Every finding on record at The Oaks at Battle Creek

Based on observation, interview and record review the facility failed to: 1.) ensure the safety and 2.) ensure a prescribed intervention related to fall prevention was in place for 1 of 2 residents (R78) reviewed for falls, resulting in R78's fall during transfer with staff. Findings include:Based on the Minimum Data Set (MDS) assessment with an assessment reference date of 4/28/26, reflected R78 was a [AGE] year-old moderately cognitively impaired male whose diagnoses included dementia, diabetes mellitus, a history of a stroke without weakness and a developmental disability. The above MDS reflected R78's Brief Interview for Mental Status (BIMS) score was 7/15 indicating moderate cognitive impairment and the Resident required staff assistance with all activities of daily living.During an observation and interview on 6/02/2026 at 3:05 PM R78 was observed lying in bed with eyes closed. R78 roommate reported R78 had recently fallen in room multiple times.Review of the facility provided Matrix, dated 6/3/26, reflected R78 was marked for falls including fall with injury.During an observation and interview on 6/03/2026 at 1:28 PM R78 was observed sitting in wheelchair at foot of bed and appeared able to answer simple questions. R78 reported waiting for staff to assist him back to bed and stated, We will see how this goes. Staff entered R78 room with mechanical lift, same staff exited R78 room and reported R78 was transferred from chair to bed with use of mechanical lift and one staff member. During an interview on 6/03/2026 2:13 PM Certified Nurse Aid (CNA) W and CNA X reported that facility staff can use one person to assist with mechanical lifts, and reported staff are required to follow resident Care Plans including transfer status.Review of R78 Incident Accident Fall reports dated 4/20/26 and 5/14/26, reflected that R78 had an witnessed fall from bed on 4/20/26 that resulted in facial abrasions and did hit head after self-transfer. Continued review of R78 5/14/26 Fall reported reflected R78 fell during a staff assisted transfer with use of sit to stand lift and hit head on the floor with no reported injury. Continued review of R78 fall on 5/14/26 reflected an investigation that included a document labeled, Episodic Event/Past Non-Compliance, dated 5/14/2026. The document reflected, Event-Resident slid out of the sit-to-stand and hit his head. Root of Cause Analysis, Identify the reason and or cause that the event occurred - CRCA reported Resident Profile said transfer status was a one person assist with gait belt. Transfer status order was for Hoyer Lift. ADHS put order in for Hoyer lift on 5/4/26.Order was not updated on the profile until 5/15/2026. CP [care plan] was updated on 5/12/2026. Review of R78 Physician orders, dated 5/4/26, reflected order for use of Hoyer lift with transfers.Review of R78 Care Plans, dated 4/28/26 through 5/12/26, reflected intervention that included one person assist with gait belt for transfers. Continued review reflected R78 Fall Care Plan reflected, Approach start date 5/15/26 Transfer Hoyer lift, edited 5/14/26.During an interview on 6/03/2026 at 2:50 PM, R78 wife reported was not present for R78 4/20/26 fall but reported R78 had abrasion to forehead and initially was doing well then had changes in alertness and was transferred to the hospital with diagnosis of Urinary Tract infection. During an interview on 6/04/2026 at 10:10 AM, Assistant Director of Nursing (ADON) C reported had been in position for about 4.5 years. ADON C reported management team met every morning to discuss falls and reported R78 had a transfer status change on 5/5/26 from one person assist with gait belt to one assist with Hoyer lift (mechanical lift). ADON C reported physician order was entered for R78, but Care Plan or Resident Profile were not updated and should have been.During review of the facility, admission Observation, dated 4/27/26, reflected R78 transfer activity was mechanical lift and R78 was marked as non-weight bearing on both right and left side. Continued review of the document under, Sit to Stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, reflected R78 was mark for, Not attempted due to medical condition or safety concerns.During an interview on 6/05/2026 at 9:05 AM, Director of Nursing (DON) B reported R78 was a one person assist with gait belt with transfers 4/28/26 through 5/5/26 and reported was changed to Hoyer lift on 5/5/26 related to decline. DON B reported completed investigation for R78 fall on 5/14/26 and determined ADON C changed R78's transfer status to Hoyer lift on 5/4/26 at 2:30 a.m. while working the floor and did not add to R78 Care Plan. DON B reported was unsure why Hoyer transfer was added to R78 Care Plan on 5/12/26 but not added to Resident Guide until after R78 fall on 5/14/26. During the interview the DON B verified R78 fell during a staff assisted transfers on 5/14/26 while using sit to stand after staff downgraded from 1 assist with gait belt. DON B verified CNA staff did nothing wrong because they followed the Resident Profile as expected. DON B reported ADON C was determined to be root cause of non-compliance because she did not add transfer status to R78 Care Plan and verified was not educated until 5/20/26 according to investigation. DON B reported all staff were not re-educated only ADON C and MDS staff and verified had only audited hospice residents. DON B verified any new orders can prompt changes to Care Plans and would expect all nurses to update Care Plans.

This citation pertains to Intakes: 2790134Based on observation, interview, and record review the facility failed to provide an environment free from physical and verbal abuse for two Residents (#29, #95) of two residents reviewed for abuseFindings Included:Resident #29 (R29)Review of the medical record revealed R29 was admitted to the facility 01/02/2025 with diagnoses that included kidney disease, type 2 diabetes, morbid obesity, hyperlipidemia (high fat concentration in blood), depression, anxiety, chronic pain, tachycardia, and heart disease. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed R29 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Resident #95 (R95)Review of the medical record revealed R95 was admitted to the facility 08/12/2025 with diagnoses that included kidney disease, type 2 diabetes, atrial fibrillation, dysphagia (difficulty swallowing), dementia, muscle weakness, anemia (low red blood cell count), osteoarthritis (degenerative joint disease), hypothyroidism (low thyroid hormone), osteoporosis (brittle/weak bones), sleep apnea, stroke, anxiety, depression, and heart disease. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2026, revealed R95 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. R95 was discharged from the facility 03/21/2026.Review of Michigan-Facility Reported Incident (MI-FRI) 00063304 revealed that on 01/25/2026 at 01:15 p.m. R29 and R95 were in their room. R95 had wheeled to R29's side of the room and pulled R29's hair. On 06/02/2026 at 11:28 a.m. during observation and interview R29 was observed sitting up in her room. R29 explained that she remembered the day that R95 had come to her side of the room and pulled her hair. R29 explained that she was just sitting and watching TV and R95 grabbed her hair and shouted, now we are going to talk. R29 explained that she does not remember any events that had led to this interaction. R29 explained that the staff assisted R95 to let go of her hair and staff removed R95 from the room. R29 explained that it did hurt when R95 pulled her hair, and she explained that the pain was a 10 out of 10.During an interview on 06/04/2026 at 03:43 p.m. Licensed Practical Nurse (LPN) P explained she recently became an LPN. LPN P explained that she remembered the incident between R29 and R95 on 01/25/26. LPN P explained that she was working as a certified nurse aide at that time. LPN P explained that she had entered R29's and R95's room because the call light had been activated. LPN P explained that once she entered into the room R95 was sitting in her wheelchair at the entrance to the bathroom. LPN P explained that R29 requested to use the bathroom but explained that she could not get into the bathroom because R95 was blocking the entrance. LPN P explained that she had asked R95 to move but she had refused. LPN P explained that she turned away form the residents and that is when R95 moved her chair toward R29 and grabbed her hair. LPN P explained that another certified nursing aide came in and assisted R95 to let go of R29's hair. LPN P explained that R95 was removed from the room.During a telephone interview on 06/05/2026 at 08:54 a.m. Certified Nursing Aide (CNA) Q explained that on 01/25/2026 she was walking by the room of R29 and R95. CNA Q explained that she heard yelling. CNA Q explained when she entered the room she observed R95 was pulling R29's hair and LPN P was attempting to separate the residents. CNA Q explained that she assisted in getting R95 to let go of R29's hair and R95 was removed from the room.During a telephone interview on 06/05/026 at 10:02 a.m. Licensed Practical Nurse (LPN) R explained that on 01/25/2026 she was walking by the room of R29 and R95 and heard yelling. LPN R explained that she entered the room and observed R95 pulling the hair of R29. LPN R explained that she assisted R95 to let go of R29's hair. LPN R explained that she then assisted R95 out of the room. LPN R could not recall if other staff was present in the room.During an interview on 06/05/2026 at 10:18 a.m. Nursing Home Administrator (NHA) A explained that on 01/25/2026 that she had received an allegation that R95 had pulled R29's hair. NHA A explained that pulling a resident hair would be defined as abuse. NHA A explained that at the conclusion of the facilities 5 day investigation she had substantiated that R95 had pulled R29's hair and therefore the facility had substantiated that resident to resident abuse had occurred.

Based on interview, and record review the facility failed to complete an accurate level I and level II screening for one (Resident #9) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR).Findings Included: Resident #9 (R9)Review of the medical record revealed R9 was admitted to the facility 10/28/2025 heart disease, bipolar disorder, hyperlipidemia (high fat level in blood), gastro-esophageal reflux disease, dementia, low back pain, depression, asthma, anxiety disorder, obstructive sleep apnea, cerebral vascular accident, dysphagia (difficulty swallowing), type 2 diabetes, urinary retention, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2026, revealed R9 had a Brief Interview for Mental Status (BIMS) of that could not be completed because R9 is rarely/never understood.Review of R9's Preadmission Screening (PAS) Annual Resident Review (ARR) level I screening (Form 3877) that was completed prior to her admission of 10/28/2025 revealed section II -Screening Criteria was documented: 1. No- The Person has a current diagnosis of mental illness or dementia, 2. No-The person has a received treatment for mental illness or dementia, 3. No-The Person has routinely received one or more prescribed antipsychotic or antidepressant mediations within the last 14 days, 4. No-There is presenting evidence of mental illness or dementia, 5. No-There person has a diagnosis of an intellectual disability or a related condition including, but not limited to epilepsy, autism or cerebral palsy and this diagnosis manifested before the age of 22, 6. No- There is presenting evidence or deficits in intellectual functioning or adaptive behavior which suggest that the person may have an intellectual disability or related condition.On 06/03/2026 at 11:21 a.m. Social Worker (SW) J explained that she reviewed all residents Preadmission Screening (PAS) Annual Resident Review (ARR) level I screening (Form 3877) upon admission. SW J explained that it was her responsibility to ensure that Form 3877 was accurate. SW J was asked to review R9's Level I PASARR that was completed prior to admission. SW J explained that R9'S Level 1 PASARR was not correct. SW J explained that R9 had diagnoses of mental illness, and dementia. SW J explained that she had reviewed and identified that R9's PASARR level I was not correct on 06/02/2026, which was the day the annual recertification process had been initiated. SW J could not explain why R9's Preadmission Screening (PAS) Annual Resident Review (ARR) level I screening (Form 3877) had not been completed accurately before 06/02/2026. SW J explained that a if any answer on the 3877 was documented as yes the facility was to be sent to the local Community Mental Health Services Program (CMHSP, with a copy of Form DCH3878. SW J explained that a DCH3878 was not completed because R9's 3877 was not correct.

