the phone was and she said she did not know and said maybe she was from hospice.

This citation pertains to Intakes 2563496 and 2748674Based on interview and record review, the facility failed to ensure medications were acquired and administered per physician orders for one [R96] of four residents reviewed for medication administration. Findings include:Review of the clinical record revealed R96 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: peripheral vascular disease, heart disease and dementia. According to the Minimum Data Set [MDS] assessment dated [DATE], R96 had moderately impaired cognition.Review of R96's progress notes revealed multiple Medication Administration Notes dated 4/2/26, 4/3/26, 4/4/26, 4/5/26 that documented Pregabalin [medication used for nerve pain] 100 milligrams [mg] was on order and waiting for the pharmacy to deliver.Review of physician orders for R96 revealed an order dated 4/2/26 for, Pregbalin Oral Capsule 100 MG. Give 1 capsule by mouth at bedtime for Neuropathy. Active. Start Date: 4/2/26.Review of R96's April Medication Administration Record [MAR] revealed R96 did not receive the Pregbalin 100 mg on 4/2/26, 4/3/26, 4/4/26 and 4/5/26.On 4/7/26 at 11:39 AM, the Director of Nursing [DON] was interviewed and asked why R96 had not received their Pregbalin since they had been readmitted . The DON explained she had not known R96 had not received their medication. The DON was asked if she used medication audits to ensure all medication were given. The DON explained she did not run audits; she relied on the Unit Managers to give reports in the Morning Meetings from their review of progress notes. The DON was asked if R96's Pregbalin had been brought up in the Morning Meetings. The DON explained they had not had a Morning Meeting since 4/2/26. The DON was asked what should the nurses have done when the Pregbalin was not available. The DON explained they should have contacted the pharmacy and the physician. The DON was asked if Pregbalin 100 mg was available in the back-up medication supply. The DON explained she was not sure but would find out.Review of a list of medications available in the facility's back-up supply included six capsules of Pregbalin 100 mg.On 4/8/26 at 9:33 AM, the DON was asked if Pregbalin 100 mg was available in the back-up supply, why did R96 not receive their medication. The DON explained the nurses should have pulled the medication from the back-up until the medication came from the pharmacy.Review of a facility policy titled, Medication Administration revised 10/17/23 read in part, .Medications are administered in accordance with written orders of the attending physician. Begin new medications orders timely.

Based on observation, interview and record review the facility failed to ensure a resident received needed pain and antibiotic medication for an infected tooth for one (R8) out of two residents reviewed for dental/pain services resulting in continuous pain for over one month. Findings include:On 4/6/26 at approximately 10:15 AM, R8 was observed sitting in their wheelchair, food covered their shirt. R8 was alert and able to answer most questions asked, however their speech was slurred at times. R8 reported that they were in pain. The resident was asked if they wanted to see a nurse and they noted they did. The resident's call light was out of reach and Nurse CC was told that the resident reported they were in pain. A review of R8's clinical record revealed they initially were admitted to the facility on [DATE] with diagnoses that included: DiGeorge Syndrome (a complex gene disorder), severe depressive disorder, and bacterial infection. A review of R8's most recent Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition). Continued review of R8's clinical record revealed the following:3/3/26: Progress Note: .Patient seen today at the request of social worker for evaluation of tooth pain. The patient reported that the pain in his right bottom tooth started three days ago and has worsened since then.The patient will be scheduled for a follow-up appointment with the dentist and will be started on Augmentin (antibiotic) 875 mg (milligrams) two times daily for a suspected tooth abscess. Continuous monitoring is recommended, and the provider should be notified if the patient's condition worsens.3/3/26: eMAR (electric Medication Administration Note): .Amoxicillin.875 mg.give 1 tablet every 12 hours for Tooth infection for 7 days.3/9/26: eMAR: .patient c/o (complains of) pain.3/19/26: Encounter: .Nursing reports resident refused dinner c/o jaw pain.3/20/26: Dental Group: .Clinical exam completed at bedside.resident has plaque and calculus build up.recommend cleaning every 6 months. Patient cc (chief complaint) dental pain on lower right. States he is 'unable to open all the way'. Exam.decayed.recommend dental extraction and course of abx 500 mg (milligrams) TID (three times per day) for 10 days.Refer to Oral Surgeon.3/21/26: Infection Note: Amoxicillin 500 mg .give 1 tablet by mouth three times a day for dental infection to lower right for 10 days.medication on order.3/22/26: eMar: Med (amoxicillin) not available.on order.3/25/26; Progress Notes: .Resident was complaining of toothache. Will order.Norco (opioid used for pain) 5-325 every 6 hours as needed for 14 days.continue monitoring resident closely.3/25/26: Order: .Hydrocodone-Acetaminophen oral 5-325 MG.Give 1 tablet by mouth every 6 hours as needed for pain for 14 days.3/26/26: Social Service Note: (R8) was seen by.Dental on 3/20/26 with c/o tooth/mouth pain.Called (name redacted) Dental.Dental could not accept (R8) because of transfer status.3/29/26: Hospital Records: .Medical Information: Diagnosis: Dental cavities.Instruction Given: Dental Pain.4/3/26: Progress Note: .was recently hospitalized for a pulmonary embolism.and a odontogenic infection (bacterial infection originated by teeth.4/6/26: eMar: 10/10 tooth pain. Resident request pain medication for relief.4/7/26: eMAR: 10/10 tooth pain.4/7/26: Pain Interview: .Should pain Assessment Interview be Conducted: Yes.Have you had pain or hurting at any time in the last 5 days: Yes.Pain Frequency: Almost always.Please rate your worse pain in the last 5 days .ten as the worst.Enter.response: 10.has mouth/tough pain.A review of R8's Medication Administration Record (MAR) for March 2026 and April 2026 noted the following:The order for 7 days of Amoxicillin 675 MG (give 2 times per day) with a start date of 3/3/26 was not provided on 3/3/26 (9PM) or on 3/10/26 (9M) indicating the resident received only six days of the antibiotic.The order for 10 days of Amoxicillin 500 MG (give 3 times per day) with a start date of 3/20/26 was not administered on 3/20/26 (x2) and 3/21/26 (x3).The MAR for April 2026 noted that on 4/6/26 and 4/7/26, R8 had a pain level of 10/10 and was given ibuprofen. There were no notes indicating the physician was contacted regarding excessive pain.On 4/8/26 at approximately 9:42 AM, an interview was conducted with Social Work Director (SW) B. SW B was asked about ancillary dental services and noted that dental services are generally in the building monthly. SW B was asked about R8's dental pain concerns and when would the resident receive the extraction recommended by dental services on 3/20/26. SW B noted that they were having difficulty scheduling the extraction based on the resident's insurance but indicated that they were scheduled to receive an x-ray on or about 4/9/26, but the extraction would not be completed until after the x-ray was completed.On 4/8/26 at approximately 12:06 PM, R8 was observed sitting in their wheelchair. The resident was asked about their tooth and reported that they were in pain and pointed to their lower left jaw area. R8 was asked if they needed assistance and noted that they did. The resident's call light was on the other side of their bed, and the resident could not push the call light for assistance. R8 noted that they believed staffing purposely does not put their light within reach.On 4/8/26 at approximately 3:54 PM, an interview and record review were conducted with the Director of Nursing (DON). The DON was queried as to R8's tooth pain/infection that started on or about 3/3/26. The DON reported that they were aware of the situation. The DON was asked about the missing doses of the antibiotic ordered for R8's infected tooth. The DON reported that they could not understand why the resident did not receive the antibiotics as the medication should have been in back-up. The DON was asked why the resident's order for Hydrocodone-Acetaminophen oral 5-325 MG was discontinued despite the fact that the resident continued to have pain caused by their tooth infection and reported 10/10 pain on 4/6/26 and 4/7/26. The DON reported that they were not sure, believed it may have been discontinued when the resident returned from the hospital on 4/3/26. However, they could not provide any further information as to why the physician was not contacted regarding the high pain levels.The facility policy titled, Pain Management (3/5/25) was reviewed and documented, the following: .The facility will evaluate and identify residents for pain, determine the type, location and severity.Subacute pain refers to pain that has been present for 1-3 months.residents will be monitored for the presence of pain when there is a change in condition and whenever new pain or an exacerbation of pain is suspected.follow the pain evaluation notify the physician if indicated and implement new orders as received.Nurse will communicate any new onset of resident pain or change in pain to the physician.Prescribing practitioners may find that opioid mediations are the most appropriate treatment for.subacute pain.

Based on observation, interview and record review, the facility failed to adhere to professional standards of practice to assess and monitor the continued need for a PICC (Peripheral Inserted Central Catheter) for antibiotic administration for one (R4) of one reviewed for Intravenous (IV) therapy. Findings include:Clinical record review revealed R4 was admitted to facility on 3/12/26 for osteomyelitis (infection in the bone) of the left foot requiring amputation of the toes and required administration of intravenous (IV) antibiotics via PICC (Peripheral Inserted Central Catheter) line, had Acute Kidney Injury (AKI) due to kidney failure and required hemodialysis. R4 was alert, orientated, and capable of making their needs known.On 4/6/26 around 10:30 AM, during initial introductions, R4 voiced concern of the PICC line observed in their right upper arm. R4 said the PICC was placed for antibiotics, not used in a while. When asked if the line was flushed (to maintain patency), R4 said the last time someone tried, it would not flush. R4 said it is uncomfortable and starting to annoy them. The dressing was observed dated 3/18, the adhesive edging was rolled not entirely adhered to the skin and the transparent window of the dressing was observed with a large amount of dark brown dried blood at the insertion site. The inside lumen of the catheter was observed with dried blood. R4 said there are times the clear part of the dressing would bubble and they would have to press the air out of the dressing.Record review documented on 3/14/26 to flush the PICC with 10 millimeter (ml) normal saline for IV maintenance until 3/23/26. Monitor the site every shift until 3/23/26.Record review documented on 3/16/2026- Change transparent dressing to PICC every day shift every Monday for IV maintenance until 3/23/26.Record Review of the Medication Administration Record (MAR) documented the last date of antibiotic infusion was on 3/17/26.On 4/8/26 at 8:30 AM, the Director of Nursing (DON) and Unit Manager Licensed Practical Nurse (LPN) N was interviewed and questioned if the above orders were dated to monitor until 3/23/26 and the dressing was observed dated 3/18/26, why was the PICC line still in R4's arm, the DON had no comment.Document review revealed on 4/6/26 at 12:00 PM shortly after R4 was interviewed, LPN N had placed an order to discontinue the PICC related to antibiotic completion. When asked what triggered them to obtain this order, LPN N said they noticed R4 had a PICC line and then realized they no longer received antibiotics. When asked if this was their first encounter with R4, LPN N stated no, they are a resident on their hall and they do daily rounds Monday-Friday. When asked why it was not addressed by Nursing until 4/6/26 and maintenance of the PICC was ceased on 3/23/26, LPN N said they never saw the PICC until 4/6/26 and when questioned if Nursing had seen the PICC line why was the need for it not addressed, both the DON and LPN N had no response, and acknowledged the PICC should have been assessed to be discontinued sooner than 4/6/26.

Based on observation, interview, and record review, the facility failed to assist one (R98) of three residents reviewed for activities of daily with oral hygiene and feeding assistance. Findings include:On 4/6/26 at 9:58 AM, R98 was observed lying in bed receiving nutrition through a feeding tube. A cup of orange juice was observed on the resident's over-bed table with a straw. When R98 opened their mouth, a copious amount of thick, stringy, white substance was observed extending from the top of R98's mouth to the bottom. When queried, R98 reported staff did not often assist with brushing their teeth. When queried about their preference, R98 reported they would like their mouth cleaned and teeth brushed. A review of R98's clinical record revealed the following active physician's orders: Regular diet Pureed texture, Thin consistency, 1:1 (one to one) assistance at all meals for Pleasure feeding with a start date of 3/11/26. On 4/7/26 at 8:48 AM, Certified Nursing Assistant (CNA) 'V' delivered a breakfast tray to R98 and placed the food in front of the resident and left the room. A cup of orange juice was also observed in front of the resident. At that time, R98's meal ticket was reviewed and it noted, pleasure tray 1:1 feed. A review of an Interdisciplinary Therapy Screen dated 3/11/26 revealed R98 was screened for modified diets. The following was documented by Speech/Language Pathologist (SLP) 'T': .spoke with PA (Physician Assistant), cleared to return to previous diet (pleasure tray, puree solids/thin liquids) 1:1 assist as needed for all meals . Further review of R98's clinical record revealed the resident's care plan was not updated to include the new intervention for 1:1 assist at meals. An intervention initiated on 2/13/26 indicated R98 required supervision/touching assist with one helper. However, that was prior to the SLP screen conducted on 3/11/26. A review of the Kardex (CNA care guide) did not include instructions to provide 1:1 feeding assistance to R98. A review of a care plan initiated on 5/15/25 revealed, (R98) is at risk for infection, pain or bleeding in the oral cavity: has oral/dental health problems . Documented interventions included, Provide/assist/encourage oral hygiene, set up and assist with brushing. On 4/7/26 at 12:15PM, an interview was conducted with the Director of Nursing (DON). The DON reported the CNA should have stayed with the resident to provide feeding assistance. When queried about when staff were to assist residents with oral hygiene, the DON reported oral care was performed when getting the residents up in the morning and when lying them down at night. The DON reported oral hygiene was also performed when visibly needed. A review of R98's clinical record revealed R98 was admitted into the facility on 8/3/23 and readmitted on [DATE] with diagnoses that included: sarcoidosis and dysphagia (difficulty swallowing). A review of a MDS assessment dated [DATE] revealed R98 had moderately impaired cognition and was dependent on staff to perform oral hygiene. At the time of the MDS assessment, R98 required supervision or touching assistance for eating. However, R98 was reevaluated by SLP upon return from the hospital on 3/10/26 which indicated they now required 1:1 feeding assistance.

This citation pertains to Intake 2789175.Based on record review and interview, the facility failed to complete a thorough investigation of alleged mistreatment for one of one resident (R106) reviewed for injury of unknown origin. Findings include:Findings include:Clinical record review revealed R106 was originally admitted to the facility on [DATE] with most recent re-admission on [DATE] and had medical history of diabetes managed with insulin, End Stage Renal Disease (ESRD) and required hemodialysis. R106 was physically compromised and required a Hoyer Lift (mechanical device to transfer an induvial with limited mobility). R106 Minimum Data Set (MDS) assessed on 1/15/2026 documented a Brief Interview Mental Status (BIMS) 13/15 indicating no cognitive impairment.On 4/6/26 at 1:25 PM, a telephone interview with the spouse (complainant) alleged on Super Bowl Sunday 2/8/26, The spouse said a nurse over the weekend called them reporting the injury and that I&A (Investigation and Accident) form had to be completed. Per the spouse R106 was verbally challenged by a Certified Nurse Assistant (CNA) early in the morning they needed to get up and dressed. It was alleged the CNA had transferred R106 via a Hoyer Lift and the improper transfer resulted in R106 sustaining skin tears to their neck and head.On 4/8/26 an Interview with Wound Care Nurse LPN M recalled on Monday 2/9/26, R106's spouse came to them around 6:00 PM asking if they knew about the new skin tears that occurred over the weekend from improper transfer with a Hoyer. Per LPN M they do not follow skin tears as part of their wound rounding but was familiar with R106 and kindly went down to observe the injuries. LPN M recalled a bandage covered the left side of R106's neck and thought there was maybe another tear on their left side of their forehead. LPN M stated she observed a moderate sized skin tear on left side of neck and another smaller skin tear on left side of forehead. Per LPN M the observations were not documented because they were instructed by Corporate not to follow skin tears. When asked if R106 was a good historian, they replied Oh yes.A Record review of the Nurses Notes dated 2/8/26 8:24 AM by LPN L documented .Nurse over heard <sic> resident yelling in room.Nurse went into the room to ensure everything was okay in which the aide explained that she explained to the resident that he was on the get up list but did not want to get out of bed. Aide stated that she informed him that was fine but she would help him put his clothes on and put Hoyer pad underneath him so when he was ready he'd be ready. Resident stated that he told aide no to getting up and getting dressed stated that he didn't want to get out of bed until 0930, also that they aide did not listen to him when he stated these thing and still got him dressed. Open areas found on left side of body, when res was informed of said open areas he requested for her to be removed from his care in the future, DON <sic> notified.On 4/8/26 at 3:05 PM a telephone interview with LPN L recalled the event with R106 and said there was arguing back and forth between CNA O and R106 and R106 said the O was not listening to them and did not want to get up. CNA O said they were on the get up list and they were just doing their job. LPN L told CNA O to just leave him alone. LPN L recalled they observed a skin tear on R106's neck, arm, and a third area but could not recall where. LPN L asked R106 what happened and said it must have been from the Hoyer sling being pulled up from under them. When LPN L asked what they believed caused the skin tears, LPN L replied it looked like it could have been from the Hoyer sling but could not confirm because they were not witness to the injuries. LPN L said they cleaned up the areas and then applied a triple antibiotic ointment and called the Director of Nursing (DON) and called R106's spouse as a courtesy even though R106 was their own person.On 4/8/26 at 3:55 PM, CNA O was telephoned for an interview, with no response by the end of this investigation.On 4/8/26 at 3:40 PM, An interview with the Nursing Home Administrator (NHA) and DON was conducted to review a Progress Note from 2/9/26 at 21:50 Documented as a Late Entry by the DON.The DON documented the IDT (Interdisciplinary Team) to discuss skin tears. The DON was asked what was discussed, and with whom? Did they speak to LPN L and CNA O and R106 as part of a debrief to get the entire story, and the DON denied having a formal discussion. When asked if the CNA had any education on the incident, the DON acknowledged the nurses who report on the I&A are to provide the education.The DON documented the resident was observed with a skin tear to their neck. When asked why the neck was only identified as the injury even though the I&A completed by LPN L documented Injuries post incident: Left elbow, Left hand (back), back of head, all injury types .Unable to determine. The DON had no comment.When asked how the skin tears developed, The DON said from the Hoyer. When asked how they came to this conclusion they replied it was just assumed because the resident has fragile skin and it must have happened in the process.The DON documented .Areas were cleansed and dressed. when questioned what the cleaning and dressing treatment was, the DON had no response.The DON documented .Intervention two staff present during care. when asked what this meant, the DON said this was the intervention, so staff have witnesses when residents refuse care.Record Review of the I&A dated 2/8/26 did not address predisposing environmental factors, physiological factors, and situation factors.The NHA and DON were provided with an opportunity to forward any further documentation on R106's incident from 2/8/26 and no further records were offered. The NHA and DON acknowledged the concern the incident of the injuries was not thoroughly investigated. On 4/8/26 at Record Review of a Late Entry Progress Note from 2/9/26 at 21:50 authored by the DON documented that the Interdictipliary Team (IDT) met to discuss skin tears on a skin tear to the neck.IDT met to discuss skin tears. The resident was observed with a skin tear to his neck. The resident was on the assignment sheet as a midnight get and the cna approached to get the resident dressed and up. Per the cna the resident stated he didn't want to get up but he would get dressed. Resident then changed his mind regarding getting dressed. Resident transfers via hoyer lift and sling was put underneath the resident; the sling was removed. The resident has fragile skin and a skin tear happened in the process. Areas were cleansed and dressed. Intervention two staff present during care. Working the night shift was arguing back and forth she wasn't listening he get up list was she left out the room-[NAME] did not want to get up-I asked CNA [NAME] told her to let him be leave him alone-Acording to the DON this was the CAN's education-Nurses involved are OK to educate the CNAPer LPN-Skin tear on his neck, arm and third area, cannot remember-said the CNA pulled the hoyer under him LPN [NAME] saw it and [NAME] he got it from pulling it up-I then provided treatment at the time I cleaned it up with triple abx-multiple skin tears from fragile-based on the how the wounds look, it appeared to be from the or looked like could have been from the hoyer-reposiioned from underneath maybe when they were resoitoned.[NAME] was yelling unable to recall along the lines not wanting to get up-after she left hey I don't want to get she is not listeningI am just doing my job per the CNAHe is own person-I made a note of it Called [NAME] (DON) at Home.

Based on observation, interview, and record review, the facility failed to release a seatbelt restraint during supervised activities and supervised dining and document the removal of the restraint every two hours per the physician's order for one resident, (R60) of two residents reviewed for restraints. Findings include: On 4/6/26 at 10:25 AM, R60 was observed in their room in their wheelchair with a seatbelt across their waist. At that time, R60 was asked if they could unbuckle the belt and they did not answer the question or attempt to release the belt, rather they pleasantly chatted about an unrelated topic. On 4/7/26 at 2:58 PM, R60 was observed in the activity room seated in their wheelchair with their seatbelt fastened across their waist. Staff were observed to be present in the room during the scheduled music activity. On 4/8/26 at 12:50 PM, R60 was observed in the dining room in their wheelchair eating their lunch meal. It was noted their seatbelt was fastened across their waist. Several staff were present in the dining room providing assistance to other residents. A review of R60's clinical record revealed they most recently admitted to the facility on [DATE] with diagnoses that included: diabetes, chronic kidney disease, dementia, depression, and anxiety disorder. A review of R60's physician's orders was conducted and revealed an order dated 8/24/24 that read, SEATBELT RESTRAINT DX (Diagnosis): Repeated falls and muscle weakness release seatbelt q (every) 2 hours and with supervised activities . R60's care plan for the use of the seatbelt restraint was reviewed and read, .Interventions .Document device use and release per facility protocol .Release and reposition q2 hours, with supervised meals, supervised activities and with toileting . On 4/7/26 at approximately 1:30 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding staff documentation for the release of R60's seatbelt every two hours, and with supervised meals and activities. The DON reported the facility did not have a place to document the release of restraints. A review of a facility provided policy titled, Restraint Management, revised 5/2025 was conducted and read, .7. During the time a restraint is in place, the restraint is periodically removed that the guest/resident assisted with change of position, range of motion, and/or stretching. Restraints should always be removed during supervised mealtimes and activities unless clinical contraindications are documented .

Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment for two (R79 and R98) of four residents reviewed for the environment, resulting in R79 having to clean their own bathroom at times and R98 expressing frustration with a non-working clock. Findings include: On 4/6/26 at 9:58 AM, R98 was observed lying in bed. At that time, an interview was conducted with the resident. R98 answered mostly with yes and no answers but appeared to understand the questions asked. The clock on the wall at the foot of R98s bed read 8:50 with the second hand staying in the same position. A second observation was made at 2:20 PM and the clock read the same time, 8:50. On 4/7/26 at 1:06 PM, an observation of R98's clock was made and it remained at 8:50. An interview was conducted with R98. When queried about whether she was able to read the clock, R98 nodded her head and said Yes. When queried about whether it was important for her to know the actual time, R98 nodded her head and stated, Yes. On 4/6/26 at 10:04 AM, R79 was observed seated in a wheelchair in her room. At that time R79 was interviewed about any concerns she had. R79 reported it took a long time for her room and bathroom to be cleaned. R79 reported when it was addressed with the staff, they had attitudes, but it's their job. R79 reported she often had to make her own bed and clean the bathroom. R79 reported the resident in the adjoining room sometimes left soiled briefs with feces, urine, and menstrual blood on the floor, the toilet was often dirty, and the trash was not emptied regularly. R79 said she had her own cleaning supplies and sometimes put gloves on and picked up the dirty briefs and wiped down the bathroom. At that time, an observation of R79's bathroom was conducted. A urinal was observed hung behind the toilet with dried brown substance caked on the bottom. R79 said the urinal was in the bathroom for a long time and did not understand why they left it in there. The trash can was observed full to the top with soiled briefs with visible fecal matter. The toilet was observed with a dried brown substance on the outside, front part of the toilet. R79 reported they typically emptied the trash cans daily, but it took a while and stated, Some people clean better than others. On 4/6/26 at 2:20 PM, R79's bathroom remained in the same condition as mentioned above. On 4/8/26 at 4:09 PM, an interview was conducted with Housekeeping Supervisor (HS) 'P'. HS 'P' reported housekeeping services are provided by housekeeping staff daily from 7:00 AM until 3:00 PM. From 3:00 PM until 7:00 AM, there was no housekeeping staff onsite, but they left supplies in each soiled utility closet for nursing staff to utilize, if needed. HS 'P' stated, Everyone is responsible to ensure a clean environment. When queried about the observation of R79's bathroom on 4/6/26 remaining unclean between 10:04 AM and 2:20 PM, HS 'P' reported the housekeepers had until 3:00 PM to get their cleaning done. When queried about whether a resident's bathroom remaining in an unclean condition for almost 24 hours was acceptable, HS 'P' stated, I don't understand what you are getting at. HS 'P' reported nursing staff were responsible to clean and/or remove urinals from resident rooms. On 4/8/26 at 4:14 PM, an interview was conducted with the Administrator. The Administrator reported all staff were responsible to ensure a clean environment. When queried about R98's clock, the Administrator reported clocks should be in working order. A review of R98's clinical record revealed R98 was admitted into the facility on 8/3/23 and readmitted on [DATE] with a diagnosis of sarcoidosis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R98 had clear speech, made herself understood, had clear comprehension of others, and had moderately impaired decision-making ability. A review of R79's clinical record revealed R79 was admitted into the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease. A review of a MDS assessment dated [DATE] revealed R79 had moderately impaired cognition. A review of a facility policy titled, Federal & State - Resident Rights & Facility Responsibilities, last revised 5/14/2024, revealed, in part, the following, .The resident has a right to a safe, clean, comfortable and homelike environment .Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .

Based on observation, interview and record review, the facility failed to ensure that two Certified Nursing Assistants (CNA NN and SS) out of five CNAs reviewed for competency evaluations received new hire evaluations, continuous yearly evaluations and 1:1 training regarding falls and transfers. This deficient practice had the potential to affect all residents at the facility, including R5. Findings include: CNA NN On 4/6/26 at approximately 12:19 PM, R5 was observed lying in bed. Their left arm was in a sling. R5 reported that on 3/4/26, a CNA (herein after CNA NN) turned them on their side and placed a bedpan on the bed. CNA NN then left the room leaving them on their side, and they rolled off the bed. They were sent to the Hospital and diagnosed with a fracture to their left shoulder. A review of the facility Incident/Accident (IA) Report involving R5 revealed the following: .Alleged Incident.Date: 3/4/26.Resident (R5).Brief Description: Nurse was alerted to resident's room. (R5) was observed lying on the floor. She complained of left shoulder pain. Was transported to the hospital for evaluation. Upon return facility was notified of a left shoulder fracture.Summary of Resident Interview.Guest (R5).Said that she needed to have a bowel movement. CNA came to the room, rolled her on her side.left out of the room. She felt a lump in the mattress.could not move her leg and she fell out of bed.Staff Member Interview (RN MM).heard yelling. Went to (R5's) room and observed her lying on the floor. Called for assistance and 911.Staff Member Interview (CNA NN).resident's call light was on.resident said she needed to have a bowel movement.the resident asked her to roll her on her side.left out of the room to give privacy.was out of the room for about 15 minutes when heard a page for assistance. On 4/7/26 at approximately 1:13 PM, an attempt to interview CNA NN via phone was made. A voice mail could not be left. The facility was asked to have CNA NN contact the Surveyor. No contact was received by the end of the survey. On 4/8/26 at approximately 8:29 AM, a phone interview was conducted with RN MM. RN MM was asked about the incident involving R5 on 3/4/26. RN MM reported that they were working that evening and while in the hall they could hear someone yelling loudly. They were able to locate them on the floor closest to the wall near the window. They immediately assessed the resident, determined that they were in significant pain and called 911 and EMS (emergency medical services) to have the resident transferred to the hospital. RN MM was asked if they were aware of how R5 fell. They reported that CNA NN turned R5 on their side and placed a bedpan/commode on the bed, they then left the room. RN MM noted that CNA NN should never have left the resident alone as they were bedbound, obese and had nothing to hold on to while on their side. RN MM reported that following in the incident they provided 1:1 training with CNA NN. The Administrator was asked to provide CNA NNs personnel file. The file indicated the resident was hired as a CNA on or about 1/20/26. There were no documents in the file that indicated CNA NN had received either initial training upon hire or 1:1 training regarding R5's fall. CNA SSOn 4/8/26 at approximately 4:00 PM, the Administrator was asked to provide documentation regarding yearly competency reviews for CNA SS. CNA SS had been hired as a CNA on 1/7/2025. The last competency evaluation was done upon hire. No yearly training or evaluation was provided.

Based on observation, interview and record review the facility failed to ensure the residents call light was within reach for one (R8) out of one resident reviewed for call light status. Findings includeOn 4/6/26 at approximately 10:15 AM, R8 was observed sitting in their wheelchair, food covered their shirt. R5 was alert and able to answer most questions asked. R8 reported that they were in pain. The resident was asked if they wanted to see a nurse and they noted they did. The resident's call light was out of reach and Nurse CC was told that the resident reported they were in pain. On 4/8/26 at approximately 12:06 PM, R8 was observed sitting in their wheelchair. The resident was asked how they were feeling and reported that they were in pain and pointed to their lower left jaw area. R8 was asked if they needed assistance and noted that they did. The resident's call light was on the other side of their bed, and the resident could not push the call light for assistance. R8 noted that they believed staffing purposely does not put their light within reach. A Certified Nursing Assistant (CNA) was told the resident's call light was out of reach and they noted they had to complete something but would put it back after they completed care.A review of R8's clinical record revealed they initially were admitted to the facility on [DATE] with diagnoses that included: DiGeorge Syndrome (a complex gene disorder), severe depressive disorder, and bacterial infection. A review of R8's most recent Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition). On 4/8/26 at approximately 4:00 PM, the Director of Nursing (DON) was interviewed about R8's dental concerns. During the interview the DON was informed as to R8's call light being out of reach and noted that staff should ensure call lights are in reach.

This citation has two deficient practices. DPS #1 This citation pertains to Intake #MI00140460. Based on observation, interview and record review the facility failed to ensure a resident with Type 1 diabetes was timely assessed for low blood sugar for one (R84) of three residents reviewed for change in condition/hospitalization resulting in R84's being found unconscious and hyperventilating with a blood sugar level of 34 causing a transfer to the emergency room and a six day stay at the hospital. Findings include: A Complaint was filed with the State Agency (SA) that alleged the facility failed to ensure R84's low blood sugar was timely addressed causing the resident to become unconscious and in need of hospitalization . On 12/19/23 at approximately 4:00 PM, R84 was observed lying in bed. The resident was alert and able to answer some questions. R84 was asked questions about the facility nursing staff's ability to monitor their blood sugar levels. During the interview R84's roommate chimed in and reported an incident that occurred in October 2023. The roommate reported that R84 returned from Dialysis and reported to a Certified Nursing Assistant (CNA) that their blood sugar was low, and they needed to see a nurse. At that time the CNA (identified a CNA J) told R84 that the Nurse was on break, and they would have to wait until the Nurse returned. The roommate noted that R84 was found unconscious and was transferred to the Hospital and that CNA was terminated and no longer works at the facility. A review of R84's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included, in part: Type 1 Diabetes, heart failure and bipolar disorder. A review of the resident Minimum Data Set (MDS) indicated R84 had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderately cognitively impaired) and had been deemed incompetent and had a court appointed legal guardian. Continued review of R84's clinical record noted, in part, the following: 10/19/23 SBAR (5:52 PM) Situation: The Change in Conditions/reported on this .Evaluation .Unresponsive .vital signs blood pressure 187/23 .Pulse Oximetry 91% .BS (blood sugar) .34 .Neurological Status Evaluation: Altered level of consciousness .Observed resident unresponsive while hyperventilating. Took vitals and they were not within normal limits, BS was 34 . 10/25/23 Nursing Summary (4:28 PM): .readmit from hospital with diagnosis of hypoglycemia . *It should be noted that there were no hospital records pertaining to the incident noted 10/19/23 in the resident's clinical record. The last BS noted in R84's clinical record prior to 5:52 PM was from a Dialysis sheet that indicated at 10:26 AM, R84's BS was 322. On 12/20/23 at approximately 10:00 AM, a request was made for any Incident/Accident (I/A) reports and/or grievances for R84. The facility did not provide any IA's/Grievances that pertained to the alleged incident/change in condition on 10/19/23. A review of CNA's personnel record revealed a form titled Separation of Employment that noted CNA J's last day worked was 10/20/23 and the effective date of separation was dated 11/3/23. The form had a handwritten note that read Too many resident complaints regarding care. On 12/21/23 at approximately 8:26 AM, the Director of Nursing (DON) was asked if they were able to locate to provide R84's Hospital records from 10/19/23 through 10/25/23 in the resident's electronic record. The DON was not able to locate the documents in the electronic record and but did provide a paper document titled Patient Discharge Summary. The document contained limited information and no physician notes. However, there was a document indicating information as to hypoglycemia (low blood sugar). On 12/21/23 at approximately 9:20 AM, a phone interview was conducted with Nurse K. Nurse K was asked as to the change in condition that occurred on 10/19/23. They reported that they were familiar with R84 and recalled that in the afternoon on 10/19/23 the resident returned from Dialysis, and they took their blood sugar, and it was 109 and then went on break. (*It should be noted that the there was no documentation that indicated R84 had a blood sugar of 109 following their return from Dialysis). Nurse K then reported that while they were on break, R84 told CNA J that they were not feeling well, and they needed to see a nurse. Nurse K noted that CNA J did not attempt to find them, nor did they attempt to get another nurse to assist. Nurse K reported that they were on break for 30 minutes and had no idea as to what time R84 told CNA J they needed assistance. Nurse K then went to see R84 and they were unresponsive with a BS level of 34 and the resident was sent via 911 to the Hospital. Nurse K reported that CNA J was terminated following the incident. On 12/21/23 at approximately 9:53 AM, an interview and record review were conducted with the Administrator. Another request was made for any IAs regarding the incident that occurred on 10/19/23 leading to the hospitalization of R84. The Administrator reported that an IA was not completed. When asked why CNA J was terminated, the Administrator reported that following an interview with R84's Roommate and other residents they determined CNA J was not providing residents with the care they needed, including R84. A handwritten, unsigned document written by the Administrator was provided. The Note documented, in part: (Roommate) Yesterday: Nurse on break, back from Dialysis asked for sandwich gave to her within 20 minutes. My sugar is low. Your nurse is on break in a rude tone. Didn't do anything to bring it up. The Administrator reported that based on the Roommate's statement they determined that CNA J should have attempted to locate another nurse to assist R84. On 12/21/23 at approximately 10:30 AM, an interview was conducted with the DON regarding the change in condition for R84. The DON was asked if CNA J should have found either Nurse J or another nurse after the resident reported their sugar was low. The DON noted that they should have. On 12/21/23 at approximately 12:14 PM a phone interview was conducted with CNA J. CNA J reported that they were no longer employed by the facility and had not worked since October 19, 2023. When asked what occurred on 10/19/23, CNA J stated that the resident returned from Dialysis in the afternoon and told them that they were not feeling well, and they wanted to see a nurse. CNA J stated that Nurse K was on break, and they tried to find them and another nurse, but they could not find anyone. CNA J stated that they recalled Nurse K was gone for at least one hour. The facility policy titled, Diabetic Management (9/23/23) was reviewed and documented, in part, Diabetic Management involves both preventative measures and treatment of complications .Blood glucose measurements are taken per physician order .Sings of Hyporglycemia-High Blood Sugar Levels .Weakness, dizziness or faintness .change in consciousness .If a resident is observed with, or complains of any symptoms of hyperglycemia, report to the nurse immediately .If the resident becomes unconscious and BS level is below 70 mg .call 911 . 38271 Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure Nurse Practitioner orders for wound care were transcribed appropriately and completed for one resident (R91) of one residents reviewed for non-pressure wound care. Findings include: On 12/19/23 at approximately 9:50 a.m., R91 was observed in their room, laying in their bed. R91 was observed to have pressure relieving booties on the ground next to them and the resident was laying in the supine position on their bed. On 12/20/23 the medical record for R91 was reviewed and revealed the following: R91 was initially admitted to the facility on [DATE] and had diagnoses including open wound of right breast, muscle weakness, and depression. A Nursing progress note dated 10/16/2023 at (21:33) revealed the following: Observed small skin tear on right breast in addition to inflamed stretch marks across the chest. Applied TAO (Triple Antibiotic Ointment) to skin tear and covered. Notified on call NP (Nurse Practitioner). A Skin/Wound progress note dated 10/17/23 revealed the following: Upon wound/skin assessment writer observed resident right breast top area with dime size abrasion, no drainage or foul smell noted at this time, tx (treatment) in progress per facility protocol . A review of R91's comprehensive plan of care revealed the following: Focus-[R91] has Actual impairment to skin integrity r/t (related to) pressure injury to the right ankle, PEG, incontinence .10-17-23 Top of right breast noted with dime size abrasion .Interventions-Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to physician. Date Initiated: 08/22/2023 .Treatment to skin impairment per order. Date Initiated: 08/22/2023 . A treatment order for R91's right breast revealed the following: Start date-11/21/23-Cleanse Right Anterior Breast abrasion with n/s (normal saline), pat dry, apply Eucerin cream 50g (grams) + Betamethasone Valerate 45g + Gentamicin ointment 45g to wound bed and cover with Border Gauze QD (every day) and Prn (as needed) every day shift for 7 Days AND as needed for Abrasion for 7 Days A review of R91's Wound Care Nurse Practitioner (NP) Evaluations revealed the following: 11/24/23-Wound Assessment(s) Wound #1 Right, Anterior Breast is a chronic Partial Thickness Nonspecific Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 1cm (centimeter) length x 1.5cm width x 0.01 cm depth, with an area of 1.5 sq (square) cm and a volume of 0.015 cubic cm .There is a Small amount of sere-sanguineous drainage noted which has no odor .The wound margin is well defined Wound bed has 90%, pink, granulation, 10 slough .Additional Orders: Treatment(s). Other - Apply Maxorb AG + Eucerin Cream 50g + Bethamethasone Valerate 45g + Gentamicin Ointment 45g QDay/ PRN x 7 days Secondary Dressing(s) Cover with secondary dressing(s) . 12/1/23-Wound Assessment(s) Wound #1 Right, Anterior Breast is a chronic Partial Thickness Nonspecific Wound and has received a status of Not Healed. Subsequent wound encounter measurements are 1.7cm length x 3cm width x 0.1 cm depth, with an area of 5.1 sq cm and a volume of 0.51 cubic cm .There is a Small amount of sere-sanguineous drainage noted which has no odor . The wound margin is well defined Wound bed has 90%, pink, granulation, 10% slough. The wound is deteriorating .Additional Orders: Treatment(s). Other - Apply Maxorb AG+ Eucerin Cream 50g + Bethamethasone Valerate 45g + Gentamicin Ointment 45g QDay/ PRN x 7 days Secondary Dressing (s) Cover with secondary dressing(s) . A review of R91' November and December 2023 Treatment Administration Records (TAR) was reviewed and revealed no treatments to R91's right breast wound were documented as being completed for 11/28, 11/29, 11/30, 12/1 and 12/2. Further review of R91's treatment orders for their right breast wound revealed no treatment orders were in place until 12/3/23 which revealed the following: 12/3/23- cleanse effected area to right breast with normal saline pat dry with 4x4 then apply Eucerin cream 50g+ Betamethasone Valerate 45g+ Gentamicin ointment 45g mixture and Maxorb AG COVER WITH BORDER GAUZE Q day/PRN for 7 days every day shift for wound for 6 Days -Start Date12/03/2023 0700 -D/C Date12/08/2023 On 12/21/23 at approximately 12:08 p.m., during a conversation with the Director of Nursing (DON), a review of R91's right breast wound treatments was completed for November and December 2023 and the DON indicated that R91 was seen by the wound doctor on 11/24/23 and on 12/1/23 but that no new orders were transcribed to R91's electronic medical record (EMR) after they were seen by the wound NP on 11/24/23. The DON indicated that a new order should have been transcribed and implemented on 11/24/23 for seven more days as ordered by the wound care NP, but was not done which was why the treatments ended on 11/27/23 and no new orders were implemented until they were seen by the wound care NP again on 12/1/23. The DON reported that R91 should have had their treatments continued and uninterrupted but the Nurse had not transcribed the order into the electronic medical record for the Nursing staff to administer the treatment. There was no documentation that R91 received treatments to their right breast wound on 11/28/23 through 12/2/23 were provided by the end of the survey.