Based on observation, interview, and record review the facility failed to ensure that food was served and held at a palpable temperature. Resulting in the potential to affect all residents (total facility census of 70) that consume food from the kitchen. Findings Included: Resident #173 (R173) Review of the medical record revealed R173 was admitted to the facility 02/14/2025 with diagnoses that included prosthetic left hip joint, fracture of left femoral neck, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), depression, anemia (low red blood cells), osteoarthritis (type of arthritis occurs when tissue at end of bones wears down), unilateral inguinal hernia, and pain in left hip. The Minimum Data Set, with an Assessment Reference Date (ARD) of 02/20/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. During observation and interview on 03/10/2025 R173 was observed lying down in bed. R173 explained that five out of seven days the food was cold. R173 explained that the food that should have been hot was cold and the food that should have been cold was warm. On 03/12/2025 at 12:19 a.m. R173 was observed to arrive in the dining room. R173 was provided a food tray which appeared to contain one fried chicken sandwich and fixed vegetables. Assistant Dietary Manager (ADM) L was asked to check the temperature of R173's lunch tray. ADM L was observed to check the temperature of the mixed vegetables, and it was observed to have a temperature of 113 degrees F (Fahrenheit). ADM L was observed to check the temperature the chicken sandwich and it was observed to have a temperature of 101 degrees F. ADM L explained that the mixed vegetables should have been at least 165 degrees F and the fried chicken should have been 165 degrees F. ADM L explained that R173 would be provided another lunch tray. On 03/12/2025 at 12:22 a.m. entered the kitchen with Assistant Dietary Manager (ADM) L and observed a tray of fried chicken setting on the top of the steam table. ADM L was observed to obtain a temperature for the fried chicken, that she reported to be 101 degrees F (Fahrenheit). ADM L explained that the chicken should be at least 165 and informed staff to remove fried chicken and re heat the fried chicken. ADM L was observed to obtain a temperature for the mixed vegetable, located in a tray on the steam table, that was reported to be 145 degrees F. ADM L explained that the mixed vegetables should have had a temperature of 165 degrees F and that those mixed vegetables would be re-heated. When asked how many Residents had received the fried chicken and mixed vegetables ADM L responded at least half of the facility to that point.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 70 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing water leaks. Findings include: On 03/10/25 at 07:35 A.M., An initial tour of the food service was conducted with Dietary [NAME] C. The following items were noted: 1 of 2 True 2-door reach-in cooler doors were observed to not automatically close completely after opening, creating an air gap (approximately 1-2-inches wide between the refrigeration unit frame and the door gasket seal). The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The can opener assembly was observed soiled with accumulated and encrusted food residue. Dietary [NAME] C indicated the can opener assembly had been used for the morning Breakfast Meal preparation. Dietary [NAME] C also stated: I didn't work this past weekend. The exterior surfaces of the Cleveland steamer were observed soiled with accumulated and encrusted food residue. The top surface of the Cleveland steamer was also observed coated with accumulated (dust, dirt, debris). The exterior surfaces of the South Bend convection oven(s) were observed soiled with accumulated and encrusted food residue. The top surface of the South Bend convection oven(s) were also observed with accumulated (dust, dirt, debris). One metal oven rack was further observed resting upon the top surface of the South Bend convection oven(s). The Globe stand mixer was observed soiled with accumulated and encrusted food residue. The backsplash plate, metal guard assembly, and spindle gear assembly were also observed soiled with accumulated and encrusted food residue. The Globe stand mixer frame legs and support table surface were additionally observed with accumulated and encrusted food residue. The Pitco fryer interior cabinet surfaces and exterior unit surfaces were observed soiled with accumulated and encrusted grease/dirt deposits. Main Dining Room: The beverage island base cabinet doors and interior cabinet surfaces were observed soiled with accumulated and encrusted food residue (soda syrup concentrate), creating door opening and closing concerns. 200 Hall Nourishment Room: The dustpan caddy was observed heavily soiled with accumulated and encrusted dust/dirt/food residue. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The [NAME] mechanical Air Curtain, located above the food service rear entrance/exit door, was observed soiled with accumulated and encrusted dust/dirt deposits. Large pockets of accumulated dust/dirt were also observed within the interior mechanics of the [NAME] Air Curtain. The flooring/wall surfaces, located adjacent to the Pitco fryer unit, were observed soiled with accumulated and encrusted grease/dirt deposits. Private Dining Room: The hand sink basin and vanity surface were observed soiled with accumulated and encrusted dirt/food residue. 200 Hall Nourishment Room: The two top sliding cabinet drawers were observed soiled and in disarray. Miscellaneous items (cloth napkins, salt packets, pepper packets, ketchup cups, metal meal knifes, metal meal spoons, metal meal forks, etc.) were also observed stored within the soiled cabinet drawers. The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. The two-compartment vegetable preparation sink faucet assembly was observed leaking water from the spout. Dietary [NAME] C stated: I am not sure if maintenance is even aware of the problem. Dietary [NAME] C also stated: The sink faucet has been leaking for about a month. Main Dining Room: The hand sink basin goose neck faucet assembly was observed loose-to-mount. The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Dry Storage Room: The Sugar storage bin clear plastic protective cover was observed three-quarters open, exposing the food product (sugar) to potential external contaminants. The 2022 FDA Model Food Code section 3-307.11 states: FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. On 03/11/25 at 08:50 A.M., An interview was conducted with Food Service Director D regarding the facility maintenance work order system. Food Service Director D stated: We have the TELS program., referring to the Direct Supply TELS software system for initiating and tracking facility maintenance work orders. On 03/12/25 at 09:00 A.M., Record review of the Policy/Procedure entitled: Kitchen Cleaning Procedures dated (no date) revealed under Mixer: Procedure: (1) Disassemble removable parts. (2) Wash all non-electrical parts in the three-compartment sink. (3) Wash non-removable parts of the mixer with a solution of pot & pan detergent. (4) Wash handle and underneath where paddle attaches. (5) Rinse with fresh water and wipe dry. (6) Using a different wiping cloth, apply sanitizing solution to the mixer. (7) Allow to air dry. (8) Reassemble. On 03/12/25 at 09:15 A.M., Record review of the Policy/Procedure entitled: Kitchen Cleaning Procedures dated (no date) revealed under Can Opener: Procedure: (1) Remove handle from base. (2) Exercise caution near the blade. It is sharp and can cause injury. (3) Wash handle in the three-compartment sink. (4) Wash base with a solution of pot & pan detergent. (5) Rinse with fresh water and wipe dry. (6) Using a different wiping cloth, apply sanitizing solution to the base. (7) Allow to air dry. (8) Place handle back into base.

Based on observation, interview, and record review, the facility failed to practice effective infection prevention standards related to hand hygiene, 1) adhere to infection control practices, during medication administration with three of four nurses; and 2) facility failed to maintain infection control practices, in one of two wounds, Resident #59 (R59). Findings Included: Resident #59 (R59) Review of the medical record reflected R59 was an initial admission to the facility on [DATE]. Diagnoses of Congested Heart Disease, Chronic Kidney Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease and Diabetes. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2024, revealed R59 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section GG0100, Activities of Daily Living (ADL) Assistance reveals R59 requires set up/moderate assist with all care. During an interview and observation on 03/12/25 at 9:37 AM of Wound Care (WC) Nurse N perform wound care on both of R59's feet. Observed WC nurse N donning a gown and gloves. WC Nurse N had gathered wound care supplies prior to donning. Supplies were visible in a container prior to entering the room. WC Nurse N washed his hands once in the room and then put gloves back on. Observation of the bottom sheet at the foot of the bed dirty from betadine leaking through the dressing. Observed blood on the bottom sheet at the head of bed from R59 scratching. Observed WC Nurse N remove the dirty dressing from right foot, laid the now soiled scissors on the bed sheet beside the resident's right foot. WC Nurse N did not change gloves or hand sanitize before reaching into the container of clean dressing supplies with the same gloves he removed the dirty dressing with. WC Nurse N cleaned the right foot great toe with betadine and applied Medi-honey to the top of the great toe on the right foot, then covered with border dressing, wrapped it with rolled gauze dressing. WC Nurse N set the box of rolled tape on the dirty bed sheet beside the right foot. WC Nurse N then cut the tape from the roll with the dirty scissors, then laid the dirty scissors back down on the bed beside the right foot. WC Nurse N went to the left foot to perform wound care on the heel of the left foot. WC Nurse N did not wash hands or hands sanitize between completing wound care on the right foot and moving to the left foot. WC Nurse N removed the soiled dressing from the left foot with the same dirty scissors and laid them back down on the dirty sheet by R59's feet. WC Nurse N placed a bath towel under R59's left foot due to the supplies used. WC Nurse N used the same gloves to touch the wound and measure it. WC Nurse N used the same gloves to clean wound with a wound cleanser. Observation of black eschar on the heel of the left foot. WC Nurse N grabbed the box of rolled tape from sitting on the dirty bed sheet. WC Nurse N grabbed a cup with betadine-soaked gauze from his clean container of supplies, wearing the same soiled gloves and placed the soaked gauze over the heel eschar and wrapped the foot with a rolled gauze dressing. WC Nurse N then removed his gloves and washed his hands in the resident's bathroom. WC Nurse N put on new gloves and cut tape off from the roll of boxed tape, with the dirty scissors that were still laying on the bed, and secured the rolled gauze dressing in place while laying the dirty scissors back on the soiled bottom sheet of the bed. WC Nurse N then doffed his gown and gloves, picked up the box of rolled tape and the dirty scissors and placed them back in the container of clean dressings and carried the container out of the room. During an interview on 03/12/25 at 10:14 AM, writer asked Director of Nursing (DON) B what her expectations were for providing wound care. DON B stated she needed to pull the policy and look at it first. During an interview on 03/12/25 at 11:21 AM, Infection Preventionist Registered Nurse (IPRN) P stated her expectations for wound care would be, prior to entering the room, either enhanced barrier or transmission-based precautions, the nurse would gown up, wash their hands before putting on gloves, make sure the necessary supplies were there. Nurses can get the supplies from one of the treatment carts on each hall so they can have the cart outside of the room or go to the gather the supplies and go to the room. Writer asked IPRN P what the expectations were for using soiled Instruments. IPRN P stated nurses need to clean scissors between each person but not between wounds. Writer asked IPRN P her expectations from removing soiled dressings, then cleaning wounds and applying new clean dressings with the same soiled gloves. IPRN P stated they should probably change the gloves, but if it isn't soiled, they don't have to. During this same interview, writer asked IPRN P what her expectations were on infection control while passing medications. IPRN P stated nurses should be washing their hands or hand sanitizing frequently and appropriately. IPRN P stated if the nurses come out of a room, and touch another item or environment, they need to perform hand hygiene. IPRN P stated they used to have more wall mounted sanitizers before remodeling. IPRN P stated she asked the nurses if they had hand sanitizer in their pockets or the top drawer of the medication cart. Writer asked IPRN P why they did not use them during medication administration if they had them. CDC Clinical Safety; Hand Hygiene for Health Care Workers Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. Resources; https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

Based on observation, interview and record review the facility failed to ensure residents prescribed anti-psychotic medication had an adequate indication for use, clinical rational to support continued use, as well as identify and monitor resident specific specific behaviors and approaches and non-pharmacological approaches for one resident (Resident #20) of five residents reviewed for unnecessary medications. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 20 (R20) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, unspecified dementia with psychotic disturbance and depression and was admitted on an anti-psychotic medication. R20 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview Mental (BIMS). The mood and behavior section of the MDS revealed R20 had no mood, behavior concerns and no hallucinations or delusions. The 11/20/24 MDS reflected R20 had no mood problems, no hallucinations, no delusions and wandered 1 to 3 days a week. R20 was observed throughout the survey R20 was well groomed, smiling and engaged with peers easily. Review of R20's pharmacy recommendations dated 1/06/25 and 3/04/25 revealed the facility needed to establish a behavioral monitor for the use on an anti-psychotic medication and address the use of the medication in the care plan. The recommendation also advised to include the behaviors that were being treated , the non-drug interventions used to treat R20's behaviors along with potential side effects. Review of the Interdisciplinary Team (IDT) note dated 12/18/24 revealed R20 had experienced hallucinations and dysuria. A urinalysis was completed, R20 was found to have a urinary tract infection and was treated with antibiotic. There was no mention if the hallucination was distressing nor was there any further documentation in R20's medical record that R20 had any further hallucinations or delusions. Review of the Nurse practitioner notes dated 1/24/25 revealed the provider saw R20 due to a possible Gradual Dose Reduction (GDR) of R20's anti-psychotic medication and was amenable to try alternative therapy. The same progress note reflected R20 was administered Seroquel for night time agitation and psychosis, and that the facility staff had been educated on close monitoring. The progress note did not include what the alternative therapy was. Review of the Nurse practitioner notes dated 1/27/25 revealed R20's family reported that R20 had an allergy to alprazolam (a medication to treat anxiety) and that Seroquel (an anti-psychotic) medication had best helped R20 maintain good mood or behavior for quality of life. The progress note reflected use of Seroquel was revisited at that time and Gradual Dose Reduction (DR) benefits outweigh the risk continuing therapy of psychiatric medication. No additional information was provided as how the anti-psychotic best helped R20 and what the symptoms of R20s mood and behavior were. Review of the Clinically At Risk (CAR) notes dated 2/08/25 Initial CAR note: Resident is being picked up on CAR for use of psychotropic medications. Resident has order for Seroquel and Sertraline. Resident has a diagnosis of Depression and Psychosis. Seroquel started on 1/27/25 after failed GDR. Sertraline increased on 1/24/25. Resident presents as stable of symptoms, behaviors, and mood at this time. No side effects noted at this time. Non- pharmacological interventions listed in care plan, current care plan reviewed and remains appropriate. Will continue to review CAR monthly with IDT. CAR Note dated 3/7 CAR NOTE: Revealed R20 was followed by CAR for psychotropic medication use. Resident continued on Seroquel tablet; 50 milligram (mg) ,1 tablet; oral and sertraline tablet; 100 mg; 1 tab. No issues or concerns at this time. On 03/11/25 at 03:22, PM during an interview with Social Worker (SW) H she reported R20 was on an anti-psychotic medication because she had a diagnosis of dementia and some behaviors when queried what R20's behaviors were SW H stated she didn't know. SW H then reported R20 had a failed GDR in January and Seroquel had to be restarted, when asked to elaborate on how the GDR was determined to have failed, SW H stated she assumed R20 had more behaviors but she really wasn't sure as no one had informed her why the medication was restarted. When asked what non-pharmalogical interventions were in place, tried failed etc SW H offered R20 had a care plan for exit seeking. When queried if R20 had been evaluated by the Psychiatry group that visits the facility, SW H stated no because R20 was a hospice resident and hospice residents were not allowed to see the psychiatrist due to reimbursement issues. When asked about behavior management and how behaviors were tracked and monitored SW H stated they had CAR meetings and psychotropic medication use was discussed in those meetings. SW H reviewed R20's electronic medical record during the interview and reported the failed GDR was evidence by the Nursing progress note dated 1/25/25. Review of nursing progress note dated 1/25/25 revealed R20 paced up and down the 100 and 200 hall that afternoon without her walker and R20 had to be reeducated on the importance of the walker. The progress note did not reflect R20 was distressed, exit seeking, delusional or hallucinating, combative a danger to herself or others. Of note, review of the January 2025 Medication Administration Record reflected R20 was administered Seroquel on 1/24/25 at night, thus the event of R20 pacing up and down the 100 and 200 hall had not missed/had the Seroquel GDR implemented. On 03/11/25 at 04:11 PM, during an interview with Certified Nursing Assistant (CNA) O she reported regularly working with R20 who had no mood or behavior concerns. When queried if R20 had hallucinated CNA O reported Oh ya once a long time ago. Was R20 distressed or upset? Oh no not at all, if anything she was happy she was seeing a little girl. On 03/11/25 at 04:19 PM, during an interview with Director of Nursing (DON) B R20's use of anit-psycotic medication use was discussed, DON B was unable to identify benefit of use, what is prescribed for, targeted behaviors, how and where behaviors were monitored , nonpharmilogical interventions implemented or what the failed GDR was based on. DON B agreed wandering and dementia did not justify use. Documentation was requested at this time to support the use of Seroquel, none was provided by end of the survey on 3/12/25.

Based on observation, interview, and record review, the facility failed to advocate for one out of two residents (#29) reviewed for dignity resulting in the resident feeling unheard, decreased self-worth, frustration, decreased quality of life and suffered mental anguish. Findings include: Resident #29 (R29) Review of the medical record reflected R29 was an initial admission to the facility on [DATE]. Diagnoses of Aphasia following cerebral infarction, anxiety, nontraumatic intracerebral hemorrhage in hemisphere, speech and language deficits following cerebral infarction, Dysarthria, Dysphagia, needs assistance with personal care, Chronic Obstructive Pulmonary Disease and unsteady gait. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2024, revealed R29 had a Brief Interview of Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. During an interview on 03/10/25 at 10:30 AM, anonymous interviewee T stated they had concerns regarding a resident that was not being heard and not having his resident rights addressed. Anonymous interviewee T stated R29 was admitted to the facility in September 2024. R29 has a court appointed guardian who R29 no longer wanted this person in that role. R29 is not allowed visits from his fiance and cannot go back to his apartment. R29 is not being told what his discharge plans are. R29 is so distraught from not being allowed visits that he had make comments about being suicidal. Anonymous interviewee T stated R29 would like his fiance to become his Durable Power of Attorney (DPOA) and was told he cannot have her. R29 was sent out to the emergency room for suicidal ideations and reported that nobody was listening to him, he didn't have a voice. During an interview on 03/10/25 at 11:02 AM, R29 stated he was not allowed to voice his concerns, wishes or wants, adding nobody will help him get a new guardian. R29 stated he wants to go home and wants his fiance to be with him. R29 stated he is frustrated and upset that she could not come to the facility to spent time with him. R29 asked writer to help him return a video call to his fiance, writer pointed to the key to push to return call. R29 also told writer again that he wanted a new guardian. Record review revealed R29 was sent out to the emergency room for suicidal ideation on 03/06/25 .Resident verbalized wanting to kill himself with a knife after not being able to see his girlfriend. Resident was not able to see his girlfriend for reasons that his DPOA/Guardian has put in place. Resident can speak with her on the phone but not have visits. Resident was sent to ED and returned to the facility and cleared of all suicidal ideations. Social Service Director (SSD) is working with resident and had completed a wellbeing check. Resident denied thoughts of suicidal ideations and has returned to baseline . Record review revealed there was not any follow up by social work following the date of his emergency room visit until this date of 03/10/25. During an interview on 03/11/25 at 3:31 PM, Licensed Practical Nurse (LPN) Q stated the guardian won't let the fiance come into the facility to visit, only facetime and phone calls. LPN Q stated it was too bad because it helped having her at the facility with him. During an interview on 03/11/25 at 3:37 PM, Social Worker (SW) H stated she did not meet with R29 at his admission, she had not started working there yet. Writer asked SW H if she had met with him after she had started working there. SW H stated R29 wanted to be discharged back to his old apartment. SW H stated he had a guardian, who was his sister, and she didn't feel he would be safe there, and wanted to find a different apartment. SW H stated the guardian did not like R29's girlfriend and stated that the girlfriend had a disability who still wanted to help take care of him. SW H added that R29 wanted to be with his girlfriend. SW H stated they still assist him with calling his girlfriend throughout the day. SW H stated sometimes he told them he didn't want his sister to be his guardian. Writer asked SW H about following R29 wishes, and what did he want. SW H stated they have discussed discharge planning, and he shouldn't be going to an apartment at all. SW H stated she was ware of residents having rights, but probably didn't know all of them. Writer asked SW H if she knew he had rights and he could ask the court to re-assign to another guardian. SW H stated she was unaware of that process but maybe the previous social worker could assist her with that. Writer asked SW H how long the sister would be a temporary guardian per the court papers. SW H stated she didn't know that or how long that would last. SW H stated R29 just had his 1st quarterly assessment, and he attended. SW H stated that R29 didn't voice he wanted to go home to her. During an interview on 03/12/25 at 8:31 AM, SW H stated the previous social worker now worked in another area of the facility, and she was off work today. During an interview on 03/12/25 at 10:02 AM, Director of Nursing (DON) B stated the expectation was they would investigate getting him another guardian, and knew he wanted to be discharged , and his sister didn't think it would be a safe choice. DON B stated they didn't think he was ready for discharge yet, just went to Neuropsychologist and would look for the report. DON B acknowledged he did have rights and would work on steps to help him on the situation. DON B stated she didn't know if a different guardian would provide anything different than the one he had. Writer asked DON B why that would stop him from asking for a different guardian, if that is his wish. It shouldn't matter on the reason, he still has rights. DON B stated she was unsure if it had been started, and was not aware she was a temporary guardian. DON B stated the social worker did know about residents' rights. DON B stated SW H knew about federal regulations and residents' rights. During an interview on 03/12/25 at 10:47 AM, previous SW R stated they can assist with that paperwork for R29. Previous SW R stated the guardian was following the recommendations given to her by the court and didn't know that a new guardian would change any of the things that she had done. Previous SW R stated that she had called the court advocate to come speak with the resident, and she would say that the guardian who was working with him now had the best interest for him. Previous SW R stated R29 has not voiced to her that he wanted a new guardian, again stated the current guardian was following the recommendations from the court. Previous SW R stated he talked about going home, but his apartment lease was up, and they need to find him an apartment. Previous SW R stated the court advocate made rounds to speak to residents. Previous SW R could call her to come meet with this resident. Previous SW R stated she had not started the process with R29 at this time. Also stated there were other family and friends who were not happy with his guardians' decisions, and she had encouraged them to apply for guardianship. Writer asked previous SW R about the temporary guardianship status, and she didn't know what the process was for that time frame. Previous SW R stated she did know R29 had resident rights. Record review revealed the facility staff had not assisted R29 to exercise his rights.

Based on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was provided for two Residents (#2 and #179) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided for three Residents (#2, #178, and #179) out of three reviewed for Beneficiary Notification. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 10/02/2024 with diagnoses that included chronic kidney disease, hyponatremia (low sodium level) type 2 diabetes, atrial fibrillation, chronic obstructive pulmonary disease (COPD), anemia (low red blood cells), hyperlipidemia (high fat content in blood), depression, chronic pain, and gastro-esophageal reflux disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 01/06/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. In an interview on 03/12/2025 at 10:25 a.m. Licensed Nursing Home Administrator (LNHA) A explained that she could not verify that R2 had a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) that was to be completed 12/02/2024 for the change in payor source date of 12/04/2024. LNHA A could not explain why the NOMNC and SNFABN was not completed as required. Resident # 178 (R178) Review of the medical record revealed R178 was admitted to the facility 02/12/2025 with diagnoses that include congestive heart failure (CHF) atrial fibrillation, kidney failure, type 2 diabetes, chronic respiratory failure, morbid obesity, depression, anxiety, atrial fibrillation, vitamin D deficiency, hypotension (low blood pressure), mitral valve insufficiency, aortic valve insufficiency, and hyperlipidemia (high fat content in blood). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. In an interview on 03/12/2025 at 10:25 a.m. Licensed Nursing Home Administrator (LNHA) A provided a Notice of Medicare Non-Coverage (NOMNC) for R178 that was completed 02/16/2025 for an effective date of 02/18/2024. LNHA A explained that she could not provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for R218. LNHA A could not explain why the SNFABN was not completed as required. Resident #179 (R179) Review of the medical record revealed R179 was admitted to the facility 09/28/2024 with diagnoses that included left artificial knee joint, spondylosis lumbar region (age related war and tear of the spinal disks in the back), type 2 diabetes, hyperlipidemia (high fat content in blood), depression, anxiety, hypertension, insomnia, gastro-esophageal reflux, and chronic pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. In an interview on 03/12/2025 at 10:25 a.m. Licensed Nursing Home Administrator (LNHA) A explained that she could not verify that R179 had a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) that was to be completed 10/08/2024 for the change in payor source date of 10/10/2024. LNHA A could not explain why the NOMNC and SNFABN was not completed as required.

Based on observation, interview and record review, the facility failed to ensure resident medical records were secured and held confidential for 1 resident (R8) of 17 residents sampled, resulting in exposed resident medical information. Findings include: On 3/10/25 at 7:55 AM, the medication cart was observed in the hallway outside of R8's room, with the computer screen open with R8's profile in focus and visible for anyone that walked in the hallway. No nurse was present at that time. LPN E returned to the cart, when asked if she would normally lock her computer screen when she walks away she reported that the screen normally locks on it's own after three seconds. On 3/10/25 at 7:58 AM, LPN E was observed walking away from the medication cart for a second time without locking the computer screen, leaving resident information exposed. LPN E was observed walking into and out of two resident's rooms before returning to the medication cart. On 3/10/25 at 8:01 AM, LPN E was observed walking away from the medication cart for a third time, without locking the computer screen. LPN E walked down the hallway and retrieved a portable vital signs cart. When questioned a second time about the computer screen being left open with resident information exposed LPN E reported that settings on the computer must have changed over the weekend causing it to not automatically lock the screen. On 3/12/25 at 1:22 PM, during an interview with director of nursing (DON) B, she reported that the expectation is that no protected health information is left open/exposed on an unattended computer screen and that staff should be locking their screen or closing the laptop when leaving the computer unattended. Review of the facilities admission packet documented in part .You have a right to personal privacy and confidentiality. This includes your accommodations, medical treatment, written and telephone communications, personal care, visits and meetings with family and other residents .

Based on observation, interview and record review the facility failed to develop and implement a person centered care plan for targeted behaviors for the use of psychotropic medications for one Resident (Resident 20) of 17 residents reviewed for care plans. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 20 (R20) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, unspecified dementia with psychotic disturbance and depression and was admitted on an anti-psychotic medication. R20 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview Mental (BIMS). The mood and behavior section of the MDS revealed R20 had no mood, behavior concerns and no hallucinations or delusions. The 11/20/24 MDS reflected R20 had no mood problems, no hallucinations, no delusions and wandered 1 to 3 days a week. R20 was observed throughout the survey R20 was well groomed, smiling and engaged with peers easily. Review of R20's pharmacy recommendations dated 1/06/25 and 3/04/25 revealed the facility needed to establish a behavioral monitor for the use on an anti-psychotic medication and address the use of the medication in the care plan. The recommendation also advised to include the behaviors that were being treated , the non-drug interventions used to treat R20's behaviors along with potential side effects. Review of R20's care plans dated 12/09/24 reflected R20 was at risk for adverse consequences related to anti-psychotic medication with a goal of R20 not having adverse effects of the medication. There was no care plan in place to address the targeted behaviors or what symptoms the antipsychotic medication was to manage, there was nothing in place to address what non-pharmalogical interventions had been tried or how any behaviors were being monitored. Review of R20's cognition and mood combination care plan dated 12/09 revealed R20 had impaired memory and altered mood with a goal of R20 remaining safe and not injure herself due to poor decision making, the interventions some of the interventions were adjust her hearing aid and redirect if she becomes agitated and obverse for wandering into others rooms. On 03/11/25 03:22 PM during an interview with Social Worker (SW) H she reported R20 was on an anti-psychotic medication because she had a diagnosis of dementia and some behaviors when queried what R20's behaviors were SW H stated she didn't know. When queried what was developed and implemented for a person centered care plan in relation to R20's prescribed an anti-psychotic medication, SW H stated R20 wandered. On 03/11/25 04:19 PM during an interview with Director of Nursing (DON) B R20's use of anti-psychotic medication use was discussed along with R20's care plans. DON B was offered no explanation as to why R20 did not have a person centered care plan that addressed the need for an anti-psychotic medication. Of note, DON B wandering was not an acceptable use of an anti-psychotic medication.