This citation pertains to intake #MI00132456. Based on observation, interview, and record review, the facility failed to perform a thorough root-cause analysis and investigation into falls and ensure interventions were implemented to prevent falls for two residents (R#'s 86 and 25) of three residents reviewed for falls, resulting in a fall with injury and transfer to the emergency room . Findings include: On 1/18/23 at 11:36 AM, R86 was observed seated in a wheelchair at their bedside. It was observed R5 had a scab on their nose and the purple/yellow appearance of a healing bruise around their right eye. R86 was asked about the scab and bruise and said about a week ago they fell out of their bed. They continued to explain their remote control had fallen to the floor and they were reaching for it they rolled out of bed. They said they broke their nose, were transferred to the emergency room , and soon they were supposed to have a follow-up appointment with an ear, nose and throat doctor. R86 was asked if they put their call light on for assistance and said they did. They were asked to estimate how long the call light was on and said more than a half an hour. R86 said they got tired of waiting and said, I went for it, I shouldn't have, but I did. On 1/19/23 at 10:14 AM, a review of R86's clinical record revealed they most recently readmitted to the facility on [DATE] with diagnoses that included: right above the knee amputation, anxiety disorder, diabetes, and major depressive disorder. R86's most recent Minimum Data Set (MDS) assessment dated [DATE] did not have R86 assessed for cognition, revealed they were not ambulatory, and required extensive assistance from two staff members for bed mobility and total assistance from two staff members for transferring. On 1/19/22 at approximately 10:45 AM, a review of a facility provided incident report for R86's fall was reviewed. The report documented R86's fall and read, .Resident Description: Res (resident) states she was looking for her TV remote and fell out of bed . The report further documented R86 was oriented to person and to situation and sustained an abrasion to their nose. It was noted that nowhere in the report did it address whether R86's call light was on or not on at the time of the fall. On 1/19/23 at 10:51 AM, a follow-up interview was conducted with the resident. They were again asked to describe what they remembered from the fall. They said their remote control was on the floor, they activated the call light for assistance and when no one came to help them, they decided to retrieve it and fell out of the bed. On 1/19/23 at approximately 12:30 PM, a review of R86's progress notes was conducted and revealed the following: A nursing note dated 1/11/23 at 3:33 AM that read, .Laying on the floor face down. Stating 'I was looking for remote' .swelling and bleeding noted to nose during assessment . A nursing note dated 1/11/23 at 10:05 AM that read, (X-ray company) in to obtain Nasal bone X-rays . A nursing note dated 1/11/23 at 12:42 PM that read, .Received X-ray results: There is fracture of distal nasal bone .NP (Nurse Practitioner) notified and ordered transfer to (Hospital) . A nursing note dated 1/11/23 at 12:54 PM that read, .Writer called residents RP (responsible party) .to notify her of nasal fracture and that resident will be transferred to hospital to see ENT (ear, nose, throat specialist) . On 1/19/23 at 4:02 PM, an interview was conducted with the facility's Administrator regarding their policy and procedures for falls. They were first asked if they were able to pull any call light logs to see whether R86's call light had been on at the time of the fall. They said their system did not allow for tracking call light times. They were then asked if they interviewed any of the staff or the resident about the fall and whether the call light had been on. They said they did interviews, but no one said whether the call light had been on or not. At that time, R86's interview was shared with the Administrator where R86 said their light had been on at the time of the fall and when no one came to help them, that's when they fell out of bed sustaining their injury. The Administrator did not offer any further response, but acknowledged the concern about the investigation not addressing the call light. 41415 R25 Review of the medical record revealed R25 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: Dementia, osteoarthritis of left hip, difficulty walking, muscle wasting and atrophy. A MDS assessment dated [DATE], documented a BIMS score of 06 indicating severely impaired cognition and required staff assistance for all ADLs. Review of the progress notes revealed the following: On 4/24/22 at 5:58 AM, . Res (resident) observed on buttocks on floor with her back against bed and legs out straight. No inward outward rotation noted, res able to move all extremities and denies pain at present . On 10/12/22 at 6:27 AM, . Resident stated that she tried to get something from her recliner, her knees got weak and she lower <sic> herself to the floor. She also stated that she did not hit her head . On 11/14/22 at 3:29 PM, . CNA (Certified Nursing Assistant) found resident on the floor sitting up. Came to get nurse. Assessed took VS (Vital Signs) and helped resident back into bed with the assistance of CNA and another nurse . On 11/15/22 a physician progress note documented in part . Patient is seen today for an unwitnessed fall which occurred yesterday afternoon when she slid out of her wheelchair onto her buttocks on the floor. She stated to staff ?I wanted someone to come in?. She had slid out of bed onto her buttocks yesterday morning, making this her second fall of the day . 0900 Notified by Nursing that resident again had an unwitnessed fall. She was sitting on her buttocks on the floor of room beside her wheelchair . Nursing is aware of her recent frequent falls. She requires frequent supervision . On 12/7/22 at 6:18 AM, . writer entered res room and observed res sitting on the floor on her buttocks legs straight in front of her and back leaning against the bed res educated on the use of call light . On 12/30/22 at 4:24 PM, . Writer was alerted that resident was on the floor. Writer went into residents room and confirms <sic> resident on the floor, in a seated position with her back up against the bed . Resident states that she was attempting to go from a seated position to standing, as it appeared that resident did not have on her footwear . Resident further educated on the importance of complying with all safety measures . On 1/17/23 at 8:32 AM, . Informed by staff that resident was observed sliding onto floor from bed. Received resident sitting on floor next to bed . Transferred back to bed with 2 person assist . All fall Incident reports with the completed investigations for R25 were requested from the Administrator. Review of the fall Incident reports revealed the following: No fall incident report, IDT (Interdisciplinary team) evaluation or investigation received for the 4/24/22 fall. 10/12/22- . Immediate Action Taken . vitals were obtained and the resident was educated on the call light. The resident is diagnosed with dementia, educating the resident on the use of the call light is not an effective intervention. No IDT evaluation or investigation provided. 11/14/22 (two incident reports provided for two separate falls that occurred on this date), fall #1- . Immediate Action Taken . Skin Assessment, VS taken, assistance back into bed. Called family . and Fall #2- . Immediate Action Taken . Assessed. VS taken. Family called . No IDT evaluation or investigation provided for either fall. 12/7/22 . Immediate Action Taken . skin assessment done, no injuries noted, notified on call NP (Nurse Practitioner) no new orders, res educated on use of call light . This is a repeated and ineffective intervention. No IDT evaluation or investigation provided. 12/30/22 . Immediate Action Taken . Resident educated on the importance of wearing proper footwear when attempting to go from a seated position to standing . Resident further educated on the importance of complying with all safety measures . No IDT evaluation or investigation provided. 1/17/23 . Immediate Action Taken . ROM (range of motion) wnl (within normal limits) . OT (occupational therapy) to evaluate bed mobility and sage bed height for transfers . The resident is documented as Setup help only for Transfer on the MDS. Review of R25's ADL care plan documented . TRANSFER: Resident requires assistance with transfers with one staff assistance . Initiated: 09/21/2021 . Review of R25's fall care plan revealed little to no review, modification or revision of the interventions implemented to prevent further falls. Further review revealed on 11/16/22 and intervention . Obtain labs as ordered, report abnormal findings to the physician . was implemented. On 1/3/23 and intervention was revised to . Encourage the resident to wear appropriate footwear as needed when going rom seated to standing position . the resident care plan documented a one person staff assistance with transfers, therefore staff should ensure that the resident is wearing the appropriate footwear at the start of the day and when transferring the resident. On 1/17/23 and intervention was documented to have OT to evaluate bed mobility and safe bed height for transfers. No further interventions were modified, revised or implemented for R25 despite the seven falls identified. Further review of the medical record revealed one IDT note dated 1/17/23 at 10:21 AM, regarding the IDT team to have met and discussed the fall and the review of fall interventions for R25. No other IDT notes were documented for the prior falls. Review of a facility policy titled Fall Management documented in part, . The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls . If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls . On 1/20/23 at 2:40 PM, the DON was interviewed and asked about each fall, the lack of identification of the root cause of the falls and the lack of interventions implemented to prevent further falls. The DON stated they were newly employed at the facility, however, would look into it and follow back up. No further explanation or documentation was received by the end of survey.

This citation pertains to intake: MI 440. Based on observation, interview and record review the facility failed implement a care plan/interventions identifying sexual behaviors towards residents and prevent sexual abuse occuring to three (R702, R706 and R707) of 4 residents reviewed for abuse resulting in Immediate Jeopardy when R702 breasts and vagina was fondled by R705, R705 held the wrist of R706 (a vulnerable resident) down into the front of their (R705's) brief, and R707 being asked to perform oral sex by R705. This deficient practice placed the residents residing at the facility at risk for continued abuse, serious harm or injury. Findings include: The Immediate Jeopardy (IJ) started on 12/13/21. The IJ was identified on 1/11/22 at 11:36 AM. The Administrator was notified of the IJ on 1/11/22 at 12:30 PM and a plan to remove the immediacy was requested. The immediacy was removed on 1/12/22 at 2:10 PM, based on the facility's implementation of an acceptable plan of removal as verified onsite by the State Agency (SA). Although the immediacy was removed, the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint submitted to the State Agency on 1/6/22 revealed concerns of R705 sexually assaulting R702 by touching R702's breast and vagina and Staff indicated this was not the first incident with (R705) assaulting a resident . R702 R702 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs). On 1/10/22 at 11:50 AM, a telephone interview was conducted with R702. R702 was discharged from the facility back to their living arrangements on 1/3/22. When asked about the incident with R705, R702 stated in part . I'll never forget it . The man across the hall from me was always watching and staring at me . during the night he came across the hall naked and pretended to be senile. I told him to go back to his room. At first I was nice but then got more forceful and told him to get out of my room. His manner changed and he came over and climbed in my bed. I originally couldn't get out of my bed because my back hurt so bad, that's why I was there (facility) because of my back. He put his hands in my hospital gown and fondled my breast and then inside my briefs and fondled that area (vagina- confirmed with resident). He kept sliding up and down my hospital gown and I was afraid that he was going to strangle me . I climbed, like slid down off the bed (because I couldn't walk) and he was following me out of the bed and kept trying to reach me. I told him if he doesn't stop I'm going to cut you and he said, cut me with what? The whole time he was in my room I was screaming for help and screaming emergency. No one helped, no one came. I crawled into my wheelchair and rolled down the hallway screaming and crying. I finally found someone at the end of the hallway, as I was crying and screaming for at least 3 to 5 minutes. It could have been longer it felt like forever to me, you know what I mean? After I found the nurse, I told them that I wanted to call the police . some of the other staff members said that he couldn't walk, but that bulls**t because I've seen him walk, we've all seen him walk before. I felt like the staff was against me . The man (R705) was so heavy. I couldn't even pick him off of me. He was heavy and disgusting, just so disgusting (R702 began to cry non-stop) . When asked, R702 stated in part . They never offered a psych consult. No one ever came into my room after that, except the nurses and aides . When asked R702 stated in part, No, the Social Worker never came to talk to me about that night . She didn't come, no one ever did. I felt alone. They (facility staff) made me feel like it was my fault it happened. Everyone around me (current assisted living facility) keeps telling me that he isn't around and to stop thinking about it (R702 starts crying again). I wish I had someone to talk to, I feel so alone. I really need someone to talk to about this. Staff said that he would be touching the women at the facility, so they (facility staff) knew that he had issues. No, I didn't feel safe after it happened. They were always so short staffed. I don't understand how they can be so short staffed that they let that happen to me. I don't feel safe anywhere. I feel dirty, like I did something wrong, and I don't know why I feel like that . the nursing staff told me about him fondling other women at the facility . I'm still afraid now that I'm back home (R702 continues to cry). I just can't sleep. I still feel like he is here . R702 denied any prior incidents with R705. On 1/10/22 at 12:43 PM, the Administrator was asked to provide all Incident & Accident reports, grievances, and concern forms for R's 702 and 705. The Administrator provided a report with two witness statements from CNA F that documented in its entirety I was giving care. I step <sic> out into the hallway and observe (R705) coming out of (R702's room number redacted). (R705) was unclothed and going back into his room. A second statement provided by CNA G documented in its entirety I was giving care. I step <sic> into the hallway and observed (R705) standing in the hallway. I ask what are you doing! He then grab <sic> his private part and shook himself and proceed into his room . Review of a Police Department (PD) report dated 1/2/22, documented in part R702's statement, . First man opens my door totally naked. At first I thought that he was just confused so, I told him that he was in the wrong room. I said No, No, No you're in the wrong room. Go back to your room! He pretended he didn't understand me and came closer to my bed. Then he sat down on my bed and that's when I started screaming. I screamed for help as loud as I could all the time til I left the room but nobody came ever. (4-5 mins) That's when I first noticed that he knew exactly what he was doing. He put first, his hand under my hospital gown and fondled my breast. Then using his middle finger, went up my legs into my briefs and fondled my front. At that time, I wiggled out of bed into my wheelchair got into the hallway went for help . On 1/10/22 at 1:55 PM, with the assistance of the facility's Administration staff (the Administrator and DON in attendance) a playback review was conducted with the facility's recorded video footage from the hallway camera. The early morning of 1/2/22 from 3:57 AM until 5:38 AM was reviewed. At 4:50 AM, R705 is seen completely naked walking across the hall into R702's room. R705 was observed to be in R702's room [ROOM NUMBER] to almost 4 minutes. Shortly after R702 is seen in their wheelchair rolling themselves down the hallway towards staff. At 4:55 AM, staff memeber can be seen watching R705 out of R702's room naked. R705 enters into their room. The staff member Identified on the video tape having first contact with R702 after the incident was Certified Nursing Assistant (CNA) F. On 1/10/22 at 2:44 PM, a telephone interview was conducted with CNA F, when asked about the incident that occurred with R702 and R705 on 1/2/22, CNA F stated in part, . the lady (R702) was yelling and crying and said there is a male in her room and to call the police he touched her. I saw the man coming out of her room naked. She said he touched me, he touched me. I wasn't assigned to that area in the hallway . They said (CNA F name redacted) you know you're supposed to do every 15 mins checks with him (again I wasn't assigned to that area) . CNA F was asked what staff member told them that R705 was supposed to be on 15-minute checks and CNA F could not recall. CNA F was informed that the video was reviewed and although they had signed that they checked on R705 at 4 AM, 4:15 AM, and 4:30 AM the video showed no staff member checking into R705's room at those times. CNA F then admitted that when they were told that the 15-minute checks had to be done, they (CNA F) completed the entire 15- minute check off sheet at that time, documenting that R705 was observed every 15 minutes, when in fact the facility video footage showed that R705 was not consistently observed every 15 minutes by the facility staff. CNA F was asked why they filled the 15-minute check off sheet for R705 if they were not assigned to the resident, CNA F did not have a response. CNA F then stated in part, . I really didn't know that I was supposed to do it (every 15 minutes checks on R705) . The CNA that gave me report didn't tell me that we had to do 15-minute checks . CNA F identified CNA G as the aide assigned to R705 at the time of the incident. On 1/10/22 at 2:53 PM, a telephone interview was conducted with CNA G. When asked if they were the assigned CNA for R705 at the time of the early morning incident on 1/2/22 involving R702, CNA G stated Yes. When asked about the incident, CNA G stated in part . my coworker said look at him and I said what are you (R705) doing? He was naked and he grabbed himself (his penis) and shook it, laughed and went into his room . When asked about the 15-minute checks that was supposed to be done on R705, CNA G stated I wasn't aware of any 15-minute checks . When asked if they (facility staff) asked R702 about the incident, CNA G stated in part, . She (R702) was crying. She wouldn't really go into details until the cop got there. Review of a facility policy titled Abuse Prohibition Policy revised 7/2019 documented in part, . Each resident shall be free from abuse . Abuse shall include freedom from verbal, mental, sexual, physical abuse . It is the responsibility of all staff to provide a safe environment for the residents . Sexual Abuse is non-consensual sexual contact of any type with a resident . R705 Review of R705's clinical record revealed the following: R705 was admitted into the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] that documented a BIMS score of 9, indicating moderately impaired cognition and requiring staff assistance for all ADLs. On 11/21/21 at 3:57 PM, a Nursing note documented in part . Resident noted doing inappropriate sexual behaviors with writer and assigned cena (certified nursing assistant), writer explained to resident that staff is here to care for you and that behavior makes writer and assigned cena feel uncomfortable, resident stated I do not care . On 11/22/21 at 11:43 AM, Nurse Practitioner note documented in part, . An occurrence of inappropriate touching during rendering of care has been reported. Redirect when behavior occurs . On 11/23/21 at 6:19 PM, a behavioral consultation note documented in part, . behavioral disturbances have been reported, including inappropriate sexual behaviors during ADL care. Noncompliance and difficulty redirecting reported by staff. He denies these behaviors occurred, then stated, So what. I educated him on facilities rules and expectations regarding appropriate oral communication and no physical touching other residents or employees. Resident verbalized understanding . On 11/24/21 at 11:05 AM, a Nurse Practitioner note documented in part, . His behavior can be inappropriate. Grabbing has been reported by staff. Continue to redirect . On 11/24/21 at 2:34 PM a Nursing note documented in part, Writer overheard the resident tell the nursing assistant I want to F you Writer informed resident that kind of language is inappropriate, we are only here to assist you Resident stated, I don't care. On 12/1/21 at 11:18 AM, a Social Services note documented in part, . Resident continues to display sexually inappropriate comments, grabbing at staff and yelling/screaming . On 12/2/21 at 10:12 AM, a Nurse Practitioner note documented in part . Nursing also reports he continue to exhibit inappropriate touching behavior . On 12/2/21 at 7:21 AM, a Nursing note documented in part .res (resident) tried to put his hand between writer legs when res was asked to stop res became very aggressive stating if you don't want it get the hell out of my room writer called a male staff to come and assist with transferring . on call doctor and responsible party notified . On 12/13/21 at 8:51 PM, a Nursing note documented in part . It was reported to me by CNA (identified as CNA H) that resident (identified as R706) wandered into his (R705) room and she (CNA H) observed him holding (R706) hand and both their hands were in his brief. (R706) was immediately removed and returned to her unit. Writer assessed res no injuries noted. Will report to Social Worker. On 1/11/22 at 8:32 AM, a telephone interview was conducted with CNA H. When asked about the incident involving R705 and R706 on 12/13/21, CNA H replied in part . It was around dinner time I had just finished feeding (resident name redacted) and I went into his (R705's) room to see if he was finished eating. I observed him having his hand on her (R706's) wrist and having her hand inside of the front of his brief. I can't get into detail if she was squeezing or rubbing his penis . I got her away from him immediately. I asked her and she couldn't tell me what happened, she has dementia and his (R705) roommate (identified as R707) didn't see anything . I don't know how long the resident (R706) was in there . They did put him on 15-minute checks that same day . I was totally in shock. I know that she (R706) is not mentally able to consent. I was really bothered by that situation . I walked in and said what are you (R705) doing to her (R706)? That was really unacceptable and inappropriate. He (R705) shouldn't have been in the facility with that type of behavior with all of these residents wandering around. I can't go into detail if she was rubbing or squeezing his penis because I removed her so fast . (R705 name redacted) just laughed. He thinks everything is funny. He is married and he says, I don't care. When asked, CNA H replied in part . Of course, I believe that he knew everything that he was doing. He will have a conversation appropriately. That's just his character that's just him. I've been in this field for six years and he knew what he was doing . When asked if any of the Administration staff followed up with them regarding the incident or to be interviewed, CNA H replied No and stated the unit manager on duty at the time had CNA H write a statement. CNA H stated in part, . I wish I was there to have catch her (R706) before she went into his (R705's) room. It just bothered me for days after. It really did. He (R705) is really disgusting when you do care for him. He can walk, that's the thing about it he can walk. He will stand up and let you provide care. That man can walk, all staff are aware of that. We have agency staff that might not know but I tell them . Review of a facility policy titled Abuse Prohibition Policy revised 7/2019 documented in part, . Sexual Abuse . is a non-consensual sexual contact . A resident forcefully requires another resident to participate in a sexual act . R706 R706 was admitted into the facility on [DATE] with a readmitted [DATE] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at 12:23 PM, R706 was observed sitting in a wheelchair in their room eating lunch. The resident was observed neatly dressed and groomed. When asked the resident was unable to answer all interview questions appropriately. Review of R706's clinical record documented R706's son as the resident's responsible party and Power of Attorney for the resident's care. Review of a care plan titled At risk for decline in cognition and has impaired cognitive function or impaired though processes r/t (related to) Dementia. Both long term and short-term memory are impaired. Son is DPOA (Durable Power of Attorney) HC (Health Care) and finance and is available to assist with all major decisions. R706 was not capable of consenting to any sexual acts with R705. Further review of R705's clinical record revealed the following: On 12/14/21 at 5:10 PM, Social Services note documented in part . Writer met with resident bedside . Education provided r/t (related to) personal space and refraining from touching others to which res was receptive . Spoke with resident's spouse . she apologized, explained that resident has HX (history) of sexual behaviors . On 12/16/21 at 5:55 PM, Nursing note documented in part . Multiple complaints of sexually inappropriate behaviors. Four different staff report Resident taking his Penis out of his brief and asking them to Suck my Penis. Resident is attempting to grab the breast of female staff during care. Attempts to redirect Resident with conversation, Television. Sexually suggestive remarks continue regardless of redirecting. Social worker informed of inappropriate behaviors. On 12/16/21 at 6:28 PM, Social Services note documented in part . Writer spoke with resident bedside r/t sexually inappropriate behaviors. Education provided to res r/t refraining from touching others and res states it figures, he repeated this multiple times throughout conversation. Resident exposed himself to writer and stated, Does this answer your questions? Writer exited resident's room at that moment. Writer called residents spouse . to discuss . ensured residents spouse that (facility initials) can provide private space for intimacy between res and spouse, to which spouse . declined . spouse is very open to medication changes as she reported intervention was used to combat sexual behaviors at home . On 12/16/21 at 6:36 PM, a behavioral consultation note documented in part . Received call from SS (Social Services), reporting worsening sexually inappropriate behaviors . Multiple medications changes were made. On 12/16/21 at 7:06 PM, a Social Services note documented in part . Writer and spouse discussed resident's HX and spouse's suspensions (sic) of childhood sexual abuse via phone call today . On 12/17/21 at 4:15 AM, a Nursing note documented in part, . Resident continue to exhibit inappropriate (sexual) behavior towards female staff, grabbing their buttocks, anytime writer tried to caution him, he became aggressive towards the writer. On 12/17/21 at 3:45 PM, a Nursing note documented in part, . Staff had to give frequent reminders to reframe (sic) from sexual behavior while care is being rendered. Resident smiled and Cena's gave Resident his privacy by pulling the curtains shut and returning later after he stopped the sexual behaviors. Resident remained in his room for the whole shift. (His personal request). New orders to send Resident out to ER (emergency room ) for mental evaluation . Due to medical transportation staff shortage the facility was unable to get transportation for R705 on 12/17. On 12/17/21 at 7:10 PM, a Social Services note documented in part . Petition for Mental Health treatment discussed r/t sexual behaviors . awaiting confirmation of transportation r/t transfer . On 12/18/21 at 3:15 PM, a Nurses Notes documented in part, (name of transport company) was called to transport resident to (initials of hospital) .stated they were unable to transport . On 12/20/21 at 2:39 AM, a Nursing note documented in part . Received resident in bed awake brief open penis out while watching TV . On 12/20/21 at 3:11 PM, a Nurses Notes documented in part, Writer attempted several times to call (name of) transportation services r/t (related to) transferring resident to hosp no answer . On 12/22/21 at 2:16 PM, a Social Services note documented in part . CNA reported to writer that resident continues with on-going sexually inappropriate behaviors such as grabbing at staff during care and touching his groin area during care. On-going difficulty obtaining transportation to hospital . On 12/23/21 at 2:52 PM, a Social Services note documented that transportation for R705 to be transferred to the hospital was obtained. On 12/24/21 at 2:04 PM, a Late Entry Social Services note documented in part . Writer spoke with discharge planner at hospital via phone call today as she called (facility initials redacted). She reported that resident is not displaying any sexually inappropriate behaviors and physician decided that a psychiatric stay is not needed, she reported physician would like him to return. Writer called . admin (Administrator) to notify and nursing notified. Review of the clinical record revealed no hospital discharge paperwork scanned in the resident's medical chart. On 1/10/22 at 12:43 PM the Administrator, DON and Social worker was asked to provide this documentation, however the documentation was not provided by the end of survey. On 1/10/21 at 4:50 PM, the Administrator and DON was asked if they felt comfortable readmitting R705 in the facility and if they felt comfortable that the facility staff could guarantee the safety of all of the other vulnerable residents and the Administrator replied No. When asked how the Interdisciplinary team decided to readmit R705 back into the facility when they couldn't guarantee the safety of other residents the Administrator stated they were told by corporate they had to take R705 back because the resident came from their facility. Review of R705's care plans revealed no care plan identifying the resident's sexual behavior with other vulnerable residents, such as the incident that occurred when R705 was seen holding the wrist of R706 into R705's brief. Two care plans titled . actual behavior problem R/T inappropriate sexual behaviors toward staff during care and . HX displaying inappropriate sexual behavior toward female staff . failed to acknowledge or document interventions for staff to utilize for resident-to-resident abuse. Review of the 15-minute checks implemented by the facility on 12/13/21 after the first resident to resident sexual abuse incident, revealed inconsistent implementation as visualized on the facility's camera video footage. The DON and Administrator was asked to provide all of the 15-minute checks completed by staff. The provided 15-minute documentation checks started on 12/17/21 (4 days after implementation) and was documented until 8:45 AM on 12/22/21. There was no documentation of the 15-minute checks being completed for the remainder of 12/22, 12/23 through 12/31 (with the exception of the 1/1/22 and 1/2/22 that CNA F admitted to completing after the incident because they were told that it was supposed to be done.) On 1/12/22 at 8:17 AM, an interview was conducted with the Administrator and DON, both were asked if they had any additional documentation to provide regarding the abuse allegations and to discuss the plan of removal for the IJ. At that time the Administrator stated the wife of R705's roommate R707 contacted the Administrator on the evening of 1/11/22 to inform them R707 did not feel comfortable having R705 as a roommate again. The wife of R707 then informed the Administrator that R705 had previously asked R707 to suck his penis. On 1/12/21 at 8:43 AM, an observation of R707 laying on their bed, sitting up to eat breakfast was observed. When asked specifically about how they felt having R705 as a roommate R707 stated in part, . He exploited women. I felt uncomfortable being his roommate. I finally let the skinny woman know. He asked me if I wanted to suck his d**k and I said no. He (R705) didn't say anything after that. Not good to the female staff, he kept hitting on them sexually . R707 stated they felt safe in the facility, however no longer wanted R705 as a roommate.