Based on observation, interview, and record review the facility failed to ensure that meaningful activities were provided for one resident (R26) out of two resident who are dependent on staff for transferring and mobility and the likelihood for depression, feelings of melancholy using the reasonable person concept. This deficient practice resulted in the potential for boredom, lack of stimulation and loneliness. Findings Include: Resident #26 (R26) Review of the medical record reflected R26 was an initial admission to the facility on [DATE]. Diagnoses of a Stroke, Hypertension, Coronary Artery Disease, Hemiplegia on right side, Malnutrition, Depression and Anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2024, revealed R26 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section GG0100, Activities of Daily Living (ADL) Assistance reveals R26 requires minimal/moderate assist with all care and minimal assist setting up for meals. During an interview on 03/10/25 at 9:30 AM, R26 stated he doesn't get to activities because it takes a lot to get him up and ready to go. R26 stated he would like to participate in some of the activities offered but it a time thing, staff do not come in and get him up in his chair in time to go to the dining room for meals or the activities that take place. During an interview and observation on 03/11/25 at 10:53 AM, R26 stated this was not a good time to visit as he is waiting for a CNA to get him cleaned up and in his chair for lunch in the dining room. R26 still had his breakfast tray sitting on his over the bed table, he was sipping the last bit of water out of his white foam water glass from earlier this morning. Did not observe an activity calendar visible in R26's room. Writer did not observe a CNA current working in this hall outside of his room. During an observation on 03/11/25 at 11:26 AM, CNAs were providing personal care, door closed. During this same observation on 03/11/25 at 12:00 PM, CNAs were still providing care, door closed. During an observation on 03/11/25 at 1:25 PM, R26 was sitting in the dining room alone in his wheelchair, slumped forward in his wheelchair sleeping. R26's lunch was sitting in front of him, plate uncovered and no longer warm, pork chop, rice, apple pie and root beer. During an interview on 03/11/25 at 2:28 PM, Life Enrichment Director (LED) S was asked where she documented activity participation's and involvement. LED S stated they used a program called life loop, documentation is not in electronic medical records, only assessments and care plans are in electronic medical record. Record review revealed R26's participation in activities from 11/01/24 through today 03/11/25, showed the report of 5 activities attempted, R26 declined 3 activities, no other attempts were documented. Documentation also showed that the resident had a personal visitor on 02/28/25 and was marked it down as an activity. R26 had a phone call in 2/18/25 and was marked as an activity. R26 had a personal visitor on 01/26/25 and was marked as an activity. Activity log reported R26 has a rehab specialty cart (cart with books, magazines and word cross books) on 03/1/25 and a 1:1 visit on 03/2/25. No other documentation to reveal R26 was engaged in any stimulating activity from 11/01/24 until 03/01/25. During an interview on 03/12/25 at 9:53 AM, DON B stated the expectation would be to involve R26 in 1 on 1 program, getting him up in time to participate in activities, allowing time to engage with other residents during meals in the dining room.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 68 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/16/24 at 09:30 A.M., An initial tour of the food service was conducted with Dietary Manager Q. The following items were noted: The Pitco fryer interior and adjacent flooring/wall surfaces were observed soiled with accumulated and encrusted grease/dirt deposits. Dietary Manager Q indicated he would have staff thoroughly clean and sanitize the fryer interior and adjacent flooring/wall surfaces as soon as possible. The Panasonic microwave oven interior was observed (etched, scored, particulate). The damaged interior surface measured approximately 5-inches-wide by 5-inches-long. The interior door panel face was also observed (etched, scored, particulate), exposing the metal subsurface. The damaged interior door panel face measured approximately 1-inch-wide by 4-inches-long. Dietary Manager Q indicated he would remove and replace the faulty microwave oven as soon as possible. The Globe stand mixer was observed with accumulated and encrusted food residue. The KitchenAid stand mixer was observed with accumulated and encrusted food residue. The Walk-In Freezer refrigeration unit Freon supply line was observed with accumulated ice [NAME]. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The mop sink basin faucet assembly was observed leaking water. Dietary Manager Q indicated maintenance has been working on the issue for the last few days. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. On 04/18/24 at 08:30 A.M., Record review of the Policy/Procedure entitled: Mixer dated (no date) revealed under Procedures: (1) Disassemble removable parts. (2) Wash all non-electrical parts in the three-compartment sink. (3) Wash non-removable parts of the mixer with a solution of pot & pan detergent. (4) Wash handle and underneath where paddle attaches. (5) Rinse with fresh water and wipe dry. (6) Using a different wiping cloth, apply sanitizing solution to the mixer. (7) Allow to air dry. (8) Reassemble. On 04/18/24 at 09:00 A.M., Record review of the Policy/Procedure entitled: Fryer dated (no date) revealed under Procedures: (1) Allow fryer to cool to safe handling temperatures. (2) Drain used cooking oil and dispose of per approved procedure. (3) Remove baskets and clean in three-compartment sink. (4) Close drain valve and flush fryer with warm water using a brush to loosen soils. (5) Drain fryer. (6) Close drain valve and refill fryer above the grease line. Do not fill more than 2/3 full with warm water. (7) Add 1 packet of fryer cleaner. (8) Carefully brush interior surfaces thoroughly. Do not place hands in cleaning solution. (9) Drain fryer. (10) Rinse fryer with clean water. (11) Rinse again with clean water. (12) Close drain. (13) Be sure fryer is completely dry before refilling with cooking oil. On 04/18/24 at 09:15 A.M., Record review of the Cooks Cleaning List dated (no date) revealed the cleaning frequency for the following tasks: (1) Clean Cooks Line & Microwave Daily. (2) Change Fryer Oil Weekly.

Based on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one Resident (# 48) of one resident reviewed for Hospice services, resulting in the lack of coordination of comprehensive services and care provided. Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] reflected Resident 48 (R48) was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included dementia. R48 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), further review of the clinical record reflected R48 was receiving hospice care as of 9/12/23. On 04/17/24 at 12:46 PM, Licensed Practical Nurse (LPN) P reported the Nursing staff were not informed about hospice schedules and do not have any type of schedule or calendar to refer to. We just know it will be twice a week. LPN P further stated when the hospice nurse comes weekly they then inform the facility staff what days the hospice Certified Nursing Assistant (CNA) will be coming that week. When queried what days the hospice Social Worker, Chaplain volunteer comes, LPN P stated they never get informed about those visits. A binder was observed at the nurses station and labeled Hospice when queried if the calendar/schedule and other hospice documentation was kept in that binder, LPN P reported R48 did not have a hospice binder and she was not sure why the binder was still at the nurses station as all documentation was electronic and the binders were obsolete. On 4/18/24 at 7:45 am, review of R48's clinical record under documents reflected one entry from hospice nurse on 4/5/2024. At 7:58 am during an interview with Director of Nursing B she reported hospice documents were faxed to the facility and uploaded into the clinical record, along with a separate binder at each nurses station for each individual hospice resident and that binder included their calendar. On 04/18/24 8:15 am, an interview with DON B and LPN P at R48's Nurses station, LPN P again reported there was no such hospice binder for R48, there was no calendar or schedule for hospice and all documentation was in the electronic medical record. LPN P stated the hospice schedule varies and the facility staff were unaware until the hospice nurse showed up and then would give the schedule for the cna that week and reiterated there was never any information provided about the hospice Social Worker, Chaplain, or volunteer. On 04/18/24 08:47 AM DON B and Social Worker (SW) L, SW L presented the binder and stated she had kept it in her office. DON B nor SW L offered no explanation for nursing staff not being aware such information was available and why the binder was not readily accessible to the nursing staff on all shifts including weekends where the SW office would be locked. SW L reported hospice Nurse and CNA visit twice weekly, neither could account for why there was only one Hospice entry in the clinical record as of the morning of 4/18, if visits were twice weekly. Further record review reflected 5 visits from the Hospice Nurse in January 2024 (1/2, 1/9, 1/11, 1/15, 1/22 ) 1 CNA hospice visit (1/2) and 2 Chaplin (1/15 and 1/26/24). February hospice visits in the electronic medical records revealed five visits from the Hospice Nurse (2/6, 2/10, 2/13, 2/20 and 2/26) of note the 2/10 and 2/13 documents were not uploaded into R48's medical record until 3/22/24. February records reflected four visits from the hospice CNA (2/6, 2/12 2/16 and 2/26) for February 2024. Of note, the 2/6 and 2/12 visits were not uploaded into R48's medical record until 3/17/2024. March 2024's hospice documentation reflected a Chaplain visit on 3/18, two visits from the hospice nurse (3/18 and 3/26) and two hospice CNA visits (3/18 and 3/27). ON 04/18/24 02:45 PM, during an interview with DON B she could not account for why there would be missing hospice visits documentation or why there was at times a 5 week delay in getting hospice documentation into R48's medical record. When queried what the expectation was for hospice documents to be uploaded into the medical record, DON B stated she was not sure as the facility Social Worker was in charge of hospice services.

This citation pertains to intake MI000139094. Based on interview and record review the facility failed to ensure resident rights in accordance to preferences were followed for one out of three residents (Resident #1), resulting in restrictions of a visitor, and the potential for further resident preferences to not be followed. Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. R1 no longer resided at the facility at the time of the onsite investigation. In an interview on 9/18/2023 at 9:32 AM, R1's wife stated that when R1 was being admitted to the facility she told a staff member (could not recall who) that she wanted to stay the night with R1. R1's wife said she was told no she could not stay the night with R1. In an interview on 9/18/2023 at 1:06 PM, Guest Relations and Admissions staff member (GRA) C stated R1's wife arrived at the facility before R1 had, but stated R1 was in route. GRA C said she introduced herself to R1's wife, and stated that she did speak to R1's wife about staying the night with R1, but said she told R1's wife that the facility did not usually allow that but she would check with Administrator A GRA C said she was on her way our the door, and planned on asking Administrator A in the morning about staying the night. GRA C said Administrator A informed her the next morning that R1's wife could stay the night. GRA C said she was not able to relay the message to R1's wife because R1 was no longer in the facility. In an interview on 9/18/2023 at 2:17 PM, Registered Nurse (RN) Dstated that R1's wife had asked GRA C if she could stay the night, but GRA C told her that the facility's policy and procedure did not allow family to stay the night. Record review of R1's signed facility contract revealed that only if the resident's Physician, Physician's Assistant, or Nurse Practitioner considered the resident terminally ill then visiting outside of the visitation hours would be permitted. The contract revealed that eight hours per day were established for visitation, and residents may meet privately with whoever chooses to during visiting hours. The contract did not reveal the set eight hours for visitation. Review of the facility policy and procedure titled, Resident Rights Guidelines dated 11/2011 revealed under, Procedure, 2. 0 Have visitors, provided the visits are conducted at reasonable hours, and the visitors are not actively disruptive of other residents. The policy and procedure did not revealed what the set times were for the daily eight hours of visitation. The policy also did not reflect that a resident had the right to visitors outside of visitation hours per the resident's preferences.

This citation pertains to intake MI00137630. Based on interview and record review, the facility failed to ensure the provider was fully informed of a change in condition for one (Resident #1) of three reviewed for notification of change, resulting in the provider not being fully informed of a change in condition and the potential for delayed identification and treatment of a fracture. Findings include: Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included aftercare following joint replacement surgery, presence of right artificial hip joint and pain in the right hip. The Admission/5 day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/23, reflected R1 required limited to extensive assistance of one person for most activities of daily living. R1 discharged to the hospital on 5/9/23 and did not return to the facility. Physical Therapy (PT) Progress Notes for 4/30/23 and 5/4/23 reflected R1's therapy sessions included walking. A PT Progress Note for 5/8/23 reflected R1 completed 15 minutes of treatment on the NuStep bike. The note did not reflect R1 walked with therapy during the session. According to the note, R1's family member was concerned about all aspects of care, including edema (swelling), call light and itchiness of the incision site. The note reflected nursing staff were notified, as well as Social Work (SW) and the Assistant Director of Nursing (ADON). The note reflected transfer training was done in R1's room, as R1's family member reported R1 could not stand, pivot or transfer. R1 was able to demonstrate the transfer, according to the note. A Social Services Progress Note for 5/8/23 at 4:25 PM, reflected the Social Worker, ADON and PT met with R1 and a family member in R1's room. R1's family member had concerns that included R1 not being able to transfer like she did earlier in the week. The note reflected R1 then transferred with PT from her wheelchair to the recliner with little to no assistance, and there was no grimacing or unsteadiness. A Nursing Progress Note for 5/8/23 at 9:01 PM reflected Nurse Practitioner (NP) N was in to see R1, and there were new orders for Tylenol 500 milligrams (mg) every four hours and cyclobenzaprine (muscle relaxer) 5 mg twice daily. A PT Note for 5/9/23 reflected R1 completed 20 minutes of therapy on the NuStep bike. The note did not reflect that R1 worked on walking during the session. R1 reported level 10 out of 10 right hip pain. Redness was noted around the right hip, around the perimeter of the incision, and it was warm to touch. Nursing and SW were notified, as there was progressive difficulty with mobility and concern from family. A Progress Note for 5/9/23 at 10:14 AM reflected R1 complained of not having control of her right leg. The note reflected, .feels like a stroke, I'm not in pain but I would like it checked out . R1 was sent to the emergency room (ER). During a phone interview on 6/27/23 at 3:04 PM, Registered Nurse (RN) E reported R1 was complaining of pain in the hip that was replaced, was having a harder time walking than before and was more painful. RN E reported requesting that Nurse Practitioner (NP) N evaluate R1 with her (on 5/8/23). RN E reported she believed NP N prescribed cyclobenzaprine, thinking it was muscle spasms. RN E stated if she remembered correctly, R1's spouse and another individual, possibly a family member were also present at the time of the evaluation with NP N. Regarding what prompted the evaluation, RN E reported R1 asked to see NP N regarding pain in her leg and to see if there was an infection or anything like that. RN E reported R1 had been reporting a little increased pain for a day or two or maybe three days, which they thought may have been related to working with therapy. The last time seeing R1 with NP N (on 5/8/23), RN E believed R1 was able to transfer but not able to walk and was using a wheelchair to use the bathroom. During a phone interview on 6/27/23 at 4:11 PM, Licensed Practical Nurse (LPN) C was asked what some concerning changes could be for a resident with a recent hip surgery. LPN C reported it could have been a change in mobility, not being able to transfer the same, an increase in pain or a change in appearance to the incision. During a phone interview on 6/28/23 at 11:14 AM, NP N reported that on 5/8/23, R1 was complaining of muscle spasms in her leg and did not have complaints about her hip. NP N stated no changes in R1's walking or transfers were reported to her. NP N reported it was only her and R1 present when she evaluated R1 on 5/8/23 and all communication had been between her (NP), R1 and facility staff. R1's medical record reflected NP N's visit note for 5/8/23 was added to the medical record on 6/28/23 at 10:19 AM, which reflected R1 had pain with range of motion of the right hip. During a follow-up phone interview on 6/28/23 at 11:40 AM, NP N acknowledged that she would have assessed R1's hip and probably ordered an x-ray if an increase in pain or difficulty transferring or walking or the inability to transfer or walk had been reported to her. NP N stated there was no redness, swelling or signs of infection reported to her. NP N denied being notified of R1 being unable to walk. A Provider Communication document was provider by the facility, which included a handwritten note by ADON O, dated 05/08. The document included six columns, which included the date, R1's name, room number and, Please assess-[family member] concerned about swelling/pain to [right] hip, [decreased] ability to ambulate [walk]. Recent replacement. I saw her transfer, slow but ok. -[ADON O's first name]. The last two columns of the document were blank, and there was no indication what the columns were to be used for, as the contents at the top of the page had been covered before being copied. There was no indication that the document had been reviewed or noted by the provider. A Hospital History and Physical Progress Note for a date of service of 5/9/23 at 2:08 PM reflected R1 was at the hospital with right lower extremity (right leg) pain. She was recently admitted for hip total arthroplasty (hip replacement), which was completed 4/27/23. The note reflected R1 was at rehab and had been complaining of increasing pain, starting 5/6/23. In the ER, a computerized tomography (CT) scan and x-rays showed a non-displaced fracture deformity at the proximal femoral diaphysis. There was also evidence of a fluid collection, .which could be hematoma versus abscess . R1's right lower extremity was tender to palpation (touch). An additional Hospital Progress Note for an encounter date of 5/9/23 reflected, .Initially she was rehabbing well until until [sic] 3 days ago when she began having noticeably increased pain in the right thigh. The pain increased and 2 days ago she was unable to ambulate or further participate in therapy. She reports some redness and swelling to the area. Most of her pain is on the medial (middle) thigh .Currently pain is controlled after receiving fentanyl in the emergency department. The pain radiates halfway down her thigh and is made worse with movement .

This citation pertains to intake MI00137630. Based on interview and record review, the facility failed to thoroughly assess a change in condition for one (Resident #1) of three reviewed for quality of care, resulting in delayed identification and treatment of a fracture. Findings include: Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included aftercare following joint replacement surgery, presence of right artificial hip joint and pain in the right hip. The Admission/5 day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/23, reflected R1 required limited to extensive of one person for most activities of daily living. R1 discharged to the hospital on 5/9/23 and did not return to the facility. Physical Therapy (PT) Progress Notes for 4/30/23 and 5/4/23 reflected R1's therapy sessions included walking. A PT Progress Note for 5/8/23 reflected R1 completed 15 minutes of treatment on the NuStep bike. The note did not reflect R1 walked with therapy during the session. According to the note, R1's family member was concerned about all aspects of care, including edema (swelling), call light and itchiness of the incision site. The note reflected nursing staff were notified, as well as Social Work (SW) and the Assistant Director of Nursing (ADON). The note reflected transfer training was done in R1's room, as R1's family member reported R1 could not stand, pivot or transfer. R1 was able to demonstrate the transfer, according to the note. A Social Services Progress Note for 5/8/23 at 4:25 PM, reflected the Social Worker, ADON and PT met with R1 and a family member in R1's room. R1's family member had concerns that included R1 not being able to transfer like she did earlier in the week. The note reflected R1 then transferred with PT from her wheelchair to the recliner with little to no assistance, and there was no grimacing or unsteadiness. A Nursing Progress Note for 5/8/23 at 9:01 PM reflected Nurse Practitioner (NP) N was in to see R1, and there were new orders for Tylenol 500 milligrams (mg) every four hours and cyclobenzaprine (muscle relaxer) 5 mg twice daily. A PT Note for 5/9/23 reflected R1 completed 20 minutes of therapy on the NuStep bike. The note did not reflect that R1 worked on walking during the session. R1 reported level 10 out of 10 right hip pain. Redness was noted around the right hip, around the perimeter of the incision, and it was warm to touch. Nursing and SW were notified, as there was progressive difficulty with mobility and concern from family. A Progress Note for 5/9/23 at 10:14 AM reflected R1 complained of not having control of her right leg. The note reflected, .feels like a stroke, I'm not in pain but I would like it checked out . R1 was sent to the emergency room (ER). During a phone interview on 6/27/23 at 3:04 PM, Registered Nurse (RN) E reported R1 was complaining of pain in the hip that was replaced, was having a harder time walking than before and was more painful. RN E reported requesting that Nurse Practitioner (NP) N evaluate R1 with her (on 5/8/23). RN E reported she believed NP N prescribed cyclobenzaprine, thinking it was muscle spasms. RN E stated if she remembered correctly, R1's spouse and another individual, possibly a family member were also present at the time of the evaluation with NP N. Regarding what prompted the evaluation, RN E reported R1 asked to see NP N regarding pain in her leg and to see if there was an infection or anything like that. RN E reported R1 had been reporting a little increased pain for a day or two or maybe three days, which they thought may have been related to working with therapy. The last time seeing R1 with NP N (on 5/8/23), RN E believed R1 was able to transfer but not able to walk and was using a wheelchair to use the bathroom. During an interview on 6/27/23 at 3:38 PM, Physical Therapy Assistant (PTA) G reported from what she recalled, she was unsure if it was Monday (5/8/23) or Tuesday (5/9/23), but when leaving the therapy gym, R1 was struggling to walk. Prior to that, R1 had been making progress and was walking with therapy. PTA G reported believing R1 could walk over 100 feet, so it was concerning when she was not able to walk a short distance. PTA G stated R1 could (walk a short distance), but it was very painful. When taking R1 back to her room, she assisted R1 to the toilet and noticed a bandage and some redness around the hip area. R1 had to use the wheelchair to go back to her room. PTA G reported she sat R1 down because something was different at that time. PTA G reported she did not believe she had R1 do any standing until walking her back to her room that day. She then stated they were either going back to R1's room or doing gait training in the middle of their session. PTA G reported she went to Social Worker (SW) U because they had a prior conversation about R1. SW U then notified ADON O, and she believed they began preparing to send R1 to the hospital. During an interview on 6/27/23 at 3:52 PM Certified Occupational Therapy Assistant (COTA) H reported towards the end of R1 being at the facility, R1 was super stiff and having some pain that we spoke to nursing staff about. COTA H reported she believed R1 said her hip was stiff, it was hard to stand and walk, and the main thing was that it was painful. During a phone interview on 6/27/23 at 4:11 PM, Licensed Practical Nurse (LPN) C was asked what some concerning changes could be for a resident with a recent hip surgery. LPN C reported it could have been a change in mobility, not being able to transfer the same, an increase in pain or a change in appearance to the incision. During a phone interview on 6/28/23 at 11:14 AM, NP N reported that on 5/8/23, R1 was complaining of muscle spasms in her leg and did not have complaints about her hip. NP N stated no changes in R1's walking or transfers were reported to her. NP N reported it was only her and R1 present when she evaluated R1 on 5/8/23 and all communication had been between her (NP), R1 and facility staff. R1's medical record reflected NP N's visit note for 5/8/23 was added to the medical record on 6/28/23 at 10:19 AM, which reflected R1 had pain with range of motion of the right hip. During a follow-up phone interview on 6/28/23 at 11:40 AM, NP N acknowledged that she would have assessed R1's hip and probably ordered an x-ray if an increase in pain or difficulty transferring or walking or the inability to transfer or walk had been reported to her. NP N stated there was no redness, swelling or signs of infection reported to her. NP N denied being notified of R1 being unable to walk. A Provider Communication document was provided by the facility, which included a handwritten note by ADON O, dated 05/08. The document included six columns, which included the date, R1's name, room number and, Please assess-[family member] concerned about swelling/pain to [right] hip, [decreased] ability to ambulate [walk]. Recent replacement. I saw her transfer, slow but ok. -[ADON O's first name]. The last two columns of the document were blank, and there was no indication what the columns were to be used for, as the contents at the top of the page had been covered before being photocopied. There was no indication that the document had been reviewed or noted by the provider. A Hospital History and Physical Progress Note for a date of service of 5/9/23 at 2:08 PM reflected R1 was at the hospital with right lower extremity (right leg) pain. She was recently admitted for hip total arthroplasty (hip replacement), which was completed 4/27/23. The note reflected R1 was at rehab and had been complaining of increasing pain, starting 5/6/23. In the ER, a computerized tomography (CT) scan and x-rays showed a non-displaced fracture deformity at the proximal femoral diaphysis. There was also evidence of a fluid collection, .which could be hematoma versus abscess . R1's right lower extremity was tender to palpation (touch). An additional Hospital Progress Note for an encounter date of 5/9/23 reflected, .Initially she was rehabbing well until until [sic] 3 days ago when she began having noticeably increased pain in the right thigh. The pain increased and 2 days ago she was unable to ambulate or further participate in therapy. She reports some redness and swelling to the area. Most of her pain is on the medial (middle) thigh .Currently pain is controlled after receiving fentanyl in the emergency department. The pain radiates halfway down her thigh and is made worse with movement .

This citation pertains to intake MI00137630. Based on interview and record review, the facility failed to maintain complete and accurate medical records for three (Resident #1, #2 and #3) of three reviewed for medical records, resulting in untimely entry of provider notes in the medical record and the potential for an inaccurate reflection of resident conditions. Findings include: Resident #1 (R1): Review of the medical record reflected R1 admitted to the facility on [DATE], with diagnoses that included aftercare following joint replacement surgery, presence of right artificial hip joint and pain in the right hip. The Admission/5 day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/23, reflected R1 required limited to extensive assistance of one person for most activities of daily living. R1 discharged to the hospital on 5/9/23 and did not return to the facility. R1's medical record reflected Nurse Practitioner Progress Notes were added to the medical record on 6/28/23, beginning at 9:57 AM, for visit dates of 5/2/23, 5/3/23 and 5/8/23. Resident #2 (R2):Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of second lumbar vertebra, unspecified fracture of sacrum and fracture of one rib of the left side. R2's medical record reflected Nurse Practitioner Progress Notes were added to the medical record on 6/28/23, beginning at 10:23 AM, for visit dates of 6/15/23 and 6/22/23. Resident #3 (R3): Review of the medical record reflected R3 admitted to the facility on [DATE], with diagnoses that included toxic encephalopathy, sepsis and urinary tract infection. R3's medical record reflected Nurse Practitioner Progress Notes were added to the medical record on 6/28/23, beginning at 10:30 AM, for visit dates of 6/1/23, 6/12/23 and 6/14/23. A voicemail was left for Nurse Practitioner (NP) N on 6/28/23 at 9:29 AM, requesting a return call. A return call was received from NP N on 6/28/23 at 11:14 AM. Upon discussing R1's care, NP N reported she documented her notes in the medical record. NP N indicated the notes may have needed to be searched by the type of note, for Nurse Practitioner. Upon ending the phone call with NP N and reviewing R1's Progress Notes again, it was identified that NP N added Progress Notes to R1's medical record on 6/28/23. During a phone interview on 6/28/23 at 11:40 AM, NP N reported she was behind on her notes and was trying to get caught up. NP N reported after seeing patients, they were required to enter their notes (in the medical record) within 48 hours.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 67 residents, resulting in the increased likelihood for cross-contamination, and bacterial harborage. Findings include: During an initial kitchen tour on 1/23/23 at 9:28 AM, Kitchen Manager (KM) X reported was working as cook that day. Observed the three-compartment sink filled and KM X reported had just been filled and tested . This surveyor requested KM X to demonstrate test and was unable to obtain reading from guat test strip. Observed test strips with expiration date of 10/2022. At 9:47 AM KM X attempted to test with chlorine test strips blue and reported was unsure why was not working. KM X obtained quat strips after communication by text and reported would record at 150 ppm (parts per million). Record review of the kitchen log including the three compartment sink revealed several blank (missing) documentation noted and the three-compartment sink documentation reflected reading of 400 for all of January(out of range for quat test strips. KM X reported unsure how staff obtained results of 400 for quat test strips because not even an option on scale. KM X reported he was responsible for reviewing kitchen logs for accuracy and should have noticed irregularity. Record review of the 2017 FDA Food Code revealed, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions During an initial kitchen tour on 1/23/23 at 9:28 AM, observed a soiled wall mounted air conditioner unit that was running with moderate amount of dark loose debris blowing from the unit directly over the clean dish area. KM X reported Maintenance department was responsible for cleaning AC unit. During an interview on 1/23/23 01:07 PM, Maintenance Director (MD) T reported kitchen air conditioner wall unit observed weekly for need for cleaning and cleaned monthly. During an interview on 1/25/23 at 2:15 PM, Regional Maintenance staff W reported it was the kitchen's responsibility to maintain the wall mounted air conditioner including cleaning.