This citation pertains to intake: MI 440. Based on observation, interview, and record review, the facility failed to have evidence that allegations of sexual abuse were thoroughly investigated for 1 (R705) of 1 reviewed for sexual abuse, resulting in allegations of abuse that were not thoroughly investigated, R705 sexually abusing other residents, and the potential for further allegations of abuse to not be thoroughly investigated. R705 R705 was admitted into the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] that documented a BIMS score of 9, indicating moderately impaired cognition and requiring staff assistance for all ADLs. Review of R705's clinical record revealed the following: On 12/13/21 at 8:51 PM, a Nursing note documented in part . It was reported to me by CNA (identified as CNA H) that resident (identified as R706) wandered into his room and she (CNA H) observed him holding (R706) hand and both their hands were in his brief. (R706) was immediately removed and returned to her unit. Writer assessed res no injuries noted. Will report to Social Worker. On 1/11/22 at 8:32 AM, a telephone interview was conducted with CNA H. When asked about the incident involving R705 and R706 on 12/13/21, CNA H replied in part . It was around dinner time I had just finished feeding (resident name redacted) and I went into his (R705's) room to see if he was finished eating. I observed him having his hand on her (R706's) wrist and having her hand inside of the front of his brief. I can't get into detail if she was squeezing or rubbing his penis . I got her away from him immediately. I asked her and she couldn't tell me what happened, she has dementia and his (R705) roommate (identified as R707) didn't see anything . I don't know how long the resident (R706) was in there . They did put him on 15-minute checks that same day . I was totally in shock. I know that she (R706) is not mentally able to consent. I was really bothered by that situation . I walked in and said what are you (R705) doing to her (R706)? That was really unacceptable and inappropriate. He (R705) shouldn't have been in the facility with that type of behavior with all of these residents wandering around. I can't go into detail if she was rubbing or squeezing his penis because I removed her so fast . (R705 name redacted) just laughed. He thinks everything is funny. He is married and he says, I don't care. When asked, CNA H replied in part . Of course, I believe that he knew everything that he was doing. He will have a conversation appropriately. That's just his character that's just him. I've been in this field for six years and he knew what he was doing . When asked if any of the Administration staff followed up with them regarding the incident or to be interviewed, CNA H replied No and stated the unit manager on duty at the time had CNA H write a statement. CNA H stated in part, . I wish I was there to have catch her (R706) before she went into his (R705's) room. It just bothered me for days after. It really did. He (R705) is really disgusting when you do care for him. He can walk, that's the thing about it he can walk. He will stand up and let you provide care. That man can walk, all staff are aware of that. We have agency staff that might not know but I tell them . Review of a facility policy titled Abuse Prohibition Policy revised 7/2019 documented in part, . Sexual Abuse . is a non-consensual sexual contact . A resident forcefully requires another resident to participate in a sexual act . On 1/10/22 at 4:02 PM, the Administrator (who also serves as the abuse coordinator) and DON was interviewed and asked why the abuse allegation involving R's 705 and 706 on 12/13/21 was not reported to the SA, neither the Administrator nor DON had a reply. When asked why a thorough investigation was not completed or documentation provided of an investigation regarding the abuse allegation with R's 705 and 706, the Administrator stated they believed the previous DON had paperwork regarding this incident, however the Administrator was unable to locate it. The Administrator then stated in part, Absolutely, the State should have been notified. The Administrator and DON was asked to provide all documentation they have regarding the 12/13/21 incident involving R's 705 and 706. Review of a facility policy titled Abuse Prohibition Policy revised 7/2019 documented in part, . Residents identified by staff as being . or exhibiting abusive behavior . will be reviewed by the physician and treatment plans modified as appropriate . The facility Quality Assurance Performance Improvement Committee will investigate occurrences . that may indicate the presence of abuse . Allegations by anyone who becomes aware of . sexual or emotional abuse and mistreatment . must immediately report it to his/her Administrator . The Director of Nursing or designee will complete an assessment of resident(s) and document findings in the medical record . A preliminary, onsite investigation will be initiated withing 24 hours of any report . The Administrator or Director of Nursing/designee shall . Interview with the person(s) reporting the incident . Interviews with any witnesses to the incident . interview with the resident . interview with staff members having contact with the resident during the period/shift of the alleged incident . Social Services will provide follow-up counseling with the resident . Any resident verified for perpetrating abuse may be subject to discharge from the facility . R702 Review of a complaint submitted to the State Agency on 1/6/22 revealed concerns of R705 sexually assaulting R702 by touching R702's breast and vagina and Staff indicated this was not the first incident with (R705) assaulting a resident . R702 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs). On 1/10/22 at 11:50 AM, a telephone interview was conducted with R702. R702 was discharged from the facility back to their living arrangements on 1/3/22. When asked about the incident with R705, R702 stated in part . I'll never forget it . The man across the hall from me was always watching and staring at me . during the night he came across the hall naked and pretended to be senile. I told him to go back to his room. At first I was nice but then got more forceful and told him to get out of my room. His manner changed and he came over and climbed in my bed. I originally couldn't get out of my bed because my back hurt so bad, that's why I was there (facility) because of my back. He put his hands in my hospital gown and fondled my breast and then inside my briefs and fondled that area (vagina- confirmed with resident). He kept sliding up and down my hospital gown and I was afraid that he was going to strangle me . I climbed, like slid down off the bed (because I couldn't walk) and he was following me out of the bed and kept trying to reach me. I told him if he doesn't stop I'm going to cut you and he said, cut me with what? The whole time he was in my room I was screaming for help and screaming emergency. No one helped, no one came. I crawled into my wheelchair and rolled down the hallway screaming and crying. I finally found someone at the end of the hallway, as I was crying and screaming for at least 3 to 5 minutes. It could have been longer it felt like forever to me, you know what I mean? After I found the nurse, I told them that I wanted to call the police . some of the other staff members said that he couldn't walk, but that bulls**t because I've seen him walk, we've all seen him walk before. I felt like the staff was against me . The man (R705) was so heavy. I couldn't even pick him off of me. He was heavy and disgusting, just so disgusting (R702 began to cry non-stop) . When asked, R702 stated in part . They never offered a psych consult. No one ever came into my room after that, except the nurses and aides . When asked R702 stated in part, No, the Social Worker never came to talk to me about that night . She didn't come, no one ever did. I felt alone. They (facility staff) made me feel like it was my fault it happened. Everyone around me (current assisted living facility) keeps telling me that he isn't around and to stop thinking about it (R702 starts crying again). I wish I had someone to talk to, I feel so alone. I really need someone to talk to about this. Staff said that he would be touching the women at the facility, so they (facility staff) knew that he had issues. No, I didn't feel safe after it happened. They were always so short staffed. I don't understand how they can be so short staffed that they let that happen to me. I don't feel safe anywhere. I feel dirty, like I did something wrong, and I don't know why I feel like that . the nursing staff told me about him fondling other women at the facility . I'm still afraid now that I'm back home (R702 continues to cry). I just can't sleep. I still feel like he is here . R702 denied any prior incidents with R705. On 1/10/22 at 12:43 PM, the Administrator was asked to provide all Incident & Accident reports, grievances, and concern forms for R's 702 and 705. The Administrator provided a report with two witness statements from CNA F that documented in its entirety I was giving care. I step <sic> out into the hallway and observe (R705) coming out of (R702's room number redacted). (R705) was unclothed and going back into his room. There was no interview questions documented for this staff member. A second statement provided by CNA G documented in its entirety I was giving care. I step <sic> into the hallway and observed (R705) standing in the hallway. I ask what are you doing! He then grab <sic> his private part and shook himself and proceed into his room . There was no interview questions documented for this staff member. The facility failed to identify and interview the nurse assigned to both residents. A 5 Day Investigation report documented R705 denied the alleged incident, however failed to interview the victim R702. Further review of the 5 Day Investigation documented in part, . After a thorough investigation, which included both residents and staff involved, we concluded that (R702 name redacted) reported to staff and police that (R705's name redacted) touched her inappropriately. This was unable to be substantiated by the facility due to lack of witnesses and (R705 name redacted) statement of denial that the incident even occurred . Review of a Police Department (PD) report dated 1/2/22, documented in part R702's statement, . First man opens my door totally naked. At first I thought that he was just confused so, I told him that he was in the wrong room. I said No, No, No you're in the wrong room. Go back to your room! He pretended he didn't understand me and came closer to my bed. Then he sat down on my bed and that's when I started screaming. I screamed for help as loud as I could all the time til I left the room but nobody came ever. (4-5 mins) That's when I first noticed that he knew exactly what he was doing. He put first, his hand under my hospital gown and fondled my breast. Then using his middle finger, went up my legs into my briefs and fondled my front. At that time, I wiggled out of bed into my wheelchair got into the hallway went for help . On 1/10/22 at 1:55 PM, with the assistance of the facility's Administration staff (the Administrator and DON in attendance) a playback review was conducted with the facility's recorded video footage from the hallway camera. The early morning of 1/2/22 from 3:57 AM until 5:38 AM was reviewed. At 4:50 AM, R705 is seen completely naked walking across the hall into R702's room. R705 was estimated to be in R702's room [ROOM NUMBER] to almost 4 minutes. Shortly after R702 is seen in their wheelchair rolling themselves down the hallway towards staff. At 4:55 AM, R705 is seen coming out of R702's room naked by staff members. R705 enters into their room. The staff member Identified on the video tape having first contact with R702 after the incident was Certified Nursing Assistant (CNA) F. On 1/10/22 at 4:02 PM, the Administrator (who also serves as the abuse coordinator) and DON was interviewed and asked why a thorough investigation was not conducted regarding the incident involving R's 702 and 705. The Administrator stated the investigation was done collaboratively between themselves and the DON. When asked how the facility felt they thoroughly investigated the incident when the victim (R702) and all staff that was on duty and assigned to that hallway were not interviewed and why the facility's social worker or behavioral consultants did not talk or assess R702's mental status before being discharged . The Administrator explained that it happened over the weekend and most of the staff was not in the building. The Administrator stated they were sick but working from home collaboratively with the DON investigating the allegation. The DON (who was the Abuse Coordinator in the absence of the Administrator) was then asked why they didn't interview R702 before they were discharged , ensure a Social Worker follow up, or a behavioral consultation to assess the resident mental status and the DON stated the unit manager that was on duty at the time of the incident followed up with the resident. The DON was asked to provide the documentation of that follow up with R702 and no documentation was received by the end of survey. The DON then stated they called R702 to follow up regarding the incident (days after being discharged ). The DON was asked if the resident refused to talk to them about the incident and the DON replied yes.

This citation pertains to Intake #MI 878. Based on observation, interview and record review, the facility failed to ensure that the attending physician conducted required visits (minimum of every sixty days) for 12 Residents currently residing in the facility (#701, #703, #705, #706, #707, #708, #709, #710, #711, #712, #713, #714) out of 14 reviewed for physician visits. This resulted in Immediate Jeopardy (IJ) when R#714 had gone more than 4 months without being seen by a physician or a Non-physician practitioner and R#701 who experienced a significant change in status that included severe weight loss, a facility acquired pressure ulcer that required surgical debridement, and hospitalization , had not received visitation by their attending physician (Dr. E) and/or a non-physician practitioner (NPP) in over four months and the likelihood that R#703, #705, #706, #707, #708, #709 #710, #711, #712, #713 and #714 who did not receive required visitation from their attending physician, at risk for serious decline, serious impairment and/or death. The IJ began on 1/6/21, it was identified by the survey team on 3/17/21 at approximately 3:00 PM. The facility was notified of the IJ on 3/17/21 at approximately 4:29 PM and a plan to remove the immediacy was requested. The immediacy was removed on 3/18/21, based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. The facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Findings include: A complaint was filed with the State Agency (SA) that alleged that a resident was not being seen by a physician. R#701 A review of R#701's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderately impaired) and required extensive one to two person assist for most Activities of Daily Living (ADLs). A review of R#701's attending physician visit documentation was conducted and revealed the last documented attending physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Request were made to the facility to provide any evidence that Dr. E or a Non-physician practitioner (NPP) associated with Dr. E had visited the resident any time after 10/30/20. No documentation was provided by the end of the survey. Continued review of R#701's clinical record was conducted and documented, in part, the following: 12/18/2020: The assigned aide reported small open area on the resident's coccyx area, .Continue to monitor. 12/30/2020: Spoke with pt (patient) pcp (primary care physician) in regard to abnormal lab value dr. states that he will look over the results himself no further orders given at this time. Lab reports dated 12/15/20 indicated several out-of-range results including, but not limited to the following: BUN (Blood Urea Nitrogen) for R#701's level (a lab level that shows information about how well the liver and kidneys are functioning) was 45, normal levels range from 7-25, Sodium level 148, normal levels range from 136-145, Hemoglobin was 8.9 and normal levels range from 13.5-17.5. 1/12/2021 (Resident at Risk): [MEDICATION(S)] increased .Res self-reported depressed mood. Significant weight loss noted with CBW (current body weight) 214.8 which is down from #234 12/3/20. Wound worsening .Needs to be fed when eating in bed . 2/10/21 (Resident at Risk) .wound remains at risk for further break down and/or deterioration of the wound r/t (due to) incontinence and refusal to turn or reposition . 2/17/21 (Resident at Risk): Resident was seen by psych . [MEDICATION(S)] increased .Sacrococcyx/Bil <sic> buttock pressure ulcer with pink necrotic base. Fragile peri wound remains at risk for further deterioration and new wound formation . 3/1/2021(Nurses Note): resident's wound noted w/odor (Name Redacted) Dr. E made aware stat x-ray to r/o (rule out) [CONDITION(S)] . 3/2/2021 (Nurses Note): Received radiology report. No fracture seen .Please note that MRI or Nuclear Medicine bone scan are more sensitive for detecting [CONDITION(S)] . 3/2/2021(Lab Results Report) documented irregular labs results, including an increase in Sodium from 145 to 151. 3/9/21 (Nurses Note): Resident continues with change in mental status, able to answer questions but very confused, still awaiting stat lab results. Resident to be sent to (name redacted) Hospital E.R. (emergency room ) r/t (due to) mental status change per Dr. E . 3/9/2021(Nurse Note): Resident seen by (name redacted) wound care Dr.H this AM . and gave new orders for stat labs .Resident out to hospital for further evaluation . Hospital (name redacted) records (3/10/2021) documented, in part, the following: R#701 was admitted on [DATE] secondary to increased confusion at (name redacted) facility .he had decreased p.o. intake, had some moaning and increased lethargy .Gluteal decubiti inspected .extremely necrotic black foul smelling tissue presumably probing down to bone with undermining .Impression: [CONDITION(S)] pneumonia/strep bacteremia .possible etiologies include necrotic sacral decubiti 2. Necrotic Sacral decubiti with likely [CONDITION(S)] .4. Severe dehydration .likely related to p.o. intake .Preliminary Report: Assessment/Plan .male with sacral decub which will require surgical debridement and possible wound VAC placement tomorrow .Final Report: Necrotic sacral decubitus ulcers s/p excision and debridement on 3/13/21 .bacteremia 3/9 likely due to necrotic decubitus ulcer .Radiology .2. Subcutaneous [CONDITION(S)] with cortical irregularity of the mid sacrum is highly suggestive of [CONDITION(S)] . On 3/17/21 at approximately 10:35 AM an interview was conducted with Assistant Director of Nursing (ADON) A regarding R#701's visitations by their attending physician. ADON A reported that the resident was seen by Wound Dr. H and could not recall when the resident was seen by Dr. E. R#703 On 3/16/21 at approximately 10:00 AM, R#703 was observed in bed. The resident was alert and able to answer most questions asked. When queried as to the last time he was seen by a physician, R#703 reported that they could not remember. A review of R#703's clinical record was conducted on 3/17/21. The record revealed R#703 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#703 had a BIMS score of 9/15 (moderately impaired). A review of R703's attending physician visit documentation was conducted and revealed the last documented visit by the attending physician, Dr. 'E' occurred on 10/23/20. A request was made to the facility to provide any documentation that indicated R#703 was seen by Dr. E after 10/23/20. No further documentation was provided by the end of the Survey. R705 On 3/18/21 at 8:45 AM, R705 was observed in their bed. R705 was alert but did not respond to attempts at verbal communication. R705 was observed to be receiving tube feeding formula and had oxygen at 2 Liters delivered via nasal cannula. A review of R705's clinical record was conducted and revealed R705 admitted to the facility on [DATE] and most recently readmitted on [DATE]. R705's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R705's attending physician visit documentation was conducted and revealed the last documented physician visit from R705's attending physician, Dr. 'E' had occurred on 11/6/20. A review of R705's nursing notes was conducted and revealed the following: 11/25/20, a nursing note indicate indicated R705's labs were reviewed with the attending physician, Dr. 'E'. The lab report dated 11/25/20 revealed R705's BUN (Blood Urea Nitrogen) level (a lab level that shows information about how well the liver and kidneys are functioning) was 43, normal levels range from 7-25. 1/4/21, a nursing note that indicated a message was left for Dr. 'E' regarding R705's abnormal lab report. The lab report dated 1/4/21 revealed R705's BUN level was 35. 1/28/21, a nursing note that indicated abnormal lab values were reported to Dr. 'E'. The lab report dated 1/28/21 revealed R705's BUN level was 43. Continued review of R705's clinical record did not reveal any documented information Dr. 'E' regarding R705's abnormal labs since the last documented physician's visit on 11/6/20. R706 A review of R706's clinical record was conducted on 3/18/21. The record revealed R706 admitted to the facility on [DATE] with a most recent admission on 1/10/20. R706's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R706's attending physician visit documentation was conducted and revealed the last documented visit by the attending physician, Dr. 'E' occurred on 11/6/20. R#707 On 3/18/21 at 11:18 am, an observation was made of R#707 having a family visit with their son. R#707 was sitting in a wheelchair with a blanket throw over them (in the room allowed for visitation). R#707 eyes were closed and was not responding to verbal stimuli. A review of the clinical record revealed the following: R#707 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS assessment dated [DATE] documented a BIMS score of 01 (indicating severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). The last physician consultation in the clinical record was dated for 12/7/21. A Nursing Note dated 12/28/20 at 11:28 PM, documented in part . (Doctor name redacted) was in the building around 4:30 PM reviewed the abdominal X-ray for peg (percutaneous gastrostomy) tube placement result. He checked for placement via stethoscope. The peg tube was out at the time, doctor reinserted new tube and another for STAT abdominal X-ray for placement of peg tube given and noted . A Nursing Note dated 12/31/20 at 5:00 PM, documented in part, . Cena (certified nursing assistant) paged this writer to the room. Cena states, I found this peg tube under the Residents blanket, out of her stomach. (Doctor name redacted) informed. New order to send resident to ER (emergency room ) for peg tube replacement . As of the start of survey 3/16/21 the physician had not assessed nor evaluated the resident since 12/28/20. On 3/17/21 the DON and administrator was asked to provide all physician consultation reports from December 2020 to March 2021. The DON and Administrator both confirmed that December 2020 was the last documented physician visit with R#707. R708 On 3/18/21 a review of R708's clinical record was conducted and revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R708's attending physician visit documentation was conducted and revealed the last documented physician visit by R708's attending physician, Dr. 'E' occurred on 12/2/20. R#709 On 3/18/21 at 11:05 am, an observation was made of R#709 laying upright in bed, with balls of yarn in front of them. When queried on how often they were seen by the facility doctor, R#709 could not recall. A review of the clinical record revealed the following: R#709 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] documented a BIMS of 15 (indicating intact cognition) and required staff assistance for all ADLs. The last physician consultation in the clinical record was dated for 10/30/20, as of 3/17/21. A Nursing note dated 12/1/20 at 6:40 am, documented in part . Spoke with (Doctor name redacted) concerning the nephrostomy tube he states when ADON (Assistant Director of Nursing) comes in have her look at it and call him . A Nursing note dated 12/1/20 at 10:55 PM, documented in part . Nephrostomy tubes left not patent, right patent and intact call into the Dr, no return call. A Nursing note dated 12/2/2020 at 7:17 am, documented in part . Nephrostomy tubes left 50 cc output, right 350 cc output, logged in DR (doctor) book to be seen. A Nursing note dated 12/26/20 at 2:50 PM, documented in part . End of shift output in R (right) Nephrostomy tube at 40cc. End of shift output in L (left) Nephrostomy tube at 30cc. Three attempts to flush with no return in drainage bags . (doctor name redacted) informed. New order to send out to ER for assessment and tx (treatment) . R#709 was readmitted back into the facility on [DATE]. The resident was not seen by the attending physician until 2/5/21, three months after their prior consult with the doctor and one month and a few days after the resident was readmitted from the hospital. On 3/17/21 the DON and administrator was asked to provide all physician consultation reports from December 2020 to March 2021. The DON and Administrator both confirmed that October 2020 was the last documented physician consultation with R#709. R710 A review of R710's clinical record was conducted on 3/18/21. The record reviewed R706 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R710's attending physician visit documentation was conducted and revealed the last documented physician visit by R710's attending physician, Dr. 'E' occurred on 11/27/20. R711 A review of R711's clinical record was conducted on 3/18/21. The record revealed R711 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R711's attending physician visit documentation was conducted and revealed the last documented physician visit by Dr. 'E', R711's attending physician occurred on 10/23/20. R712 A review of R712's clinical record was conducted on 3/18/21. The record revealed R712 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R712's attending physician visit documentation was conducted and revealed the last documented physician visit by Dr. 'E', R712's attending physician, occurred on 10/23/20. R713 A review of R713's clinical record was conducted on 3/18/21 and revealed an admitted [DATE] and a most recent re-admitted [DATE]. R713's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R713's attending physician visit documentation was conducted and revealed the last documented physician visit by Dr. 'E', R713's attending physician, occurred on 10/30/20. R714 A review of R714's clinical record was conducted on 3/18/21 and revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R714's progress notes was reviewed and revealed a note dated 11/27/20 that indicated R714's guardian had been contacted to inform them that R714's attending physician was temporarily being switched from Dr. 'F' to Dr. 'E'. A review of R714's attending physician visit documentation in the record was conducted and revealed the last documented note was dated 8/27/20 by Nurse Practitioner (NP) 'G', Dr. 'F's NP. There was no documented evidence in the record that indicated Dr. 'E' had seen the resident since R714's transfer of service from Dr. 'F' to Dr. 'E'. On 3/17/21 at approximately 12:52 PM, an interview was conducted with the Administrator regarding the facility's protocol pertaining to attending physician coverage and visitations. The Administrator reported that Dr. E who acts as the Medical Director as well as the attending physician is assigned to approximately one half of the facility's residents. According to the Administrator, Dr. E is a solo practitioner and does not have any Non-Physician Practitioners that work with him. When queried as to the lack of documentation that would indicate the Dr. E visited with residents according to their needs and the facility's policy, the Administrator indicated that they were aware that Dr. E was not recording notes into the electronic record and/or paper record. At the time of the interview, the Administrator was again asked to provide any documentation that R#701 was seen by Dr. E any time after 10/30/20. No further documentation for R#701 was provided by the end of the survey. On 3/18/21 at approximately 11:30 AM the Administrator was again asked to provide any additional documentation of physician consultation notes/reports for resident(s) #705, #706, #708, #710, #711, #712, #713 and #714. No documentation was provided by the end of survey. A review of the facility policy titled, Physician Services (released 9/2013) was reviewed and documented, in part, the following: Policy: Each resident must be under the care of a licensed physician authorized to practice medicine in the state. Each resident must be seen by their physician at least every 30 days for the first 90 days after admission, and then every 60 days thereafter .Procedure: 1. All persons admitted or accepted for care by the facility must be under the care of a physician selected by the resident or the resident's authorized representative. 2. Physician services include but are not limited to: .b. a medical evaluation of the resident .d. Advice, treatment, and determination of appropriate level or care needed for each resident; .f. Progress notes and other appropriate entries in the resident's medical record; g. Provision for alternate physician coverage in the event the attending physician is not available .Emergency physician care is available to all residents. a. If the resident's attending physician is not available when an emergency situation occurs, the covering physician on call must be contacted .