Based on interview and record review the facility failed to ensure resident council complaints were followed-up with a response for a resolution from the appropriate department, resulting in the potential for resident frustration and needs not being met. Findings included: On 1/24/2023 at 1:14 PM, during a confidential resident group meeting, two out of five residents stated that a male resident would frequently enter their rooms and take their belongings. Record review of Resident Council Meeting Minutes dated 11/15/2022, revealed, under Social Services, documentation that residents had complained about a male resident who wandered into their rooms. Review of a Resident Council Response form dated 11/15/2022, revealed Social Services did not address resident complaints regarding a male resident who wandered into their rooms. Record review of Resident Council Meeting Minutes dated 1/19/2023, revealed, under Social Services, residents had the same complaint regarding a male resident wandering into their rooms, putting his hands on their personal items, and taking other resident's snacks. Review of Resident Council Response form pertaining to the Resident Council Meeting Minutes for the month of January 2023 revealed no Resident Council Response form from Social Services regarding resident's complaints of the male resident. In an interview on 1/25/2023 at 8:53 AM, Social Worker (SW) D stated she would receive a copy of the resident council meeting minutes, and she would then document a response on the form. SW D stated that she had no documentation, or documented resolution that addressed resident's complaints of a male resident who wandered into their rooms or taking their personal belongings. In an interview on 1/25/2023 at 9:08 AM, Certified Nurse Aid (CNA) F said the male resident of concern continued to enter into other resident rooms. CNA F stated that redirection and activities only were effective for a short time. In an interview on 1/25/2023 at 9:15 AM, Administrator A stated that the resident's complaints made in resident council regarding the male resident were probably lacking a resolution. Administrator A said she did not have documentation of a root cause, interventions, or audits for effectiveness of interventions regarding resident's complaints of the male resident who wandered into their rooms. Record review of the facility's policy and procedure titled, Resident Council dated 6/2/2023, revealed under, Procedures, #8. The group's grievances and recommendations will be brought to the attention of the Executive Director (Administrator A) who will forward the concerns to the appropriate department leader for attention and response. Under 8.1 the policy revealed, Responses regarding resolutions will be documented, reviewed by Executive Director, and kept with Resident Council minutes, and under #9 the policy revealed, Actions taken and/or considerations given to issues will be reported back to the Resident Council at the next meeting.

This citation pertains to Intakes: MI 021, MI 041, MI 102, and MI 252. Based on interview and record review, the facility failed to: 1) ensure resident safety when using a transfer device, and 2) transfer residents according to resident's care plans, facility policy and professional standards of practice for one Resident (#14) of four residents reviewed for accidents. This deficient practice resulted in actual harm when Resident #14 sustained significant injuries (right arm fracture, left leg fracture and left ankle fracture), subsequent surgery for repair of the fractures, hospitalization and pain. Findings include: Resident #14 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety disorder, and unspecified [CONDITION(S)]. A review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #14 had severe cognitive impairment. Further review of the MDS assessment revealed Resident #14 required two-person physical assistance with transfers (moving from one surface to another such as from a chair to bed). A review of Resident #14's care plan, provided by the Nursing Home Administrator (NHA), revealed the following, in part: Problem Start Date: [DATE]. ADLs (activities of daily living): Resident requires staff assistance to complete ADL tasks completely and safely. Edited: [DATE]. Goal: Resident will (have) ADL needs met safely by staff assistance. Edited: [DATE]. Approach: Transfer Status: Assistance x 2 (staff members) with a gait belt. Created: [DATE]. A review of an Investigation Summary, submitted to the State Agency (SA) by the facility on [DATE] at 12:43 p.m., revealed the following, in part: Incident: On [DATE] (Resident #14) complained of pain during repositioning. Nurse completed assessment of resident, discovered discoloration and swelling to left lower leg. (Resident #14's) leg was painful to touch and movement . Investigation: . Reenactment of transfer complete . Conclusion: X-ray results note right humeral (right upper arm) fracture, left distal tibia and fibula (left ankle) fracture, and left femur (left upper leg) fracture. Based on investigation, it is believed the injuries occurred during pm (evening) care which consisted of a transfer with a mechanical lift and turning and repositioning. A review of an ED (Emergency Department) Provider Note, signed and dated [DATE] at 12:54 p.m., revealed the following, in part: (Resident #14) . presents having been found by staff at (facility). (Resident #14) was reportedly found on the ground this morning and was to have incurred a fall sometime in the night . (Resident #14) has deformity to (the) left ankle and ecchymosis (bruising) to the right shoulder . Further review of the ED Provider Note, revealed Resident #14 had the following injuries: 1) Closed fracture of proximal end of right humerus (right upper arm), 2) Closed fracture of left ankle, 3) Closed fracture of distal end of right femur (right leg, above right knee), and 3) Traumatic rhabdomyolysis (systemic reaction to the breakdown of muscle due to prolonged pressure on a muscle group). A review of a Hospital Discharge Summary, signed and dated [DATE] at 10:40 a.m., revealed Resident #14 underwent surgical repair for the left ankle fracture and right femur fracture on [DATE]. Further review of the document revealed Resident #14 expired on [DATE] at 6:15 a.m. In an interview on [DATE] at 2:00 p.m., the Director of Nursing (DON) reported per the facility's investigation, Resident #14 had not been found on the floor the morning of [DATE]. The DON reported by conducting multiple staff interviews and a transfer reenactment, it was determined Resident #14 sustained the identified injuries during a transfer performed by Certified Resident Care Aid (CRCA) A on the evening of [DATE]. The DON reported Resident #14 had not complained of pain when assessed by nursing staff after the transfer, therefore the Resident's full injury was not identified until morning care on [DATE]. A review of a statement provided to the DON by CRCA A, on [DATE] revealed the following, in part: I went to put (Resident #14) in bed from (the) wheelchair and (Resident #14) was sleeping after nurse gave her meds and I felt it wasn't safe to use (the) sit-to-stand, so I used the (total mechanical lift). I went to transfer (Resident #14) and (Resident #14) woke up and was startled and started to swing arms and I put her down. I went to take sling off and (Resident #14) said, that hurts, that hurts. I went and took her top off and noticed 2 skin tears, I got the nurse . A review of a statement provided to the DON and the Vice President of Operations, Registered Nurse (RN) F by CRCA A, on [DATE], revealed the following, in part: . I usually use the sit to stand but (Resident #14) was asleep, so I decided to use the (total mechanical lift). I got the (total mechanical lift) sling under (Resident #14) all by myself, I know how to do it so it (was) all on my own. (Resident #14) woke up during transfer and said, it hurts, .I used the sling that was in the closet, gray or blue, it was the right size for her. (Resident #14) started shaking and saying, help, help. I put her down in the bed . she was freaking out when I transferred her, shaking her arms, kicking her legs. A review of a statement provided to the Nursing Home Administrator (NHA) and signed by CRCA A on [DATE], revealed the following, in part: (Resident #14) was sleeping, leaning forward, was easy to get the sling under her . Had a hard time getting (mechanical lift) under bed because of cord under the bed, bent down to move cord. (Resident #14) began to freak out, moving around and kicking legs and waving arms. I hurried up and got her to bed because she was moving too much . After cleaning her up, I noticed a skin tear to right arm. Resident kicked lift several times while kicking her legs in sling . In a telephone interview on [DATE] at 2:43 p.m., CRCA A reported working at the facility on an as-needed basis. This Surveyor read CRCA's witness statements included in the facility investigative file (dated [DATE], [DATE] and [DATE]) aloud to CRCA A during the interview. CRCA A reported all of the statements she had provided to the facility during the investigation of Resident #14's injuries, to be true and accurate. During the interview on [DATE], CRCA A was asked to give a verbal account of the incident involving Resident #14 on [DATE]. CRCA A reported on [DATE] she transferred Resident #14 from a geriatric chair (a padded, reclining chair with wheels) to the bed using a total mechanical lift. CRCA A reported Resident #14 was sleeping when she entered the Resident's room, and no other staff were present in Resident #14's room during the transfer. CRCA A reported placing the lift sling underneath Resident #14 and fastening the sling to the lift, without assistance from another staff person. CRCA A reported she then proceeded to lift Resident #14 into the air to position over the bed. CRCA A reported Resident #14, woke up in the middle of the transfer. When asked if Resident #14 had become startled, CRCA A reported Resident #14 was kicking her legs and waving her arms sporadically, causing the Resident to swing while suspended in the air. CRCA A could not recall if Resident #14 had hit the lift or other objects in the room while the sling holding the Resident was swinging in the air but was, sure she did. CRCA A reported once Resident #14 was in bed, she changed Resident #14's clothing and noticed a skin tear on the Resident's right upper arm and alerted the nurse. When asked how Resident #14 usually transferred from the chair to the bed, CRCA A reported the usual procedure was to use a sit-to-stand lift to transfer Resident #14. When asked why she did not use the sit-to-stand lift to transfer Resident #14 to bed on [DATE], CRCA A reported Resident #14 was asleep in the geriatric chair and was difficult to arouse, therefore, the only option was to use the (mechanical lift). CRCA A could not remember if she had alerted the nurse assigned to care for Resident #14, RN C, of the need to downgrade Resident #14's transfer status from using the sit-to-stand to using the total mechanical lift. CRCA A reported she did alert RN C of the skin tear on Resident #14's right upper arm and that Resident #14 was, unusually drowsy. When asked if Resident #14 had fallen during the transfer, CRCA A reported, (Resident #14) never fell . A review of a written statement, signed by RN C and dated [DATE], revealed the following, in part: (Resident #14) had just been toileted and put to bed by (CRCA A). (CRCA A) then alerted me of the skin tears . My assessment was that the skin tears happened during transfer (versus) self-inflicted . (CRCA A) did not ask me to help her with transfer. (CRCA A) didn't tell me she downgraded (changing transfer status in response to need to provide more assistance to a resident) her. I questioned why she downgraded, and she said because (Resident #14) wasn't very alert . (CRCA A) never said (Resident #14) was startled during the transfer. (CRCA A) didn't mention any behaviors or kicking, swinging of arms. I don't know what lift (CRCA A) used to transfer. No slings were anywhere that I saw. In an interview on [DATE] at 2:30 p.m., RN C reviewed her written statement, dated [DATE] and reported the statement to be true and accurate. During the interview on [DATE] at 2:30 p.m., RN C reported she had worked with Resident #14 on many occasions prior to [DATE]. RN C reported she had not learned that CRCA A had transferred Resident #14 from the geriatric chair to the bed using the total mechanical lift prior to Resident #14 being transferred by CRCA A. RN C reported when a resident is downgraded for transfer status, nursing should be notified prior to transfer to allow nursing to assess the resident to determine what type of transfer is appropriate. RN C reported she had never known Resident #14 to transfer using a total mechanical lift. RN C reported she had not completed a full assessment of Resident #14 due to Resident #14 being at baseline upon assessment of the skin tears that were reported by CRCA A. In an interview on [DATE] at 4:00 p.m., the DON reported the facility procedure for downgrading of transfer status was for nursing to be alerted to the need for downgrading prior to the transfer. The DON reported CRCA A should have alerted RN C that Resident #14 could not participate in the transfer per the Resident's care plan to have allowed for RN C to assess Resident #14 and assist with the transfer. The DON reported it was not appropriate to transfer Resident #14 while the Resident was sleeping or without ensuring Resident #14 was safe to transfer via the total mechanical lift. RN F, who was present during the interview, reported CRCA A had acted outside of her scope of practice when she made the decision to use the total mechanical lift without alerting a licensed nurse prior to the transfer. A review of the facility policy, titled, Guidelines for Resident Utilizing a Lift, dated [DATE], revealed the following, in part: Purpose: To ensure the safety of residents and staff when performing lift transfer tasks . Procedures: 3. If the resident requires the use of a lift device, this will need to be added to the resident plan of care that will be communicated to the caregiver. 4. All devices are safe to be used by one staff member per manufacturer's guidelines. Staff should seek the assistance of a second person for those residents care planned for assistance of two with the lifting device or as needed for safe handling. A review of the Episodic Event/Past Non-Compliance, document provided by the DON and RN F, revealed the following: Event: (Resident #14) presented ([DATE]) at 0445 (4:45 a.m.) with redness and bruising to her R (right) lower leg. Nurse assessed area and reported injury of unknown origin to DHS (DON). Physician notified and x-ray ordered. At 0845 (8:45 a.m.) CRCA noticed a second bruise to the upper right arm. Physician notified and order to send (Resident #14) to ER (emergency room ). Hospital assessment indicated fractures to the left tibia and fibula, right femur and right humerus. Root Cause Analysis: CRCA failed to follow care plan related to the resident's transfer status. On [DATE] at 4:10 p.m., the DON and RN F reported the facility had completed staff education, as of [DATE], regarding transfers with and without the use of mechanical lifts and utilization of resident care plans to determine specific care guidelines. The DON reported the facility would be auditing staff five times per week for eight weeks for compliance with facility policy and had already begun the process. A review of the Transfer Audits, provided by the DON and RN F revealed the following: [DATE]: Five audits completed on day shift (6 a.m. to 2:30 p.m.). [DATE]: Three audits completed. No times given. [DATE]: Three audits completed. No times given. [DATE]: Three audits completed. All on day shift. Further review of the Transfer Audits, revealed the names of the care staff being observed for safe transfers were not recorded on the audit forms. The audit forms did not include information relating to what surfaces the residents were being transferred to and from. In addition, nine of the audits did not revealed how many staff participated in the transfer. During the survey, which began on [DATE] and exited on [DATE] at 4:25 p.m., the DON and RN F provided a copy of audits at exit. The DON and RN F confirmed all audits began two days after the onsite survey began, on [DATE] and had all been completed on the day shift. It was determined the facility's corrective action was still in process and not yet completed.

This citation pertains to intake MI 7483. Based on interview, and record review the facility failed to properly transfer one out of three residents (Resident #8) resulting in a left leg tibia (shinbone) fracture. Findings Included: Per the facility face sheet Resident #8 (R8) was admitted to the facility on [DATE]. Diagnoses included fracture of left leg femur and difficulty in walking. R8 no longer resided at the facility at the time of the investigation. Review of a facility Event Report, dated 1/13/2021, revealed a note, dated 1/14/201, that R8 complained of pain to her left leg when two Certified Resident Care Associates (CRCA) assist her with a transfer. The report revealed that an X-ray was done which revealed R8 had a fracture to her left leg tibia. Review of a care plan, titled ADL's (Activities of Daily Living), dated 09/21/2020, and revised on 1/4/2021 revealed R8 required staff assistance to complete ADL tasks completely and safely. The care plan revealed, under Approach, dated 1/4/2021, R8' transfer status was, Transfer Status: EZ (easy) stand lift (mechanical lift) X (times) 2 person. Review of a written statement by R8, dated 1/13/2021, revealed R8 stated that when a female and male CRCA transferred her from her wheelchair to her recliner her left leg started to hurt. R8's statement revealed the two CRCA's had put a belt (gait belt) around her, helped her under her arms, stood her up, pivoted and turned her, and then her leg started to hurt. Review of a written statement, dated 1/13/2021, CRCA C wrote that she assisted R8 with a transfer form her wheelchair to her recliner with a gait belt. CRCA C's statement revealed that the EZ stand lift was not used when transferring R8 because R8 said the EZ lift hurt her and complained every time the lift was used. Review of a written statement, dated 1/13/2021, CRCA D wrote that he assisted R8 with a transfer from her wheelchair to her recliner. The statement revealed that R8 complained of pain in her left leg after the transfer and her leg had become swollen. CRCA D's statement revealed that the EZ stand lift was not used for the transfer because R8 would yell out in pain when the lift was used. Record review of an X-ray report, dated 1/13/2021, revealed R8 had a new fracture to her left leg tibia. In an interview on 3/17/2021, at 9:25 AM, CRCA C stated R8 had returned form therapy and she put on her call light to get to bed. CRCA C said R8 would refuse to use the EZ lift, and said that day (1/13/2021 R8 absolutely refused to use the EZ lift. CRCA C said she told R8 that she was care planned to use the EZ lift for transfers and she still refused. CRCA C said she did not tell anyone R8 had refused to allow the use of the EZ lift for the transfer. CRCA C said her and CRCA D put a gait belt around R8, then stood R8 up and pivoted her to her recliner. CRCA C said after the transfer R8 complained of pain to her left leg. CRCA C further stated that she had told therapy staff previously that R8 would not allow the use of the EZ lift, but stated that therapy never changed R8's transfer status from the EZ lift. In an interview on 3/17/2021, at 9:45 AM, CRCA D stated that on 1/13/2021 he and CRCA C went into R8's room to get her ready for discharge to home, and had taken the EZ lift into R8's room. CRCA D said R8 told him that she was not using the EZ lift, but said he had told R8 that the EZ lift needed to be used for her transfer because that was what the therapy department had in place for her. CRCA D said R8 still refused so he and CRCA C performed a two person assist stand pivot transfer with a gait belt. CRCA said they transferred R8 from her bed to her wheelchair, then from her wheelchair to her recliner. CRCA D said he used a gait belt around R8, and he was on R8's left and CRCA C was on her right side, they both grabbed the belt on each side, put their arms under R8's arms, stood her up, had R8 touch her left toe to the floor, and bear all her weight on her right foot. CRCA D said they then turned and pivoted R8 to her wheelchair without her taking any steps. CRCA said they wheeled R8 over to the recliner, and performed the stand pivot transfer with the gait belt one more time and assisted R8 to her recliner. CRCA D said it was about 30 minutes later that R8 was crying out that her left leg was painful. In a further interview CRCA D stated that when R8 refused to allow the use of the EZ lift he nor CRCA C told anyone of her refusals, and said he decided to allow her to stand and transfer with the gait belt and pivot because he felt it was more weight bearing on her leg to use the EZ lift, and he did not want to leave her in her bed, so he and CRCA C decided to use a gait belt and perform a stand pivot transfer. CRCA D said R8 would cry out in pain when the EZ lift was used to transfer her, and stated that he had informed the therapy staff and a nurse (could not recall who). In an interview on 3/17/2021, 10:56 AM, Physical Therapy Assistant (PTA) E, who was also the director of the therapy department, stated that R8's transfer status that was in place on 1/13/2021 was to transfer her with an EZ lift. PTA E said she worked with R8 a lot, and stated that no nursing staff member had ever brought to her or any therapy staff member any concerns R8 had with the use of the EZ lift. PTA E said if R8 was refusing to allow an EZ lift to be used to transfer her then the nursing staff should have reported that to her or a therapy staff member, and further stated that a full mechanical lift (lift with a sling that lifts the resident up for transfer) should have been used, but not a gait belt stand pivot transfer. In an interview on, 3/17/2021, at 11:22 AM, Director of Nursing (DON) B stated CRCA C and D did not perform R8's transfer per her care plan, and instead transferred R8 the way she asked to be transferred. DON B no staff member ever made her aware that R8 did not like to use the EZ lift when transferring, and said CRCA C and D knew R8's transfer status was with the use of the EZ stand, and said CRCA C and D had just chosen not to use the EZ stand based on R8's refusal to use it. DON B stated that her expectation was that CRCA C and D would not have performed R8's transfer on 1/13/2021, because of R8's refusal to allow the use of the EZ lift, and report R8's refusal to R8's nurse or herself. Review of an Employee Counseling Record Form, dated 1/19/2021 revealed that both CRCA C and D received a written notice related to, .transferred resident (R8) using a 2 person Assist with another employee. Resident (R8) had an order to be an EZ Stand. Improper transfer resulted in a fracture.