This citation pertains to Intake #MI 478 and MI 756. Based on interview and record review the facility failed to consistently ensure skin and wound assessments were completed timely, timely notify physician(s), and timely update and implement interventions to prevent the worsening of a pressure for one (R#701) of two residents reviewed for pressure ulcers, resulting in R#701 developing a small facility acquired wound to the coccyx that worsened to an unstageable (layer of dark brown/tan slough with areas of pink and yellow exposed tissue) and [CONDITION(S)] (infection of the bone) that required hospitalization and surgery. Findings include: A complaint was filled with the State Agency (SA) that alleged that due to an extreme lack of care R#701 developed a pressure sore at the facility resulting in hospitalization . R#701 A review of R#701's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderately impaired cognition) and required extensive one to two person assist for most Activities of Daily Living (ADLs). Hospital (name redacted) records (3/10/2021) documented, in part, the following: Consultation Note: (R#701) was admitted on ,d+[DATE] secondary to increased confusion at (name redacted) facility .he had decreased p.o. intake, had some moaning and increased lethargy .Gluteal decubiti inspected .extremely necrotic black foul smelling tissue presumably probing down to bone with undermining .Impression: [CONDITION(S)] pneumonia/strep bacteremia (infection) .possible etiologies include necrotic sacral decubiti 2. Necrotic Sacral decubiti with likely [CONDITION(S)] (infection of the bone that can lead to death of the bone tissue) .4. Severe dehydration .likely related to p.o. intake .Preliminary Report: Assessment/Plan .male with sacral decub which will require surgical debridement and possible wound VAC (Vacuum-assisted closure device) placement tomorrow .Final Report: Necrotic sacral decubitus ulcers s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .bacteremia 3/9 likely due to necrotic decubitus ulcer .Radiology .2. Subcutaneous [CONDITION(S)] with cortical irregularity of the mid sacrum is highly suggestive of [CONDITION(S)] . A Wound Care Consultation (Final Report) for (name redacted) Hospital dated March 10, 2021 documented: Location, Type: Sacrum, unstageable. Wound bed: layer of dark brown/tan slough in the center attached to border, with areas of pink and yellow exposed tissue .Measurements 16.5x10.4cm (centimeters) .Drainage: moderate serous with hint of green note .Odor: foul . Continued review of R#701's clinical record documented, in part, the following: 12/18/2020 (nursing note): The assigned aide reported small open area on the resident's coccyx area, assessed and a new order for Calmoseptime cream to be applied every shift and every brief change put in place and to be turned and re-position every two hours. Continue to monitor. 2/10/21 (Resident at Risk) .wound remains at risk for further break down and/or deterioration of the wound r/t (due to) incontinence and refusal to turn or reposition . 2/17/21 (Resident at Risk): Resident was seen by psych . [MEDICATION(S)] increased .Scarococcyx/Bil <sic>buttock pressure ulcer with pink necrotic base. Fragile peri wound remains at risk for further deterioration and new wound formation . 2/23/21 (Social Service Note): Writer called son regarding guardianship petition. Son reported that he filled out petition, however, hasn't taken it to the court . 3/1/2021(Nurses Note): resident's wound noted w/odor (Name Redacted) Dr. E made aware stat x-ray to r/o (rule out) [CONDITION(S)] . 3/1/21 (Nurses Note): Spoke with residents son informed of odor in wound possible infection and decline in wound . 3/2/2021 (Nurses Note): Received radiology report. No fracture seen .Please note that MRI or Nuclear Medicine bone scan are more sensitive for detecting [CONDITION(S)] . 3/4/2021 (Nurses Note): .Resident seen by Wound Dr. 3/2/2021 with recommendation to debride coccyx wound .informed Son .on 3/3/2021 of abnormal lab, new orders and recommendation of debridement of coccyx wound . 3/9/21 (Nurses Note): Resident continues with change in mental status, able to answer questions but very confused, still awaiting stat lab results. Resident to be sent to (name redacted) Hospital E.R. (emergency room ) r/t (due to) mental status change per Dr. E . 3/9/2021(Nurse Note): Resident seen by wound care Dr. H this AM . recommended peg tube placement r/t po intake as evidenced by weight loss and to move forward with debridement of sacral wound .resident continues to decline; nursing staff has expressed great concerns of acute change in mental status .Primary physician has been made aware of overall decline and gave new orders for stat labs .Resident out to hospital for further evaluation . There were no Skin and Wound Evaluations for R#701 for the month of December 2020. A Skin and Wound Evaluation (effective date 1/11/2021) documented .Type .15. Pressure. 15 (a) Stage: BLANK. 22. Location: Coccyx. 23. 1. In-House Acquired. 24. How long has the wound been present? BLANK .Wound Measurements: 1. Area 16.6 cm(centimeters) ]. Length 3.5 cm. Width 5.4, Depth: [MEDICATION(S)]. C. Wound Bed: granulation .Surrounding Tissue: 11. Fragile. G 1. Goal of Care: 1. Healable . A Skin and Wound Evaluation (effective date 1/19/2021) documented, .Type .15. Pressure .15(a) stage 2 .Acquired: 1. In-house .Wound Measurements: Length 5.6 cm, Width 4.3cm, Depth: [MEDICATION(S)]: Goal of Care: healable .Additional Care: Mobility aids provided .turning and repositioning program. Education: Resident and staff re-educated on risk/benefit of frequent turning and repositioning . A Skin and Wound Evaluation (effective date 2/23/2021) documented, .Type .15. Pressure .15(a) stage 3 .Acquired: 1. In-house .Wound Measurements: Length 7.6 cm, Width 7.8cm, Depth: [MEDICATION(S)]: Goal of Care: healable .Additional Care: incontinence management, Moister Control, Nutrition/Dietary supplementation Progress: deteriorating .turning and repositioning program. Education: Resident and staff re-educated on risk/benefit of frequent turning and repositioning . Wound Consultation Notes authored by Wound Dr. H were reviewed and documented, in part, the following: 12/22/20: Reason for visit. L heel ulcer. No documentation pertaining to wound on coccyx as noted on 12/18/20. 12/29/20: Reason for visit: Lt heel ulcer. No documentation pertaining to open area on coccyx as noted on 12/18/20. 1/5/20; Reason for visit: Lt. heel ulcer. No documentation pertaining to open area on coccyx as noted on 12/18/20. 1/12/21: Wound cite: Coccyx ulcer. Measurements L(length) 3.4 W(Width) 5.3. D(Depth) BLANK. 1/14/21: Reason for Visit: Coccyx ulcer. Measurements 5.6x4.3x.3. Wound bed pink. 1/26/21: Reason for Visit: Multiple: Coccyx ulcer. Measurements 5.0 x8.2 .wound bed pink .slough. 2/16/21: Reason for Visit: Coccyx ulcer. Measurements 8.8 x 7.9 .Treatment recommendations: Air loss mattress, Nutritional Consult . 3/2/20: Reason for Visit: Coccyx ulcer. Measurements: 9.4 x13.3 Wound bed: Pink .Necrotic .Treatment .discuss debridement with family. 3/9/20: Reason for Visit: Coccyx ulcer. Measurements 8.8 x 12.7 A review of R#701's Care Plan for Skin revealed, R#701 is at risk for impairment skin integrity/pressure injury .(revision date 12/17/2020) .Interventions: .Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician (7/11/2019), Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Provide incontinence care with each incontinent episode and as needed and apply moisture barrier cream/ointment per facility policy/orders .CANCELLED: Turn/reposition resident every hours and PRN (as needed) (7/11/19) . On 3/17/21 at 10:35AM an interview was conducted with the Assistant Director of Nursing (ADON) A. ADON A reported that in addition to working as the ADON they also served as the wound nurse starting in January 2021. When queried as to the facility acquired pressure sore to the coccyx for R#701, ADON A reported that she took over as wound nurse in January 2021 and was responsible for completing the resident's Skin and Wound Evaluations. When asked, what if any, interventions were put in place to prevent the worsening of R#701's pressure sore, the ADON reported that she may not have been updating the care plan but believed a low air loss mattress may have been ordered in January and that they were trying to reposition the resident, but he would refuse. When further queried as to why R#701 who was showing signs of foul odor in the wound around 3/1/21 and a recommendation of debridement that was made on 3/4/21 were not addressed until the resident was sent to the hospital on 3/9/21. ADON A reported they were not made aware of the foul odor noted and that they were waiting for confirmation from the family who was trying to obtain guardianship regarding the debridement and possible tube feeding placement. When further queried as to why R#701 did not receive any follow-up regarding the X-ray completed on 3/2/21 that recommended further MRI or nuclear scanning to determine [CONDITION(S)], the ADON did not provide an answer. ADON A was able to provide a Late Entry Effective Date (2/17/2021) Resident at Risk Note that indicated Action Taken: .low air mattress. However, no evidence that a mattress order or indication of an update in the care plan was provided by the end of the survey. On 3/17/21 at approximately 1:35 PM an interview was conducted with the DON. The DON reported that she had recently returned to the facility after being off for several months. The DON reported that in March 2020 she identified residents that had acquired wounds at the facility and deficient practices that may have contributed to the development/worsening of the residents wound. R#701 was identified as a resident of concern. The DON reported that the facility was in the process of undergoing several corrective actions to ensure proper treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/21 at approximately 4:47 PM a phone interview was conducted with Wound Dr. H. When queried as to why the first wound consultation was completed on 1/12/21 approximately three weeks following the identification of an open area, Dr. H reported that they are informed by the facility and he was not made aware until 1/12/21. When asked about the radiology report (3/2/21) that suggested further MRI's/bone scan to full-out [CONDITION(S)], Dr. H stated that he could not remember the results but did recall discussing a debridement. When queried as to why no debridement was implemented following the 3/2/21 consultation, Dr. H reported the facility was waiting for approval from the son. It should be noted that at the time, R#701 was still noted as his own personal representative. A review of the facility policy titled, Skin Management (revised 10/2019) documented, Policy: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .Practice Guidelines .3. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan .if a new area of skin impairment is identified, notify the guest/resident, responsible party, attending physician, DON/designees and treatment team, if applicable .Guest's/residents with pressure injury and lower extremity ulcers will be evaluated, measured and staged weekly (pressure injury only) .until resolved the licensed nurse will notify the attending physician with any changes as needed .The DON/designee will document any changes in the care plan/Kardex at the meeting .

This citation pertains to Intake # MI 273: Based on observation, interview and record review the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control Prevention (CDC) safety measures to prevent the exposure/transmission of residents to 2019 Novel Coronavirus (COVID-19) by: 1) ensure staff working on the designated COVID-19 containment unit donned new/sanitized PPE (Personal Protective Equipment) when caring for non-COVID positive residents that resided within that unit (R#s 806, 807, 808 and 813); and 2) consistently screen with verification for incoming staff/visitor temperatures and review of assessment questions/responses. The failure to follow current CDC recommendations for COVID-19 resulted in an Immediate Jeopardy (IJ) to the health and safety of all residents, many of whom were at high risk due to age and co-morbidities, to be exposed and/or develop COVID-19, given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from resulting in serious health complications from COVID-19 hospitalization s, and death. Findings include: The IJ began on 4/23/20. The IJ was identified on 5/14/20. The Administrator was notified of the IJ on 5/14/20 at 4:45 PM and a plan to remove the immediacy was requested. Although the immediacy was removed on 5/18/20, the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint filed with the State Agency on 5/13/20 included an allegation that the facility failed to follow current guidance related to infection prevention and control. On 5/13/20 at 5:50 PM, interview with the complainant by phone included concerns regarding the cohorting of and sharing bathrooms of positive and negative COVID-19 residents throughout the facility, and the lack of daily staff and/or visitor screening. An onsite investigation into the above complaint was conducted from 5/14/20 to 5/19/20. On 5/14/20 at 8:15 AM, the Administrator was queried about the facility's practices for placement of positive, presumptive, or negative COVID-19 residents. The Administrator reported the previously identified COVID-19 unit was the New admission/containment unit and further reported that residents that were admitted from the hospital were placed on that designated unit, even if negative for COVID-19 to monitor for 14 days. When asked if there were any other residents on isolation precautions throughout the facility, the Administrator reported there were. When asked why those residents on isolation were not placed onto the designated containment unit, the Administrator reported, If they were positive, we try not to move them. At that time, the Administrator was requested to provide a list of residents that were on isolation precautions, and to identify if any residents were positive for COVID-19. The Administrator reported there were four residents on the containment unit that were not positive, but being monitored due to recent hospitalization (R#s 806, 807, 808, and 813). Review of the documentation provided by the facility included lists of residents that identified 38 positive COVID-19 residents, and three presumptive positive residents. Resident #809, #810 & #811 A review of census records revealed R#809 shared/had access to an adjoining bathroom with R#811 from 2/15/20 to 5/17/20, and R#810 from 4/30/20 to 5/17/20. On 5/17/20, R#809 was moved to a different room on the same unit. A review of R#809's clinical record revealed R#809 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the physician orders [REDACTED]. As of 5/18/20, R#809 remained on contact and droplet isolation precautions. A review of R#810's clinical record revealed R#810 was admitted into the facility on [DATE] and readmitted to the facility's COVID-19/containment unit on 4/16/20 with [DIAGNOSES REDACTED]. A review of the census information revealed R#810 moved to the room shared with R#811 and adjoining bathroom with R#809 on 4/30/20. Review of the hospital discharge summary which read, .4/9/2020 .Molecular Infectious Diseases .COVID-19: DETECTED . Further review of the physician orders [REDACTED]. As of 5/18/20, R#810 remained on contact and droplet isolation precautions. There was no lab testing for COVID-19 conducted at the facility for R#810. A review of R#811's clinical record revealed R#811 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the physician orders [REDACTED]. A review of the census information revealed R#811 remained roommates with R#810 who had previously tested positive for COVID-19. There was no documentation that R#811 had any laboratory testing for COVID-19 ordered while at the facility. As of 5/18/20, R#811 remained roommates with R#810 and on contact and droplet isolation precautions. On 5/18/20 at 6:10 PM, observation of the hallway R#809, R#810 and R#811 resided revealed there were no posting of isolation precautions, or PPE available on the unit. On 5/18/20 at 6:13 PM, Licensed Practical Nurse (LPN Q) was queried about whether there any residents on contact or droplet isolation precautions and LPN Q stated, No one on isolation at this time. When asked about R#809, R#810 and R#811, LPN Q proceeded to open the door to the room shared by R#810 and R#811, entered without donning PPE and stated, Yes, they're in here. LPN Q further reported that R#809 was now in a different room in that hallway. On 5/18/20 at 6:25 PM, the Director of Nursing (DON) was queried about the lack of signage for contact/droplet isolation precautions and PPE on the unit R#809, R#810 and R#811 resided. The DON reported there had been a miscommunication with the nursing assistant who had removed the PPE and signage and that R#809, R#810 and R#811 remained on contact and droplet isolation precautions. When informed of the discussion with LPN Q, the DON was unsure why LPN Q responded as such and was unable to offer any further explanation. Resident #806, #807, #808 and #813 On 5/14/20 at 8:23 am, a review of the facility's rosters of current residents and of COVID positive residents revealed several residents that were confirmed COVID positive resided on multiple units throughout the facility, despite having a designated COVID unit. Further review of both documents revealed there were four residents that resided on the designated COVID unit that were not COVID positive. At 11:07 am, the Assistant Director of Nursing (ADON) G was queried on why on R#'s 806, 807, 808 and 813 resided on the designated COVID unit if they weren't positive for COVID and stated the four residents were not COVID positive and resided on the designated COVID unit because they were readmissions from the hospital and they wanted to monitor the residents for 14 days. When queried on why the facility had residents who were COVID positive on units (throughout the facility) instead of containing those residents on the designated COVID unit and why the four residents (who were not COVID positive that resided on the designated COVID unit) couldn't be monitored and isolated on a non COVID unit, the ADON G did not provide an answer or any additional information. At 12:53 pm, Nurse Manager (NM) F was observed on the designated COVID unit going into multiple rooms of COVID positive residents picking up lunch trays and assisting staff with care. At 12:58 pm, NM F was observed going into (room number redacted) of a resident (R#806) who was negative for COVID with the same gown that was worn when they exited the resident's room who was COVID positive. At 1:07 pm, observations were made on the designated COVID unit of Certified Nursing Aides (CNA) and Physical Therapist (PT) staff going in and out of resident's rooms who were COVID positive and COVID negative with the same Personal Protective Equipment (PPE) on. Staff failed to sanitize or don on new gowns and PPE when exiting the rooms of COVID positive residents and before entering the rooms of residents who were negative for COVID. A review of CDC's COVID-19 in Nursing Homes guidance documented in part, .Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19 .the unit will be used to cohort residents with COVID-19 .Identify HCP (health care professionals) who will be assigned to work only on the COVID-19 unit . The HCP on the COVID designated unit provided care for the COVID residents and the four residents without COVID that resided on the COVID unit. R#806 was admitted into the facility on [DATE] with a readmission date of [DATE] and [DIAGNOSES REDACTED]. R#806 was not diagnosed with [REDACTED]. The other residents that were negative for COVID and resided on the designated COVID unit were: R#807 who was admitted into the facility on [DATE] with a readmission date of [DATE] and [DIAGNOSES REDACTED]. R#808 who was admitted into the facility on [DATE] with a readmission date of [DATE] and [DIAGNOSES REDACTED]. R#813 who was admitted into the facility on [DATE] with a readmission date of [DATE] and [DIAGNOSES REDACTED]. On 5/18/20 at 7:25 am a Nurses Notes documented in part .writer noted gurgling sounds .observed resident diaphoretic (sweating heavily) .O2 (oxygen saturation) 45 room air .administered 02 went up 55% .Resident transported to (hospital name redacted) . A Clinical Discharge Summary (for R#813) dated May 6, 2020 at 9:53 am documented in part .COVID-19: Negative ., despite R#813's negative COVID results R#813 resided on the designated COVID unit upon readmission into the facility. On 5/14/20 at 4:45 pm, the Administrator was queried on the observation regarding the staff on the designated COVID unit wearing the same gowns to care for both the COVID positive and negative residents and stated the staff were trained on the correct utilization of PPE for COVID and non COVID residents and that additional training will be provided to all staff. A facility policy titled CORONAVIRUS (COVID 19) with a revision date of 4/23/20 was reviewed and revealed no documentation or guidance on placing readmitted residents with a negative COVID status on the designated COVID unit. A facility policy titled Extended use of PPE dated 4/16/20 was reviewed and contained no guidance for staff regarding the use of PPE on the designated COVID unit between residents who are COVID positive and negative. On 5/14/20 at 10:48 AM, review of the facility's screening log for nurses, vendors and visitors form 5/1/20 to 5/14/20 revealed multiple blank entries for the responses to the section that asked about symptoms experienced, temperatures, and name of the person performing the screening. Further review of the documented section which identified the name of the person performing the screen also revealed multiple entries of the staff's own initials that was reporting to work. On 5/14/20 at 10:51 AM, Certified Nursing Assistant (CNA P) was observed to enter the facility and upon checking in at the receptionist desk with Staff Q stated, Finally, someone is up here. On 5/14/20 at 10:56 AM, Staff Q was asked about the facility's screening process for staff, vendors and visitors and reported it was usually the staff with offices in the front lobby. Additionally, Staff Q reported there was usually a button that would ring to the phones or other employees would screen one another. On 5/14/20 at 11:25 AM, an interview was conducted with the ADON. When asked about the facility's screening process for staff, vendors and visitors, the ADON reported the front desk staff usually did that and if on break, or not available, staff would have to page another person. When asked who monitored the screening logs to ensure they were being completed properly, the ADON reported the front desk person and end of month take and put in a log. The ADON further reported daily staff were supposed to ensure everyone was screened and signing per shift. At that time, the ADON was asked to review the screening documentation and confirmed the blank entries and/or staff's own initials documented as name of screener. The ADON was requested to provide a facility's policy for the specific screening process, however none was provided by the end of the survey. On 5/14/20 at 1:45 PM, an interview was conducted with the DON, ADON and Administrator. Upon review of the concerns regarding the facility's screening for staff, vendors and visitors, all acknowledged the concerns. The Administrator was asked about whether there was a facility policy regarding the screenings and reported there was none. Abatement Plan: (Facility name redacted) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F880 regarding the facility's alleged failure to follow accepted standards of practice for Infection Control. Residents with the potential to be affected by the alleged deficient practice. Residents placed on Isolation and residents sharing a bathroom with a resident on isolation have the potential to be affected by this practice. Facility assessed all residents on isolation for incontinence and bathroom use to ensure residents sharing a bathroom don't have the potential to spread their infection. Residents that are currently on isolation were reassessed for the potential transfer of Covid-19 infection related shared bathroom use. As of 5/18/2020 the facility has a total of 23 residents that are on Contact/Droplet Precautions. Out of our 4 units the breakdown in isolated patients is as follows: Unit A- Resident #807 -The resident is considered [MEDICATION NAME] isolated due to returning from the hospital on [DATE]. She does not share a bathroom with any other residents. Unit B-Resident #808-The resident is [MEDICATION NAME] isolated to monitor for signs and symptoms of Covid-19 after returning from the Hospital for peg tube placement on 5/6/2020. Resident has no signs and symptoms of Covid-19. The resident is incontinent of both bowel and bladder. Resident #806-The resident is [MEDICATION NAME] isolated to monitor for signs and symptoms of Covid-19 after returning from the hospital on [DATE] for removal of her Jackson Pratt drain. The resident has bilateral Nephrostomy tubes. Both [MEDICATION NAME] isolated residents share a bathroom. Both of these residents have negative Covid-19 test results. These 2 residents are isolated due to return from a Hospital visit according to Company Policy. Resident #814 is in a Private room and the resident is continent of both bowel and bladder and she does not share a bathroom. Unit C has 2 [MEDICATION NAME] isolated residents, Resident #811 and Resident #810. Resident #810 is a previous Covid-19 positive resident that completed 14 days of isolation on the Covid-19 Unit, was transferred to (C-10-b) on 4/30/2020. On 5/7/2020 resident complained of a sore throat during his respiratory screen. The resident also has a [DIAGNOSES REDACTED].#810 history of Covid-19 both residents were placed in [MEDICATION NAME] isolation. Neither resident has displayed any signs or symptoms of Covid-19. Unit D has 16 residents that have been diagnosed with [REDACTED]. All residents, visitors, and staff have the potential to be affected by the inconsistent screening process. Facility implemented a designated staff member to conduct screening of all staff and vendors consistent with CDC guidelines. In addition screening is applicable to anyone entering into the facility and includes Hospice staff, lab techs, x-ray techs, job applicants, new hires, and Physicians. All residents that reside on our Containment unit have a potential to be affected by the deficient practice of PPE use related to ensuring donning new/sanitized PPE when going from one patient to another patient to provide care. Systemic Measures. On 5/14/2020 the facility began in servicing nursing staff regarding the potential for transmission of Covid-19 between residents utilizing the same bathroom. The facility reviewed all residents on contact/droplet precautions that have adjoining bathrooms to evaluate the possibility of transmission. After reviewing and discharging several residents off isolation it was determined there is no longer a risk of transmission related to shared bathrooms between a positive Covid-19 resident and a non Covid-19 resident. Moving forward residents on contact/droplet isolation will not share a bathroom with a non-isolated resident. On 5/14/20 the facility began in-servicing staff on the protocol for screening staff and visitors. Staff will enter and exit through the front door and complete the CDC approved screening requirements prior to the start of work and at the end of their shift have their temperature taken following CDC guidelines and recorded on the facility approved form (see attached). The individuals conducting the screens understand the actions to be taken if staff/visitor does not pass the screening. If facility does not have a designated screener (i.e. off hours) in lobby staff educated that when they allow someone access through the front door they must go to the lobby and conduct screen and that no staff member can screen themselves. Facility started in-servicing staff in all departments on 5/14/20 the process for PPE use/reuse and the appropriate way to don and doff PPE per CDC recommendations (see attached). Facility acknowledged the non-compliance concerns of staff with donning new/sanitized PPE when caring for Non-Covid to Covid-19 positive residents. To ensure compliance staff was educated re-educated on when to sanitize/change PPE when caring for residents on isolation. Administrator and DON will monitor CDC and MDS guidance for updates to policy.

Based on observation, interview and record review, the facility failed to ensure consistent compliance with facility wide systems for the prevention, identification and/or control of infections of residents pertaining to isolation precautions, and appropriate use of personal protective equipment (PPE) per Centers for Disease Control (CDC) recommendations to prevent the exposure of residents to 2019 Novel Coronavirus (COVID-19), resulting in an Immediate Jeopardy (IJ) when staff failed to identify, monitor and notify the physician of R#714's change in condition, who became symptomatic, tested positive for COVID-19 and died ; the increased likelihood and/or actual transmission of COVID-19 for residents (R#s: 703, 704, 707, 708, 709, and 713) that were exposed to symptomatic and/or positive COVID-19 residents and did not have vital signs monitored at least every shift and were not isolated for 14 days since last exposed; and multiple residents not having their nose and mouth covered when outside the room on the A, B and C hallways, as well as while in the therapy gym. These deficient practices had the increased likelihood to affect all residents (many of whom were at high risk due to age and co-morbidities) that resided at the facility to be exposed to, or contract COVID-19 resulting in serious health complications from COVID-19 including death. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:30 PM and a plan to remove the immediacy was requested. The IJ was removed on [DATE], based on the facility's implementation of the plan of removal and verified by the Surveyors on-site. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy. A facility policy titled Change in status, identifying and communicating, long-term care (dated [DATE]) documented in part, .Change in a resident's status can be identified by any employee of the facility .In a long-term care setting, it's important to identify and address any change in a resident's status from baseline .Upon recognition of a potentially life-threatening condition or significant change in status, you must communicate with other health care providers to meet the resident's needs .You should assess changes from the resident's normal status .whenever there's a change in the resident's status .As a nurse, you're responsible for communicating a resident's change in status, including the assessment findings, to the practitioner . On [DATE] at 9:30 AM, during an interview with the Administrator, when asked about the facility's Personal Protective Equipment (PPE) supply, the Administrator reported there were no concerns. On [DATE] at approximately 10:40 AM, during an observation of the facility's B-hallway, there were multiple residents observed seated in the hallway participating in an activity with staff. None of these residents were observed to have their nose and mouth covered. On [DATE] at approximately 10:40 AM, during an observation of the facility's A-hallway, there were five residents observed seated in wheelchairs in the hallway. None of these residents were observed to have their nose and mouth covered. On [DATE] at 10:45 AM, Certified Nursing Assistant (CNA A) was asked about the residents observed in the hallway and whether they were offered to wear a covering over their nose and mouth and stated, No. When asked if there were any concerns regarding the availability of PPE such as a face mask, CNA A stated, No. On [DATE] at 10:54 AM, Unit Manager B was asked about whether residents were offered to wear face masks in the hallway and reported, No masks in hall. When asked if there were any concerns regarding the availability of PPE, Unit Manager B reported there were no concerns. On [DATE] at 11:00 AM, R#703 (later identified as last exposed to a roommate (R#704) on [DATE] who was diagnosed with [REDACTED]. and access the bathroom in that room. R#703 was not observed to have any protective covering over the nose and mouth. Nursing and housekeeping staff were present in the hallway at that time, however, no one identified a concern with R#703 entering the room of another resident, nor offered to have the resident wear a face mask. Another unidentified resident was observed seated in a wheelchair behind the nursing station without their nose and mouth covered. Resident #704 and Resident #703 A review of R#704's clinical record revealed R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#704 (who shared a room with R#703 at that time) was sent to the hospital on [DATE] and readmitted on [DATE] (to the facility's COVID-19 unit) with [DIAGNOSES REDACTED].#704 expired at the facility on [DATE]. A review of R#703's clinical record revealed R#703 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of R#703's progress notes included an entry on [DATE] at 4:11 PM which read, resident placed in isolation [MEDICATION NAME] for 72 hrs (hours). The most recent documented entry was dated [DATE]. A review of R#703's vitals which included: temperature, blood pressure, pulse, respiration rate, and oxygen saturation since [DATE] revealed these were completed every shift from ,[DATE] - [DATE], but were completed once on ,[DATE], twice on ,[DATE], once on ,[DATE], none on ,[DATE], and once on ,[DATE] - [DATE]. R#703's oxygen saturation on ,[DATE] at 8:29 AM was documented as 86%. The next documented oxygen saturation was ,[DATE] at 6:49 PM. There were no progress notes to indicate whether nursing had notified the physician, implemented other interventions, or any additional monitoring had occurred. Resident #707 and Resident #708 A review of R#707's clinical record revealed R#707 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#707 (who shared a room with R#708) was sent to the hospital on [DATE] for cough and fever (103.8 degrees Fahrenheit/F). R#707 readmitted on [DATE] with [DIAGNOSES REDACTED].#708. R#707 was sent to the hospital on [DATE] for shortness of breath, dry hacking cough and fever (100.0 degrees F). R#707 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#708's clinical record revealed R#708 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#708 was sent to the hospital on [DATE] for change in status, readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of R#708's vital sign documentation from [DATE] to [DATE] revealed temperature and blood pressure monitoring were completed at least twice a day from [DATE] to [DATE], however from [DATE] to [DATE], the temperatures were only obtained once a day. The resident's blood pressure was only monitored once a day on [DATE], [DATE], [DATE], and [DATE]. There were several Warnings regarding low diastolic readings. The BP on [DATE] at 11:38 AM read, ,[DATE]. The next documented BP was on [DATE] at 9:08 AM which was ,[DATE]. There were no progress notes documented between [DATE] at 10:40 AM and [DATE] at 4:29 PM (such as any notification to the physician or implementation of other interventions and/or additional monitoring had occurred). On [DATE] at approximately 11:00 AM, the facility's Assistant Director of Nursing (ADON - who also functioned as the Infection Control and Education Nurse) provided documentation which included 16 resident names that were placed on [MEDICATION NAME] Isolation for three days (72 hours). When queried about how this length of time had been determined, the ADON reported it had been a company decision and if no symptoms, residents were removed from isolation precautions after three days. When asked about monitoring of residents' vitals at least every shift for 14 days since last exposed to positive or presumptive positive COVID-19 residents, the ADON reported the documentation that was available was under the vitals section of the electronic clinical record. Upon review of the facility's infection control policy which read, .Roommates of residents infected with COVID-19 should be considered potentially infected and not share rooms with other residents unless they remain asymptomatic for 14 days after their last exposure . the ADON was queried why the facility had not followed their policy as it reflects current CDC guidance, the ADON was unable to offer any further explanation. On [DATE] at 5:00 PM, the Administrator was interviewed regarding concerns identified with the facility's infection control practices and reported that efforts were done to attempt to stay on top of concerns but that the facility's staff, including the Director of Nursing (DON) and ADON, were out sick related to COVID-19. The DON was out of the building from [DATE] to [DATE] and the ADON was out of the building from [DATE] to [DATE]). The Administrator further reported he had worked with corporate and other facility staff to maintain processes but acknowledged the concerns identified with current infection control practices as identified during this COVID-19 survey. Resident #709 and Resident#713 A review of R#709's clinical record revealed the following: R#709 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurse's note dated [DATE] at 8:37 am, documented in part .vitals elevated temp 99.9 and cough, congestion . A Nurse's note dated [DATE] at 15:54 (3:54 pm) documented in part .100.9 given Tylenol temp 100.0 after administration. Physician ordered COVID-19 swab ordered and collected by writer .placed on droplet precaution. R#709 and R#713 remained in the same room despite R#709's symptoms and being placed on droplet precautions. Per a review of Centers for Disease Control and Prevention (CDC) guidelines which documented in part, .Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from severe infections, hospitalization s, and death .Actively monitor all residents .for fever more or equal to 100.0 and symptoms of COVID-19 .If positive for fever or symptoms, implement Transmission-Based Precautions .Identification of these symptoms should prompt isolation and further evaluation for COVID-19 . A Medical doctor note dated [DATE], documented in part .Suspected COVID-19 virus infection . A Nurse's note dated [DATE] at 23:31 (11:31 pm) documented in part, .O2 Sat 88% on RA (room air), ,[DATE]L (liters) O2 (oxygen) via NC (nasal cannula) .contact and droplet isolation cont. (continued) . A Nurse's noted dated [DATE] at 7:42 am, documented a temperature of 100.3. A Nurse's note dated [DATE] at 8:44 am, documented in part Resident is pale O2 sats ,[DATE]% until O2 was increased .Cough and SOB (shortness of breath) noted . A Nurse's note dated [DATE] at 10:15 am, documented R#709 had been transferred to the hospital. Prior to being transferred to the hospital, R#709 continued to share a room with R#713. A Resident/Guest [MEDICATION NAME] Isolation Log was provided by the Assistant Director of Nursing on [DATE], which documented the following: R#709 on droplet and contact precautions on [DATE] for 3 days and discontinued on [DATE]. R#713 on droplet and contact precautions for 3 days with no start or discontinued date documented. On [DATE] at 4:03 PM, the DON was queried on why R#709 wasn't isolated after displaying symptoms (consistent with COVID-19) on ,[DATE] and why R#713 remained in the room (with R#709) despite R#709 being placed on isolation precautions and no further explanation/information was provided by the end of survey. A facility policy titled Containment Unit (COVID 19) Clinical Guidelines (dated [DATE]) documented in part, .When placing Guests/ Residents on the containment unit, consider placing Guests/Residents that are showing signs/symptoms of COVID 19, and not tested , in a room together .Place a guest/resident with a suspected or confirmed COVID 19 [DIAGNOSES REDACTED]. Place a mask on the guest/resident prior to moving the guest/resident . Review of the facility's Guidelines Coronavirus (COVID 19) dated [DATE] documented, in part: .If signs/symptoms are present, whether suspected or confirmed COVID 19 .If the guest / resident was previously sharing a room with another guest / resident, then the roommate should be placed on droplet and contact precautions as well .Use droplet and contact precautions, including gowns, gloves, masks and protective eyewear .Follow CDC guidelines on what PPE (Personal Protective Equipment) should be used . Review of the facility's Michigan Department of Health & Human Services (MDHHS) information sheet dated [DATE] provided for review documented, in part: .Roommates of residents infected with COVID-19 should be considered potentially infected and not share rooms with other residents unless they remain asymptomatic for 14 days after their last exposure .Ideally maintain precautions for residents on the unit until no additional clinical cases for 14 days or until cases subside . Review of the CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes guidelines, .Encourage residents to remain in their room .except for medically necessary purposes. If they leave their room they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing . (Facility Name) Removal of Immediate Jeopardy (Facility Name) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy for F880 regarding the facility's alleged failure to follow accepted standards of practice for Infection Control. Resident identified to be affected by the alleged deficient practice. Resident #703 Resident continues to reside in the facility. Resident #704 Resident no longer resides in the facility. Resident #707 Resident continues to reside in the facility. Resident #708 Resident no longer resides at the facility. Resident #712 Resident continues to reside in the facility. Resident #714 Resident no longer resides at the facility. Residents with the potential to be affected by the alleged deficient practice. On [DATE] the 98 current residents within the facility were assessed for signs and symptoms of COVID-19. 98 out of the 98 residents had an additional respiratory screen completed and were assessed for cough shortness of breath and sore throat along with a complete set of vital signs including blood pressure, pulse, temperature, respiratory rate and pule oximetry. On [DATE] out of the 98 residents that were assessed, there were 15 residents that were previously diagnosed as COVID-19 positive. On [DATE] the facility discontinued current policy of three day isolation for presumptive residents. Moving forward the facility implemented the CDC guidelines related to isolation observation (see CDC attachment). The facility also increased observation of residents that are confirmed and presumptive. Residents will be placed in isolation for 14 days and at the end of the 14 days the infection control nurse/designee will review the resident electronic medical record to make sure that the resident no longer exhibits any signs and symptoms of COVID-19. Ultimately the DON and ADON will be the only personnel allowed to approve d/c (dis-continuation)of isolation precautions. The facility will continue to utilize CDC guidance to determine if the resident is deemed appropriate to be discharged off isolation precautions. On [DATE] the current residents and future residents that are persons under investigations for COVID-19 along with their roommate will remain in droplet isolation precautions in the room in which they currently resident with the door closed in accordance with the CDC guidelines. If the resident is asymptomatic the resident will remain in isolation according to CDC guidelines. The facility will utilize CDC guidance (see CDC attachment). In-service training will be ongoing for licensed nurses of the requirements to notify physician of residents change in condition. On Wednesday [DATE] facility started in-servicing afternoon and midnight staff regarding the CDC guidance that all residents must be wearing a face mask outside of their room including residents receiving therapy in the therapy gym. License Nurses will be in-serviced on how to identify an change of condition and notification of physicians during the change of status with expected COVID-19 symptoms. Licenses nurses' will observe respiratory status and vital signs each shift. Prior to leaving the room residents will be donned with a mask for protection. On [DATE] staff was in-serviced of the importance and monitoring of resident to have a mask on. Systemic Measures. There are currently 121 ofemployees <sic>. Re-education of employees began on [DATE] regarding F-Tag F880. Ongoing in-services to employees will continue as it relates to COVID-19 policies. In-services began as it relates to tag F880 IJ. The following in-services were conducted: Identify reassessment and monitoring of resident exposed to symptomatic or suspected COVID 19 patients. Nurses are to increase monitoring by obtaining vital signs every 4 hours for presumptive residents that exhibits signs and symptoms, documentation of isolation and monitoring every shift. All resident that room with a COVID 19 positive resident must go on droplet and contact isolation for 14 days. Notifying physician as it relates to change of condition: License nurses should notify physicians with any change of condition related to COVID-19 and document findings. Any resident that exhibits s/s of COVID 19 must be tested and placed in droplet and contact isolations. Interventions must be put into place to treat signs and symptoms. Insuring the staff monitors the appropriate usage of PPE for the residents: All residents that are out of their room will wear a face mask PPE, including while in therapy, activities or being transported throughout the facility. The facility has the following PPE available to staff and residents, disposable gowns, reusable gowns, N95 masks, surgical masks, face shields and googles <sic>, gloves. Currently, there is no shortage of PPE. On [DATE] resident was provided with PPE as necessary. Per facility guidelines as stated by CDC the facility will provide PPE mask for all current and future residents. Beginning on [DATE] staff was educated on the importance of when a resident is noted to be in common areas that residents are to be wearing face mask PPE. The Director of nursing/designee and Nursing Home Administrator will continue to contact the CDC and Oakland County Health Department for updated guidelines and recommendations. The Director of Nursing/designee and NHA will continue to review and make all attempts to have consistent staffing care for the residents on precautions and on the dedicated COVID-19 unit. On [DATE] the DON, administrator, Medical Director and Interdisciplinary Team members reviewed current practices that placed residents and employees at risk for becoming symptomatic and positive of COVID-19. A plan of correction was developed and initiated to the above mentions of our policies.

Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychoactive medication for three (#s 86, 40, and 82) of six residents reviewed for unnecessary medications, resulting in residents remaining on psychoactive medication without adequate indication for use, without documentation of non-pharmacological interventions, without signed consent, without identification of resident specific targeted mood/behaviors and the failure to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence leading too a decreased quality of life. Findings include: Resident #86 On [DATE] at approximately 10:00 AM, R#86 was observed in their room, seated in their wheelchair. R#86 was interviewed regarding life in the facility and answered interview questions appropriately. A review of R#86's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#86's most recent Minimum Data Set assessment dated [DATE] revealed R#86 was cognitively intact as indicated by a Brief Interview for Mental Status score of 13 out of 15, was not coded for any hallucinations, did not exhibit any behaviors, and required extensive assistance of one to two staff members for activities of daily living. Review of R#86's record also indicated R#86 had not been deemed incompetent, was their own responsible party, and had a career as a psychologist. A review of R#86's psychiatric consultation notes, social services notes, and nursing notes was conducted and revealed the following: A Psychiatric Consultation note by Nurse Practitioner (NP) 'D' dated [DATE] that read, .Complaint: Initial psychiatric assessment to assist in treatment planning/medication management .She admitted to the facility on .[MEDICATION NAME] (antipsychotic medication) 25mg (milligrams) Qhs (at bedtime). Per discharge paperwork [MEDICATION NAME] was prescribed for[NAME]Bonnett Syndrome (a condition that some people get when they lose some or all their vision. It causes them to have visual hallucinations). There are no behaviors noted by staff .Patient reports she is feeling alright. Appeared adequately groomed, well nourished, speaking clearly and legally blind .Patient states she believes her medications may be causing her hallucinations . A Social services Noted dated [DATE] by Social Work Tech 'C' that read, Writer spoke with (R#86) [DATE] re: [MEDICATION NAME] .use. (R#86) appeared irritable and upset, stating that she believes the start of [MEDICATION NAME] by her physician (prior to admission to current facility) is what caused her to experience hallucinations. (R#86) recognizes that she experiences hallucinations, and informed writer matter-of-factly <sic> that she will not be taking the [MEDICATION NAME] . It was noted the Social Services note went on to explain that Social Work Tech 'C' contacted R#86's daughter and explained that R#86 did not want to take [MEDICATION NAME]. The note documented the conversation between R#86's Daughter and Social Work Tech 'C' and continued to read, .(R#86) had taken a trip to China, and had to take [DIAGNOSES REDACTED] medication .Daughter stated that the [DIAGNOSES REDACTED] meds may have been found to cause[NAME]Bonnet Syndrome. She also stated that Dementia may also be a part of it as well. (R#86's) Neurologist did not see any evidence of Dementia 2 years ago .Per daughter (R#86) is legally blind and can 'see' in her mind what she is hearing, which may contribute to her hallucinations as well. A Psychiatric Consultation note by NP 'D' dated [DATE] that read, .She frequently refuses medication, stating she is trying to figure out why she is having the hallucinations by systematically eliminating medications. She is alert and oriented .Gdr (gradual dose reduction) started on [MEDICATION NAME] .We discussed her hallucinations, and the likely cause being[NAME]Bonnett syndrome, and she says, 'I know, but maybe it isn't.' Says she <sic> hallucinations do not cause her stress so she, 'Isn't too concerned.' A Psychiatric Consultation note by NP 'D' dated [DATE] that read, .She frequently refuses medication, stating she is trying to figure out why she is having the hallucinations by systematically eliminating medications. She is again alert and oriented .Mood is calm and pleasant. Gdr attempt started on [MEDICATION NAME] .at last visit . A Psychiatric Consultation note by NP 'D' dated [DATE] by NP 'D' that read, .She frequently refuses medication, and a gdr of [MEDICATION NAME] was started on [DATE] .Seen last on [DATE] <sic> ([DATE]) in the dining room .[MEDICATION NAME] was discontinued, and [MEDICATION NAME] (anti-psychotic medication) 0.25mg po (orally) qhs (at bedtime) was added to treat her ongoing visual hallucinations. She is seen in her room, and is alert and oriented, and her mood is again calm and pleasant .ASSESSMENT & PLAN .Plan: Increased [MEDICATION NAME] to 0.25mg po qd (daily) and 0.5mg po qhs . It was noted the consultation note did not demonstrate that the hallucinations R#86 was experiencing were causing R#86 any distress. A review of the nursing notes from [DATE] when the [MEDICATION NAME] was changed to [MEDICATION NAME] until [DATE] when the [MEDICATION NAME] dose was increased after initiation on [DATE] was conducted. The notes document R#86 was experiencing hallucinations and was refusing medications, however; clinical documentation did not indicate that the hallucinations were distressing to R#86 and did not include any types of non-pharmacological interventions utilized by staff to address the hallucinations. A Psychiatric consultation note dated [DATE] by NP 'D' that read, .She frequently refuses medication .Seen last dose <sic> was [DATE]. [MEDICATION NAME] 0.25 mg po qhs was added on [DATE] to treat her ongoing visual hallucinations, and on [DATE], [MEDICATION NAME] was increased to 0.25 mg po qd, and 0.5mg po qhs. She is seen in her rom <sic> and is alert and oriented, and her mood is again calm and pleasant. Per resident and staff, hallucinations persist. Increased [MEDICATION NAME] hs dose to 1mg . It was noted the consultation note did not identify any targeted behaviors or descriptions of the hallucinations that demonstrated they were causing R#86 any type of distress. A review of nursing progress notes from [DATE] to [DATE] when the [MEDICATION NAME] hs dose was increased from 0.5 mg to 1 mg was conducted and revealed periods of refusing medications, however; the notes did not address the hallucinations as causing R#86 any types of distress or any types of non-pharmacological interventions attempted by staff to address the hallucinations. A Psychiatric Consult Note by NP 'D' on [DATE] that read, .Psych increased Risperidal ([MEDICATION NAME]). (R#86) continues with periods of hallucinations and delusions. (R#86) periodically refuses her meds and eye drops .Pt. (patient) reports that the hallucinations she has she will eventually realize that they are not real. Pt. admits that they are very impressive hallucinations. Pt reports that she doesn't have hallucinations when she doesn't take the medication . A Psychiatric Consult Note by NP 'D' on [DATE] that read, .Increased [MEDICATION NAME] to 0.5mg qd, and continue 1 mg po qhs .intermittently complains of hallucinations . It was noted the consultation report did not identify any targeted behaviors or descriptions of the hallucinations that demonstrated they were causing R#86 any type of distress. A review of nursing progress notes from [DATE] to [DATE] when the daily dose of [MEDICATION NAME] was increased from 0.5mg to 1mg was conducted and did not reveal any evidence that R#86's delusions were causing R#86 significant distress. On [DATE] at 3:05 PM, R#86 was observed in their wheelchair in their room. An interview was requested with R#86 and R#86 agreed. During the interview, R#86 was asked about her history with antipsychotic medications including the [MEDICATION NAME] and the [MEDICATION NAME]. R#86 stated, I refused to take the [MEDICATION NAME]. R#86 was asked if they were aware if they were on another type of antipsychotic medication and stated, I don't know, I think so. At that time, R#86 was queried if [MEDICATION NAME] sounded familiar and she indicated she believed she was on the medication. R#86 was queried if they ever refused the medication and stated, I used to, but I just gave up because they won't listen to me. I just take them now. R#86 went on to state, No one believes me, everyone thinks I'm crazy. I'm a smart woman and I think I have hallucinations because of the medications. I tie it to the medications. After two days of stopping them I don't have hallucinations. When they come to talk to me, they just think I'm crazy and they don't listen to me. R#86 was asked to describe her hallucinations and stated, I'm blind, I have a fear of depths. Blind people, we don't trust our perceptions and then we can go into hallucinations. I think the pills make it worse. I just threw my hands up and gave up the fight, I just take them now because no one listens to me. At that time, R#86 was observed to become visibly upset and started crying. R#86 then, through tears, stated, Those pills ruin my days, I feel like I lose days at a time because of them. After a few moments, R#86 was asked if she was fearful of the hallucinations and stated, They aren't terribly scary. They are just very detailed. R#86 continued to state, It's like this, if I know there are hanging lamps in the room then, even though I am blind, I can see hanging lamps. When R#86 was informed her concerns with her antipsychotic medications was going to be looked at, R#86 appeared very grateful and stated, That's an answer to my prayers, plus, aren't those medications dangerous for the elderly? I would like someone to look into it. When I report it, I think I report it rationally enough that they still just think I'm crazy, but I'm not. I wish someone would do a study on my case. On [DATE] at 3:35 PM, an interview with NP 'D' was conducted regarding their role in R#86's care. NP 'D' was asked about R#86's medication regimen and reason for antipsychotic medications and stated, She has hallucinations I think related to the[NAME]Bonnett Syndrome and she was refusing the [MEDICATION NAME] so it got changed to [MEDICATION NAME]. NP 'D' was asked where he obtained his information to justify the change from [MEDICATION NAME] to [MEDICATION NAME] and the multiple increases in the [MEDICATION NAME] and indicated that he reviewed progress notes and talked to the staff. NP 'D' was queried why a trial of discontinuing the the antipsychotic medications after the refusals wasn't attempted and stated, She was still having hallucinations and was refusing her eye drops. NP 'D' was then asked if it was R#86's right to refuse medications and whether that would be an appropriate indication for the increase in the medications and stated, Yes, it's her right, but she was refusing medications such as her eye drops that were supposed to be helping her. NP 'D' was then asked if R#86's hallucinations were causing distress to R#86 and stated, No, not when we first started, but they became distressing. When queried where the evidence was of the distress, NP 'D' again indicated he referred to the progress notes. NP 'D' was then asked about specific targeted behaviors, descriptions of the hallucinations, ongoing monitoring of the behaviors and hallucinations, non-pharmacological approaches at management, and evidence that the hallucinations were causing causing distress to R#86, and NP 'D' indicated the nursing staff should be documenting it. NP 'D' then stated, Good luck with that, she is going to be a bear for the staff. She isn't going to be honest with them, and she might be manipulating you. NP 'D' was queried if he ever felt R#86 had been manipulating him during his visits with her and stated, I just question her judgement. A thorough review of R#86's clinical record was conducted and revealed some documentation that R#86 experienced hallucinations and periods of refusing medications, however; R#86's clinical record did not demonstrate the specific targeted behaviors, descriptions of the hallucinations, the ongoing monitoring of the behaviors and hallucinations, any non-pharmacological interventions attempted in response to the behaviors or hallucinations, or any evidence that the hallucinations R#86 experienced were causing them distress. On [DATE] at 4:11 PM, a follow-up interview with NP 'D' was conducted in the presence of the survey team. NP 'D' was asked if they participated in any type of behavior management meetings with the facility staff and indicated they did not. NP 'D' then stated, Hallucinations themselves are not normal, that in itself is distressing, because it's not normal. Keep digging, you'll find problems everywhere. On [DATE] at 10:30 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding the management of R#86's antipsychotic medications. The DON acknowledged the concerns presented to them with regards to the dose increases in the absence of evidence of distress, ongoing behavior monitoring, and the absence of evidence of non-pharmacological. The DON was asked if NP 'D' attended any types of interdisciplinary meetings and indicated that she believed he attended one, but she would have to check. No documentation was provided by the end of the survey. Resident #40 On [DATE] at 9:49 AM, R#40 was observed seated in a wheelchair next to the medication cart. At that time, nursing staff was observed repeatedly asking the resident to sit down as the resident attempted tried continuously to get up from the wheelchair. R#40 was unable to participate in an interview due to significant cognitive impairment. Review of the clinical record revealed R#40 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#40 had severe cognitive impairment, had no hallucinations or delusions, had no behavioral concerns, had received antipsychotic medication on a routine basis, had a gradual dose reduction (GDR) on [DATE], and had no physician documentation that a GDR was clinically contraindicated. Review of R#40's Order Recap Report which included physician orders [REDACTED].#40 received multiple antipsychotic (AP) and antianxiety (AA) medication ([MEDICATION NAME] (AP), Quetiapine [MEDICATION NAME] (AP), [MEDICATION NAME] (AP), [MEDICATION NAME]/[MEDICATION NAME] (AA)) had been prescribed without adequate documentation of the resident's specific targeted symptoms and/or supporting documentation of mood/behaviors to warrant continued use of these medications. Review of the current physician orders [REDACTED]. Ordered [DATE]: [MEDICATION NAME] Tablet 2.5 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] related to Delusional Disorders. Ordered [DATE] (which had been increased from 5 MG that had been started on [DATE]): [MEDICATION NAME] Tablet 7.5 MG Give 1 tablet by mouth at bedtime related to Delusional Disorder. Ordered [DATE] (same dose and had been re-ordered on [DATE] through [DATE]): [MEDICATION NAME] Tablet 0.5 MG Give 1 tablet by mouth at bedtime for Anxiety related to Anxiety Disorder. Ordered [DATE] through [DATE]: [MEDICATION NAME] Tablet 0.5 MG Give 1 tablet by mouth every 24 hours as needed for Anxiety related to Anxiety Disorder. Review of the P[NAME] Response History for Behavior Monitoring: Fabricating Stories for the past 30 days (max look back period available for review) revealed there were no documented behavior symptoms from [DATE] to [DATE]. Review of the interdisciplinary progress notes from [DATE] to [DATE] from when the antipsychotic medications had been prescribed revealed there was no adequate documented evidence of R#40 exhibiting distressing delusions/hallucinations. Some documented entries included multiple attempts by the resident attempting to get up without assistance from bed and wheelchair which resulted in falls, asking for family members, repeating the rosary prayer, and hitting at staff at times during care. Some of the entries were documented at times the resident had been treated with antibiotic medication for a urinary tract infection. Review of the recent PRN [MEDICATION NAME] administrations revealed inconsistent documentation of what specific behaviors were exhibited, and what specific non-pharmacological interventions had been attempted prior to administering the medication. administrations. A review of R#40's psychiatric consultation notes was conducted and revealed the following: Between the psychiatric consultation conducted [DATE] and [DATE], there was no documented entries in the EMR that identified any behaviors of distressing delusions/hallucinations. A Psychiatric Consultation note by Nurse Practitioner (NP) 'D' dated [DATE] that read, .Complaint: Follow up, delusions, med efficacy eval .Staff reported intermittent mood changes, agitation, and delusions, and on [DATE], added [MEDICATION NAME] 25 mg po qhs (every evening). [MEDICATION NAME] was found ineffective and therefore d/c'ed (discontinued), and [MEDICATION NAME] 5 mg po qhs was added on [DATE]. [MEDICATION NAME] was increased to 7.5 mg po qhs, and [MEDICATION NAME] changed to 0.5mg po qhs, and 0.5mg po qd (every day) prn (as needed).on <sic>[DATE], r/t increased delusions .Staff report increased daytime delusions, and anxiety persists, and [MEDICATION NAME] 2.5mg po qd was added, and [MEDICATION NAME] was changed back to 0.5mg po q12hrs, and 0.5mg po qd prn to continue .Assessment & Plan .[MEDICAL CONDITION] with late onset .Dementia in other diseases classified elsewhere with behavioral disturbance .Anxiety disorder due to known physiological condition .Changed [MEDICATION NAME] to 0.5mg po bid, and continue prn [MEDICATION NAME] .[MEDICAL CONDITION] with delusions due to known physiological condition .(deteriorated) .Continue [MEDICATION NAME] to 7.5mg po qhs, and added 2.5mg po qd .Behavioral Management Planning: Continue present management. Will continue to follow up . There were no resident specific details of what delusions were being reported, as well as no documentation in the clinical record of any specific behaviors to warrant the continued use of and increase in these medications. R#40 has had notable increased lethargy and falls following these medication changes. A nursing note dated [DATE] at 6:59 AM that read, .as CNA (certified nursing assistant) was making rounds res was observed attempting to get out of bed without assistance . A Psychiatric Consultation note by NP D dated [DATE] that read, .Complaint: Follow up, delusions, med efficacy eval .Staff reported intermittent mood changes, agitation, and delusions, and on [DATE], added [MEDICATION NAME] 25mg po qhs. Delusions, mood changes, and combative behaviors continue. [MEDICATION NAME] ineffective. D/c'ed [MEDICATION NAME], and added [MEDICATION NAME] 5mg po qhs added on [DATE] .Increased delusions, and daytime lethargy. Increased [MEDICATION NAME] to 7.5mg po qhs, and changed [MEDICATION NAME] 0.5mg po qhs, and [MEDICATION NAME] 0.5mg po qd prn x 14 days .intermittently complains of paranoia; intermittently complains of mental disturbance .+Delusional Material expressed (no specific details of what, if any, the delusions were) .Dementia in other diseases classified elsewhere with behavioral disturbance .Dementia in other disease classified elsewhere without behavioral disturbance .Anxiety disorder due to known physiological condition .GDR over sedated - changed [MEDICATION NAME] to 0.5mg po qhs, and 0.5mg po qd prn .[MEDICAL CONDITION] with delusions due to known physiological condition .(deteriorated) .Increased [MEDICATION NAME] to 7.5mg po qhs .Behavioral Management Planning: Continue present management .Continue to monitor and document any changes in mood or behavior . A Psychiatric Consultation note by NP D dated [DATE] that read, .Complaint: Follow up, delusions, med efficacy eval .Staff reported intermittent mood changes, agitation, and delusions, and on [DATE], added [MEDICATION NAME] 25mg po qhs. Delusions, mood changes, and combative behaviors continue. [MEDICATION NAME] ineffective. D/c'ed [MEDICATION NAME], and added [MEDICATION NAME] 5mg po qhs added. Continue to monitor and document mood changes and behavioral disturbances .intermittently complains of paranoia; intermittently complains of mental disturbance .+delusions; intermittently complains of irritability; intermittently complains of agitation .(no specific details of what, if any, the delusions were) .Dementia in other diseases classified elsewhere with behavioral disturbance .Dementia in other disease classified elsewhere without behavioral disturbance .Anxiety disorder due to known physiological condition .Continue [MEDICATION NAME] as ordered .[MEDICAL CONDITION] with delusions due to known physiological condition .(deteriorated) .Discontinued [MEDICATION NAME] - ineffective .Continue [MEDICATION NAME] 5mg po qhs .The risks of antipsychotic therapy include increased risks for cardiovascular and [MEDICAL CONDITION] events .and mortality. However, the medication benefits such as improved quality of life by a decrease in distressing delusions, hallucinations and agitation outweigh any of the aforementioned risks .Continue to monitor and document any changes in mood or behavior . (There have been not documented episodes of distressing delusions, hallucinations, or severe agitation.) Resident #82 On [DATE] at 12:35 PM, review of the clinical record revealed R#82 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], R#82 had severe cognitive impairment (scored ,[DATE] on BIMS), had no hallucinations or delusions, had no behavior concerns, received antipsychotic medication on a routine basis with the last attempted GDR on [DATE], and the section that asked Physician documented GDR as clinically contraindicated was marked 0.No. Review of the current physician orders [REDACTED].>Ordered [DATE], [MEDICATION NAME] tablet 25 mg give 0.5 mg tablet by mouth at bedtime related to Delusional Disorder. Ordered [DATE], discontinued [DATE], [MEDICATION NAME] tablet 25 mg give 25 mg by mouth at bedtime related to Delusional Disorder. Review of the P[NAME] Response History for Behavior Monitoring: (Specify) did not identify specific targeted behaviors (left blank) and was check marked under None of the above observed from [DATE] to [DATE]. (The maximum look back period was 30 days.) Review of the Behavior Note available in the EMR was last documented in (YEAR). Review of the Resident At Risk (name of company) progress notes available for review from [DATE] to [DATE] revealed no behaviors or mood concerns since the last GDR on [DATE]. There were no identified resident specific behaviors to warrant continued use following successful GDR notes. There was a GDR on [DATE], however the resident remains on this antipsychotic medication without any specific targeted clinical justification. Review of the care plans included: (Name of R#82) has a [DIAGNOSES REDACTED]. She receives anti-depressant and anti-psychotic medications. She exhibits periods when she speaks to her (deceased ) son out loud in her room.[NAME]has believed he is coming to her via sea in a boat. Followed by psych as needed. Mood currently at baseline. (initiated on [DATE], revision on [DATE]) Review of the most recent Social Service-Re-eval dated [DATE] documented 2. No for: Has the resident experienced any change in their mood/behavior status since the last assessment. the question that asked Is the resident receiving any psychoactive medications? was marked 1. Yes. The section for Additional Information documented, (name of R#82) remains alert and verbal with periods of confusion and forgetfulness due to dx dementia. She also has dx depression and delusional d/o. She is followed by psych as needed and receives [MEDICATION NAME] and [MEDICATION NAME]. Her mood is at baseline (There were no specific resident targeted behaviors documented.) On [DATE] at 4:00 PM, SWT C was asked about R#82's behaviors and use of antipsychotic medication. At that time, SWT C reviewed the EMR and reported there were no behaviors documented. When asked what the facility's process was for ensuring documentation and reporting of changes in resident's behaviors, SWT C stated, CNA should let the nurse know or put in the clinical alerts. We review those at weekly At Risk meetings. SWT C was requested to provide any further documentation of R#82's behaviors and psychiatric consultations since (MONTH) 2019. Review of the documentation provided by SWT C revealed there was no adequate documented evidence that R#82 had exhibited distressing delusions/hallucinations. On [DATE] at 4:15 PM, Psychiatric Nurse D was interviewed regarding both R#40 and R#82's use of psychoactive medications. When asked about the clinical justification to support continued use of these medications, how this information was obtained such as were staff asked, or was there any documentation to show what specific behaviors were exhibited, Psychiatric Nurse D stated, What staff say. Just ask me. There is no documentation. You can go into any building, it's not there. When asked if he participated in the facility's behavior management to assist with identifying resident specific targeted behaviors and approaches, Psychiatric Nurse D reported, No. Review of the facility's Psychoactive Medication Management policy dated, Revised: ,[DATE] documented, in part: .Residents receiving psychoactive medicaitons to treat behavioral symtpoms are evaluated, monitored, and managed by the interdisciplinary team including, but not limited to, facility clinical staff, practitioner, and a pharmacist. The interdisciplinary team works with the resident and/or family/legal representative to determine an appropriate plan of care to treat the cause of the symptoms .Non-pharmacologic interventions are the first choice in management of behavioral symtpoms .Confirm and document that the resident .has been informed of the purpose and potential side effects of the psychoactive medication on the Psychoactive Medication Informed Consent form .A Resident at Risk meeting will be conducted weekly by the Interdisciplinary Team and any changes documented in the care plan at the meeting .

Based on observation, interview and record review the Facility failed to ensure the proper use of a Hoyer lift for the transfer of one (#21) resident out of six residents reviewed for falls/accidents from a total sample of 30, resulting in Resident #21 sustaining a fractured patella (knee cap), pain and a hospital stay. Findings include: On 06/26/18 at 08:48 AM a record review was conducted for Resident # 21 and documented, that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Residents MDS (minimum data set) dated 3/27/18 indicated that the Resident had a BIMS (brief interview for mental status) score of 3/15 (severely cognitively impaired) and required extensive two person assist for all transfers and bed mobility. A review of the Resident's Care Plan noted Hoyer lift X2 (dated 3/20/18). Continued review of the Resident's medical record documented, in part, the following progress notes: 5/12/18: Resident transferred to Hospital (name redacted) via EMS (emergency medical service) 2 personal resident sent r/t knee injury 5/14/18 Resident arrived to facility from Hospital (name redacted) at 1800 via stretcher .Brace to left extremity noted due to patellar fracture. No nursing progress notes reviewed detailed any information pertaining to date, time or cause of the knee injury. Further Review of Resident #21's clinical record documented a Physician note dated 5/11/18 - (authored by Physician L ) that read, in part, Reason for appointment: Right knee pain, follow up on X-ray Details .Patient with acute onset of pain in the right knee the x-ray shows [MEDICAL CONDITION] aspects of the patella .upon examination of the knee patient does seem to have swelling and effusion and extreme tenderness .staff has not reported any falls or injuries or any other incidents related to the findings. Pt was sent out to the hospital due to fractured effusion and poorly controlled pain .Since patient is currently .in bed tonight and not have physical activity I will send the patient first thing in the morning and he is agreeable to that. Will continue to pain management A review of Resident #21's MAR (medication administration record) dated 5/11/18 at 2248 indicated that the Resident had a pain level of 9/10 and was provided [MEDICATION NAME] ( a narcotic used to treat pain). On 06/27/18 at approximately 09:36 AM an Interview was conducted with Resident #21. Resident #21 was alert, but presented with confusion at times. When queried as to whether Resident #21 recalled having a fractured knee, the Resident responded Yes. When queried as to his recollection as to how the knee was fractured, Resident #21 stated, I was hit with a pipe when I was doing construction and boy did it hurt. When asked if it happened recently, Resident #21 stated, I think so, but was not able to provide a date/month. When asked if he every reported the incident to anyone, Resident #21 stated, I think so, but I don't know who. When asked if he recalled going to the Hospital, Resident #21 stated, Yes, I think so. On 6/26/18 at approximately 08:40 AM review of a Facility I & A (incident and accident) report and dated 5/11/18 was reviewed and documented, in part, the following: Person involved: (Name redacted/ Resident #21) .time of day: 23:00 Date of Occurrence .5/10/18 . Location of Injury: .pain right knee .Describe the nature of the Accident/Incident .: Resident c/o (complains of) pain in the right knee. Writer pulled cover off of resident to assess knee and noticed redness and swelling resident stated, I hit my knee while being assisted with transferring .Physician statement: order x-ray right knee . Additional investigation documents pertaining to the 5/11/18 I & A were reviewed and documented, in part, the following: A hand written document titled statement of (name redacted) dated 5/11/18 read as follows, Went in to get up around 5:00 PM c/o knee and foot. Left foot & R knee. He said he was banged up earlier. I asked him if he was still in pain. I looked at his knee and it didn't look swollen or hurt it looked normal. Statement of (name redacted) CNA (certified nursing assistant) K. On 06/27/18 at 10:54 AM a record review and interview was conducted with CNA K . CNA K was queried to Resident #21 and the fractured knee. CNA K reported that Resident #21 complained of pain in his knee sometime on 5/10/18 around dinner time. CNA K was queried as to the statement that Resident #21 was banged up earlier CNA K stated, Resident #21 told me that he was hit with a pole. He could give me much more information and told me that it hurt so I told a nurse, I believe it was Nurse M. When queried if she had used the lift for the Resident on that date, CNA N reported, No. A hand written document dated 5/11/18 at 10:30 PM .used the Hoyer lift 5/10/18 .He was c/o their process. He was fussing. He was fussing. I don't recall the lift hitting him at all. It was just a natural transfer. He was talking .Statement of CNA J. A review of CNA J personnel file documented that CNA J last day worked in the Facility was 5/11/18. On 6/27/18 at approximately 10:00 AM a phone interview was conducted with CNA J . CNA J reported that she no longer worked at the Facility and that the last day of work was on 5/11/18. When queried as to the incident regarding Resident #21, CNA J stated, I really don't remember any of the Residents by name. I only worked on the floor at the Facility for two days. I was in orientation. I do remember that a Nurse talked to me and asked me a few questions about a Resident that got hurt. I don't remember what I said. I never signed anything. I never went back to work there (the Facility) because of family issues. A hand written document dated 5/11/18 was reviewed and documented the following5/11/18 left message x2 8:30 pm/9:30 pm .spoke with (name redacted/ CNA J ) CNA J did not recall anything happening to resident and he and CNA J transferred him and did not remember him c/o or appearing to be in pain .statement taken by person on 5/14/18.) On 06/27/18 at approximately 10:08 AM a phone interview was conducted with CNA I. CNA I reported that he no longer works at the Facility and worked in the Facility for about one month because it was not a good fit for him. When queried about Resident #21, CNA I stated, I became a CNA in (MONTH) (YEAR). My first job as a CNA was at the Facility beginning in April. I remember Nurse A called me to interview me about Resident #21. I never had to sign a statement. I don't remember much. I don't remember using a Hoyer lift. The only thing I really remember about Resident #21 was that he didn't like to have his clothes changed. On 06/27/18 at 10:24 AM an interview and record review was conducted with the Director of Nursing (DON ) and Nurse A regarding the injury (patella fracture) of Resident #21. Nurse A indicated that she was involved in the investigation pertaining to Resident #21 and had taken statements from staff and Resident #21. Nurse A reported that the Resident indicated that he hit his knee when he was being transferred. Nurse A further reported that she believes the incident occurred on 5/10/18 before 5:00 PM. Nurse A indicated that she interviewed both CNA I and CNA J and documented their statements on a piece of paper. Nurse A further indicated that Nurse M called the physicain and an X-ray was completed on 5/11/18. Nurse A stated, Following the X-ray, the Resident was sent to [MEDICAL TREATMENT] and when he returned he was assessed by Physician L the evening of 5/11/18 and pure the physicain's order, Resident #21 was sent to the hospital on [DATE] and treated for [REDACTED]. On 06/27/18 01:30 PM an Interview was conducted with the Administrator regarding the incident involving Resident #21. The Administrator reported that the Facility determined that Resident #21's [MEDICAL CONDITION] was determined not to be an injury of unknown origin and probably occurred during a transfer using a Hoyer lift. The Administrator was queried as to whether it was determined by the Facility that the transfer was provided by CNA I a CNA being oriented in the Facility and CNA J a newly licensed CNA. The Administrator reported that he believed they were involved in the transfer. The Administrator then reported that staff were provided in-service training by Therapist E. It was noted that CNA I did not receive the training and CNA J was not working at the Facility when the training occurred. On 06/27/18 at 02:00 PM an interview was conducted with Therapist E. Therapist E was queried as to the incident pertaining to Resident #21. Therapist T stated, I was asked to provide in-service training on Hoyer lift transfers to the staff/CNA's to ensure safe use of the lift and avoid potential injuries. I did not talk to Resident #21, but it sounded like the Resident #21 was injured when he was turned the wrong way on the Hoyer lift and may possibly have bumped his knee into the stand. Therapist E provided a demonstration using one of the Facility's Hoyer lifts on the proper use of the lift and how to avoid an improper transfer. On 6/27/18 at approximately 4:00 PM a review of a document provided by the Facility and titled Transfer with a hydraulic lift was conducted and revealed, in part, the following: Critical notes .all mechanical lifts require two staff members be present .Introduction .using a hydraulic lift to raise an immobile patient from the supine to the sitting position allows safe, comfortable transfer from bed to a chair read all the instructions provided by the manufacturer before operating the device. Proper transfer and understanding of how to operate the lift can help reduce the risks associated with its use .Best Practices for hydraulic lift use .avoid use of the device if the patient becomes restless or agitated .clinical alert .ensure the patients knees are slightly higher than the waist so that the patient does not slide out of the sling .steady the patient as you move the hydraulic lift, or preferably, have a co-worker guide the patient's body while you move the lift .release the turnscrew. Then depress the hydraulic lift handle or turn it counterclockwise to lower the patient into the chair. Make sure the patient is positioned correctly over the chair. While lowering the patient, push gently on the patient's knee to maintain the correct sitting posture

Based on observation, interview and record review, the facility failed to honor a resident's choice by physically forcing one (#516) sampled Resident , of ten Residents reviewed for Activities of Daily Living (ADL) out of a total sample of 24, to take a shower despite her repeated requests not to take a shower, and continued to assign the same staff person to take care of the Resident after the shower incident, resulting in the Resident having a catastrophic reaction -- striking out, cursing at staff, and experiencing mental anguish, physical pain, being grabbed by staff at the wrists. Findings include: On 6/10/14 at 12:15 P.M., during a lunch meal observation, Resident #516 was observed sitting at the table, in the dining room, in her wheelchair waiting for her meal. When the Resident was asked how she was doing she stated, "I been here six years too long. I was hurt in here by one of the nurses -- the head nurse for that day. I was in my room dressing for the day, a young lady (Certified Nursing Assistant, CNA) came in my room and said it was my shower day. I didn't know what my shower day was at that point. I told her I had a terrible cold. I didn't want to take a shower. She dropped my hand and went out the door to the head nurse. The nurse came in and said, 'She's (Resident #516) gonna take a shower. You (CNA) hold her and I'll undress her.' She grabbed my arms like she had iron claws. My shoulder and arms haven't been right since. I reported it. Yes, I did, to (Nurse Manager "A"). I cried and cried and begged her to leave my arms alone. I still have pain in my arm. It's been several months ago." Resident #516 also indicated that the Nurse involved in forcing her to take a shower, Nurse "I", still takes care of her. On 6/10/14 at 3:00 P.M., the facility's written investigation regarding Resident #516's shower incident which occurred on 3/22/14 was reviewed. The investigation contained written statements provided by Nurse Manager "A", Nurse "I" and CNA "H". Nurse "I" and CNA "H" were the staff members present during Resident #516's shower on 3/22/14. CNA "H"'s written statement, undated, revealed the following: "After breakfast, I informed (Resident #516) that it was time for her shower. I gathered her items and upon going into the shower room she began to curse. The Nurse (Nurse "I") heard the yelling and came in trying to explain to (Resident #516) that she needs her shower. (Resident #516) began cursing and swung her fist and open hands at the nurse. The nurse (Nurse "I") grabbed her arm and asked her to calm down several times. (Resident #516) received her shower, thanked me, and called the nurse a [***] ." Nurse "I"'s written statement, dated 4/5/14, revealed the following: "(Resident #516) shower day 3/22/14. Resident refused shower at first. (CNA "H") reported it to Writer (Nurse "I"). Writer (Nurse "I") went to (Resident #516) in hallway, encourage Resident to take shower. She will feel good after shower. (Nurse "I") went into shower room to assist (CNA "H") with shower. Resident was hitting and cursing at staff (CNA "H" and Nurse "I"). Writer (Nurse "I") grabbed (Resident #516's) hands and said 'that's not nice hitting out and cursing staff. ' Resident calm down. Writer (Nurse "I") helped (CNA "H") take Resident's clothes off and helped transfer Resident to shower chair. Writer (Nurse "I") left out of shower room." Nurse Manager "A"'s written statement, dated 4/5/14, based on interviews with CNA "H" regarding Resident #516's shower on 3/22/14, revealed the following: "When I (CNA "H") informed her (Resident #516) I was going to give her a shower, the Resident stated, 'I don't know. I am cold.' I informed the nurse. I waited and then went back to Resident, I said, 'Come on.' The Resident wanted to go to an activity. I said 'I get you (Resident #516) in and out (of the shower) and I will take you to activity.' I took her in the shower room and the Resident said, 'I don't want it now.' I stepped out and asked (Nurse "I") to come in that Resident didn't want it now and that she had a cold. Did not see a runny nose or Resident coughing. Nurse came in and talked to Resident to take the shower. Informed her that she had been refusing shower and that she needed to take one - it would make you (Resident #516) feel better." Nurse Manager "A"'s statement based on an interview with CNA "H" continued: "Resident was on the shower chair. Nurse (Nurse "I") was talking to her, I bend down to take her shoes off and she (Resident #516) was cursing and trying to hit me. The Nurse (Nurse "I") grabbed her at the wrist to keep her from hitting me (CNA "H"). Nurse (Nurse "I") informed her (Resident #516) to stop. Resident told her she would hit her and she was swinging with her other hand. Nurse (Nurse "I") said, 'Don't dig your nails in her (CNA "H").' Resident (#516) said, 'I can do whatever the hell I want to [***] .' Resident was cursing saying, 'she never like the [***] anyway (Nurse "I").' Resident was calm during the shower. I (CNA "H") apologize to her (Resident #516). When asked if Nurse was rude or loud, (CNA "H") stated, She (Nurse "I") was only trying to keep Resident from hitting (CNA "H") while I was removing Resident's shoes." On 6/12/14 at 12:30 P.M., Resident #516's clinical record was reviewed. The Resident's face sheet indicated the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent Annual Minimum Data Set (MDS) Assessment, dated 3/12/14, revealed the Resident's cognition was severely impaired, had clear speech, made herself understood, and usually understands others. The MDS also revealed the Resident required extensive assistance of one staff for transfers between surfaces, i.e. moving from bed to wheelchair, hygiene and bathing. The Resident's active ADL care plan, initiated/created on 3/26/12, revealed, "(Resident #516) has an ADL Self Care Performance Deficit, Bathing: Provide Resident with a sponge bath when a full bath or shower cannot be tolerated." The Resident's active Dementia care plan, initiated/created on 3/15/12, revealed, "Offer choices to (Resident #516) to participate in daily decision making. Establish environment of mutual trust and respect." On 6/12/14 at 3:10 P.M., CNA "H" was interviewed in person. CNA "H" was queried as to if she felt Resident #516 experienced a catastrophic reaction on 3/22/14 during her shower and if she had ever experienced that before with that Resident in the past. CNA "H" stated, "It (care for Resident #516) had never went like that before. I never really seen her (Resident #516) explode like that until then." CNA "H" explained that when Resident #516 resisted care in the past, the Resident would be left alone and reaapproached, but felt that "when you do so many reapproaches she'll (Resident #516) probably just refuse." On 6/13/14 at 11:40 A.M., Nurse "I" was interviewed in person. Nurse "I" was queried as to if she was still caring for Resident #516 since the shower incident on 3/22/14. Nurse "I" indicated she was still assigned to care for Resident #516 since the shower incident, including caring for her presently, and stated, "It's something about me she (Resident #516) does not like. For a while (after the shower incident on 3/22/14) she (Resident #516) wouldn't let me give her her medicine. I'd go in and (Resident #516) would say, 'You [***] cannot give me my meds.' I'd walk out (of the Resident's room) and go back in with a CNA and she (Resident #516) would take the meds." Nurse "I" indicated that she questioned why she was still assigned to Resident #516 after the shower incident, because although she loved the Resident it was difficult to take care of the Resident with the Resident calling her names. On 6/13/14 at 1:45 P.M., the facility's Director of Nursing (DON) and Administrator, co-Abuse Coordinators for the facility, were interviewed in regards to the shower incident involving Resident #516. The DON stated, "(Resident #516) reported it (the shower incident) to her CNA (on 5/24/14). I interviewed them (CNA "H" and Nurse "I") separately, and that was what I wanted to know -- 'Why didn't ya'll guys (Nurse "I" and CNA "H") leave her (Resident #516) alone (once the Resident indicated she did not want the shower)?' (Nurse "I") felt the Resident was calm and she left the room (while Resident #516's shower continued with CNA "H"). If she (Resident #516) would have been still at it (hitting and cursing at staff) she (Nurse "I") would've stopped the shower. As a nurse, she (Nurse "I") is trained to assess and saw she (Resident #516) was agitated, tried to calm (Resident #516) down and she (Resident #516) agreed to have the shower." When queried as to why Resident #516 was not given the option of a sponge bad on 3/22/14 instead of the forced shower, the Administrator stated, "There's not a problem with (Resident #516) refusing her showers." When queried as to why Nurse "I" had remained assigned to Resident #516 after the shower incident, and the Resident felt that staff person (Nurse "I") had physically forced her to take a shower against her will, the DON stated, "They (Nurse "I" and Resident #516) get along. If it would have been a continued problem, there would have been a change (in staffing)." When informed that Nurse "I" during an interview had expressed concerns caring for Resident #516 immediately after the shower incident, the DON indicated she was unaware that the nurse felt uncomfortable caring for Resident #516 and stated, "This is the first I heard of that." When the DON and Administrator were queried as to their expectations of how Residents are handled during a catastrophic reaction, the DON stated, "If a Resident is having a behavior, Stop!, if the Resident is having a catastrophic event. They practice that. They know that." The DON stated that the staff involved, Nurse "I" and CNA "H", did not receive retraining after the shower incident on how to handle Residents who are experiencing catastrophic reactions. The DON nor Administrator provided an explanation for why witness statements were written on 4/5/14 or undated for a shower incident which occurred on 3/22/14. On 6/13/14 at 2:30 P.M., the facility's policy entitled, "Resident Rights", with a release date of 9/2013, was reviewed and revealed, "The facility protects and promotes the rights of each Resident. The Resident has a right to a dignified existence, self-determination. Facility staff will not hamper, compel by force, treat differently, or retaliate against a Resident for exercising his or her rights. Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting Resident conduct and those regulations governing protection of Resident health and safety. Prior to or upon admission, a representative of the admitting office will provide the Resident with a written copy of Resident rights. The Resident will be informed of his or her rights and responsibilities in a language or mode that is both clear and understandable to the Resident." On 6/13/14 at 2:45 P.M., the facility provided copy of "The Resident's Rights Under State Law, MCL 333XXX (2)-(8) ( )" was reviewed and revealed, "(f) A patient or Resident is entitled to refuse treatment to the extent provided by law and to be informed the consequences of that refusal. (l) A patient or Resident is entitled to be free from mental and physical abuse." The facility's "Abuse Prohibition Policy", with a revision date of 3/2014, continued,... "Catastrophic reactions are defined as reactions or mood changes of the Resident in response to what may seem to be minimal stimuli, such as the attempt to provide care. Examples: bathing, dressing, or having to go to the bathroom. The Resident may begin to weep, become angry, become agitated or become stubborn." The policy does not specifically state how staff should handle Residents during a catastrophic reaction; however, the policy goes on to give the example of a Resident who reacted to the color "pink" and how staff would not wear pink, a psychiatric consult would be obtained, behavior tracking would be initiated, a care plan written, and CNAs and nurses would be inserviced on handling of the situation. ( )