Based on observation, interview, and record review, the facility failed to identify, thoroughly investigate, and implement corrective action for alleged and/or actual abuse and injuries of unknown origin for 16 out of 19 residents (Resident #'s 2, 4, 13, 21, 24, 32, 38, 40, 44, 48, 55, 74, 75, 76, 77, and 78), resulting in Immediate Jeopardy when the facility failed to identify the alleged perpetrators related to staff to resident abuse, identify injuries of unknown origin, ensure prevention of further verbal and physical abuse of residents, and put corrective action into place to prevent further incidents of abuse placing all 67 residents who reside at the facility at risk for serious harm, injury, impairment, and/or death. Findings Included: Resident #24 (R24): Per the facility face sheet R24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an X-ray report, dated [DATE], revealed R24 had a fracture of his left hip. Record review of a, Statement of Witness Form, dated [DATE], revealed Certified Nurse Aid (CNA) J made a written statement that on [DATE] she had entered R24's room to assist with changing his brief, when R24 told her that he had fallen four minutes prior. CNA J's statement revealed she had not observed R24 on the floor, and R24 had not complained of any pain. In an interview on [DATE], 1:57 PM, CNA J stated that on [DATE] R24 was wet and she assisted him to the bathroom and changed him. CNA J said R24 told her that he had fallen two minutes prior. CNA J stated she was not able to verify that R24 had just fallen, and stated she did not observe R24 to have any injuries. In an interview on [DATE], at 9:41 AM, with Director of Nursing (DON) B, was asked if R24's [MEDICAL CONDITION] was reported to the State Agency as an injury of unknown origin. DON B said no because R24 said he had fallen. DON B stated that on [DATE] when R24 was found to have a left [MEDICAL CONDITION] she considered that the cause of the fracture was from a fall R24 stated that he had on [DATE]. DON B said that was how she made the connection of his left [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Further interview with DON B on [DATE], at 9:41 AM, DON B stated that if a nurse believes that an injury of unknown origin was abuse then the nurse was to report it to the Abuse Coordinator, who was the Administrator. DON B said the event was reviewed in a morning meetings and included what follow-up would need to be completed. DON B was asked how a nurse determined an injury of unknown origin, in which she stated that was what she was working on now. Review a written statement, dated [DATE], Registered Nurse (RN) H documented that on [DATE] she was told by CNA J R24 stated he had fallen out of his wheelchair and onto the floor. The statement revealed CNA J reported to RN H she had not witnessed R24 fall, and when RN H went to assess R24 he had no pain or discomfort, and his skin was assessed to have no abnormalities with the exception of both of his hands and left elbow having [MEDICAL CONDITION] (irritated itchy dry skin). RN H's document statement revealed she had asked other staff members if they had witnessed R24 fall, or had seen him on the floor, in which they had not. Review of a progress note, dated [DATE], revealed R24 had verbalized having spinal, pelvic, and left hip pain, and an X-ray was obtained which revealed a left [MEDICAL CONDITION] and R24 was transferred to the hospital. Resident #40 (R40): Per the facility face sheet R40 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Per a Minimum Data Set (MDS), dated [DATE], revealed R40 had a Brief Interview of Mental Status (BIMS) score of zero out of 15 indicating an impaired cognitive (understanding) ability. Review of a progress note, dated [DATE] at 6:30 PM, revealed R40 was documented to have discolorations observed on her left forehead, right inner thigh, left hand, right upper breast, and scratches were observed on her left upper inner thigh, mid abdomen, and right lower outer leg. Another progress note, dated [DATE] at 6:39 PM, revealed R40 had a Skin Assessment which revealed she had a small green bruise noted on the left upper side of her forehead, a large purple/blue bruise on her right inner thigh, a small blue/green bruise on her left hand, a small green bruise on her right upper breast, scratches were noted on her left upper inner thigh, right lower outer leg, and mid-abdominal area. Record review of a progress note, dated [DATE], revealed a Hospice aide had observed scattered bruises and scratches while bathing R40. The note revealed R40 has history of being combative during care. In an interview on [DATE], 10:28 AM, DON B stated she did not know who the Hospice CNA reported her findings of bruising and scratches too. DON B said she did not believe the scratches or bruising was an allegation of abuse because R40 was combative with care, and stated that the scratches and bruising was from the use of the mechanical lift. DON B said R40's thigh bruising could have been from the strap used with the mechanical lift, and her forehead bruising was from the arm of the mechanical lift. DON B said she had no documentation that she investigated whether the mechanical lift was the reason for the bruising on R40's forehead and right inner thigh, and further stated she had no documentation that assured the staff were correctly using the mechanical lift on R40 to confirm that. DON B said the bruises and scratches observed on R40 was not investigated as alleged abuse because they were from the mechanical lift. On [DATE] this surveyor verified that the facility implemented the following to remove the Immediate Jeopardy that began on [DATE], and was identified on [DATE]: 1). On [DATE], all residents have been identified that could have potentially been abused or mistreated. Employees listed or mentioned on the resident identifier list have either been suspended or terminated, pending further investigation on [DATE]. 2). On [DATE], all residents who could be interviewed were interviewed related to any concerns of abuse or mistreatment. 3). On [DATE], residents who were admitted after [DATE] were interviewed. 4). On [DATE], residents who were not able to be interviewed had head to toe skin assessments complete on [DATE]. 5). On [DATE], residents who were not able to be interviewed and were admitted after [DATE] also had head to toe assessments completed on [DATE]. 6). Beginning [DATE], management staff were educated by the regional support nurse about abuse prevention and reporting policies and procedures. 7). Beginning [DATE] all reported incidents will be kept on the MI FRI tracking log; which will contain an area that ensures proper follow up from social services. Facility will initiate utilization of resident concern form log, which will be maintained by the executive director who will bring to each morning meeting for review to identify any possible concerns related to abuse or mistreatment. 8). Beginning [DATE], education of the facility abuse policy will be provided to all staff presently in the facility, and all other staff members will be educated prior to returning for next worked shift on reporting missing items belonging to resident and any injuries of unknown origin such as bruising, skin tears or impairments. Initial re education was provided by vice president clinical support and administrator in training. Specifically information was provided about injuries of unknown source which is stated in the abuse policy with conditions listed to identify those allegations. Conditions and criteria were also emphasized in re-education for identifying allegations of abuse as described in the facility abuse policy. Policies have been reviewed by the interdisciplinary team and has been deemed appropriate. Resident #2 (R2) Review of the Continuity of Care Document (CCD) revealed R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and needed extensive assistance for Activities of Daily Living (ADLs). Review of the Nursing Note dated [DATE] at 10:09 AM revealed nurse was called into resident suite and observed large skin tear on left leg, resident stated tape was tore off her leg, dressing applied small amount of drainage noted. On [DATE], the surveyor requested all incident reports with investigations for Resident #2. The information received included the following: 1) Statement of Witness Form for R2 dated [DATE] that revealed Resident was interviewed regarding a (Certified Nursing Assistant (CNA)). She stated that the (CNA) came into my room after 4:00 in the afternoon and said you are going to take a shower. I informed her that I could not get my leg wrap wet. She said that's ok I will just take it off. I told her that she could not take it off. She said that she could wrap it with plastic to keep it dry. She put the plastic on and used tape to hold it in place. She placed the tape over the blisters on my leg. When she was finished with my shower she started to rip the tape. I asked her to use my scissors and cut it. She ripped the tape off and it ripped my skin off. Then she said it was my fault. I asked her to wash my foot because I couldn't reach it and she said no. She was hateful and said that I was yelling at her. She has a very grumpy voice. She was that way all night. She said that she only had the (CNA) for second shift. I tried to hand her a dressing that came off my right leg during the shower and she yelled at me. The sheets on my bed got bloody and she said that it was my fault. She said I have been doing this work along time and I even watch them die. This upset me because I lost my husband in January. This made me cry. She is callous .I felt she was taking her anger out on me .Prior to this interview the resident's daughter had called and spoke with the BOM (Business Office Manager) and said that her mother had called and said that (CNA S) was nasty and argued with my mom. The form revealed Assistant Director of Nursing (ADON) R interviewed R2. 2) A written statement by a staff member that revealed Upon entering (R2's room) (R2) was waiting to use the bed pan and I noticed what I thought was a busted blister to find out was later a skin tear. Res (Resident) stated that the girl who gave her the shower last night rip (sic) the tape off her leg and didn't cut it which she stated she asked her to do. Res asked me to tell the nurse and I called her in her room. Showed the nurse and nurse dressed it and put a note in the matrix and also on 24 hour report. 3) A written statement from CNA S revealed [DATE] 4:30 am related to R55 4) A Statement of Witness Form for R55 dated [DATE] 5) A Statement of Witness Form dated [DATE] for Resident #44 (R44) 6 ) A written statement by Certified Nursing Assistant (CNA) U related to R44 Resident #44 (R44) Review of the CCD revealed R44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R44 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and needed extensive assistance for Activities of Daily Living (ADLs). Review of Statement of Witness form dated [DATE] that was provided to the surveyor as part of R2's investigation, revealed Resident asked to talk regarding a (CNA). He stated that (CNA S name) is rough and I don't want her to take care of me. She doesn't have to do much for me during the night. She doesn't knock on the door before coming into my room. Sometimes she comes in and just takes things and leaves without saying a word. Other times she responds to the call light and says what do you want. The voice she uses sounds mean. She is argumentative. If I ask for something to be done a certain way, she wants to argue about it. Review of a written statement signed by CNA U revealed On Wed [DATE]th (R44) told me he finally figured out who it was that was being rough and mean to him .(CNA S) was rough and throws him around in bed. Review of the Personnel Action Form revealed CNA S was terminated from employment on [DATE] for unsatisfactory performance and customer satisfaction complaints. Resident #55 (R55) Review of the CCD revealed R55 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R55 scored 8 out of 19 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On [DATE] at 01:04 PM, R55 was observed in his recliner. R55 did not respond to questions asked. Review of a written statement from CNA S that was provided to the surveyor as part of R2's investigation revealed [DATE] 4:30 am Resident made a statement that the BIG black guy was hitting him. This statement referenced the room number for R55. Review of R55's Statement of Witness Form dated [DATE] (provided as part of R2's investigation) revealed Resident was interviewed regarding an abuse allegation. He stated that he has never been hit by anyone here. He stated that a black man did not hit him last night or at any other time. He stated that he receives good care here. He stated that he does feel safe staying here and that he trusts staff . In an interview on [DATE] at 01:49 PM, ADON R reported investigations were done by her as assigned by Director of Nursing (DON) B, including some abuse investigations. ADON R reported the investigation information was then given to DON B or Nursing Home Administrator (NHA) [NAME] When asked about R2's investigation, ADON R reported she remembered the investigation and interviewing every single resident on the hall about the CN[NAME] ADON R reported she worked on the investigation for a day and a half and filled out paperwork for each resident she spoke to. The investigation given to the surveyor only had statements by two other residents. ADON R reported someone must have a soft file somewhere. ADON R reported during the investigation, Resident #44 (R44) also reported concerns with the same CNA (CNA S). When asked if the statement given by R2 was an abuse allegation, ADON R stated yes. ADON R reported Nursing Home Administrator In Training (NHAIT) C would have more information. In an interview on [DATE] at 02:15 PM, NHAIT C reported he was an unlicensed administrator in training. NHAIT C reported the facility did their investigation and found she (CNA S) was being negligent with care and we terminated her .didn't find any harm but it wasn't consistent with the type of care we want. She was kind of gruff in her approach and that's not what we want here. When asked if this was reported to the State Agency, NHAIT C reported he could not recall and that was up to the former Nursing Home Administrator (NHA). On [DATE] at 02:27 PM, Director of Nursing (DON) B and Corporate Clinical Support (CCS) T were interviewed. DON B reported she was aware of the allegation brought forward by R2 and CCS T reported she was not. When asked about the packet of statements provided by the surveyor that included R2, R44, and R55, DON B stated we had an employee (CNA S) say a resident (R55) told her a big black guy had hit him. Based on that, we had one big black guy working .Then we began to interview with other people along that assignment. The specific resident that was interviewed (R55) said nothing happened, no bruising, nothing like that. Talked to other people. (R2) said the aide that alleged it (CNA S) .tore the tape and when she did it opened a blister on her skin. The surveyor then read R2's statement to DON B and asked if this was an abuse allegation. DON B stated The way I took it is she taped around it. We asked if she was safe. Asked if she felt it was abuse. She said she felt the aide was angry. When asked again if this was an allegation of abuse and DON B stated It was an interview based on a different allegation. When asked about R44's statement, DON B reported he was interviewed based on the allegation of the big black guy hitting R55. When asked if R44's statement of CNA S being rough and having a mean voice was an allegation of abuse, DON B stated we concluded it to be part of our investigation. When asked if it was possible for additional allegations to come out of an investigation, DON B stated yes. When asked why these were not considered additional allegations of abuse, DON B did not respond. On [DATE] at 02:35 PM, Nursing Home Administrator (NHA) A joined the interview and reported R2's allegation was Not a reportable. It was taken as a concern, addressed. Final piece was she (CNA S) was terminated, not that there was an allegation. NHA A stated none of it was reported to the state. We wouldn't report a customer service concern. When asked if the allegation that a big black guy was hitting R55 was reported, NHA A stated No it wasn't. When asked why not, NHA A reported First thought was to make sure the resident was safe. We knew that gentleman was not working that shift. When asked if it was an allegation of abuse, DON B stated It could be considered an allegation. When asked why it would not be an allegation of abuse, DON B stated I believe the two employees had an issue and it was her disliking him and that's why we investigated if further. When asked how the facility determined what to report, NHA A stated If I determine that a resident is letting me know there is an allegation. So if I get a statement from a staff, family member or resident saying there was abuse, I look for those red flags. Then I would consult with corporate division. Ultimately I would make that decision. On [DATE] the surveyor requested all allegations of abuse with investigations that had not been reported to the State Agency and also anything the NHA A had reported to the State Agency during her time at the facility. On [DATE] at 02:38 PM, NHA A provided the following: 1) Statement of Witness Form dated [DATE] for Resident #74 (R74) that revealed (staff name) brought to writers (DON B) attention documentation of bruising on (R74). Writer asked (staff member) to begin investigating the situation. (staff member) got writer and we observed bruising on the residents L (left) breast and upper arms. Both arms had ,[DATE] small areas no larger than a nickel .(staff) interviewed staff and requested statements from them. The resident record included a note about combative behavior during care while putting the resident to bed. Writer requested we continue to monitor the resident. Review of the staff statements revealed the following questions were asked 1. When is the last time you took care of (R74)? 2. Did you observe any skin abnormalities? 3. Do you have any knowledge of any skin abnormalities? 4. Have you witnessed any combative behavior with res (resident) recently? Statements revealed (staff member) worked with her 3 days prior and reported skin abnormalities to the nurse. Nurse's statement revealed she charted on skin abnormalities. A second Statement of Witness dated [DATE] revealed Observed unit manager and ED (Executive Director/Nursing Home Administrator) looking at residents skin because event was opened by 3rd shift nurse. Resident has discoloration across her chest and bilateral arms . There was no documentation of statements from other residents or skin assessments of other residents. Resident #74 (R74) Review of the CCD revealed R74 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R74 scored 00 out of 15 (severe cognitive impairment) on the BIMS. R74 expired on [DATE]. Review of the Event Report dated [DATE] revealed [DATE] 04:14AM While changing and dressing resident CRCA (CNA) noted bruising in multiple areas across upper chest and upper lt (left). arm, with some red areas across lt. side of chest. Bruises are blue/red in color and resident shows mild discomfort when areas touched while dressing. Cause is unknown but the CRCA who put resident to bed reported combative behavior with care. In an interview on [DATE] at 09:39 AM, when asked about R74's bruising, DON B stated she was quite frequently combative with care. When asked if this is how the bruising happened, DON B stated it's plausible. When asked how she determined if something was an injury of unknown origin, DON B stated we check to see if anything is charted that could explain the possibility. When asked what would make it suspicious, DON B stated If we didn't have a plausible explanation. DON B reported the bruising was not reported to the State Agency because R74 was combative quite frequently. 2) An untitled and undated typed document that revealed Nurse wheeled (R4) to SS (Social Services) office on [DATE] concerning resident being tearful and very upset. Resident explained to SS that she wanted to change rooms. SS asked if there was a problem with her room or with her roommate. Resident stated her roommate was great and they got along well, she was having an issue with her 2nd shift care giver. Resident stated that both her and her roommate had to use the bathroom. Her roommate went first, but could not go. The resident then asked the roommate if she was sure she did not have to go, her roommate replied that she did not have to, so the resident went into the bathroom to relieve herself. While in the restroom, resident states her caregiver came into the room yelling at her about being in the bathroom before her roommate. SS interviewed (R13) on [DATE] concerning conflicting statements from resident roommate and caregiver. (R13) states that she remembers the incident with the restroom and her roommate was not yelling at her at all she just had to go to the restroom. When the caregiver came into the room she was yelling at her roommate and was very angry because her roommate was on the toilet. Resident #4 (R4) Review of the CCD revealed R4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R4 scored 7 out of 15 (severe cognitive impairment) on the BIMS. Resident #13 (R13) Review of the CCD reviewed R13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R13 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). There was no evidence that the facility investigated this allegation of abuse. In an interview on [DATE] at 09:43 AM, DON B reported the allegation made by R4 and R13 was against CNA V. When asked what the facility determined with this allegation, DON B stated (CNA V has an extremely loud voice and we believe because of how loud she speaks that it was perceived as yelling. When asked if the resident statements were an abuse allegation, DON B stated It could have been. When asked why it would not be, DON B stated because of how loud (CNA V's) voice is. She seems like she is yelling with everyday tone. DON B reported the facility investigated the allegation before they did anything else. DON B reported she was not sure if CNA V was suspended pending investigation. DON B reported the allegation was not reported to the State Agency because CNA V's voice is very loud. When asked if other residents were interviewed, DON B stated I would have to look into that. When asked where that information was, DON B stated I'm not sure if social work interviewed anyone else. I don't believe nursing did. Review of CNA V's personnel file revealed an Employee Counseling Record Form dated [DATE] that revealed Reason for Employee Counseling: Failure to follow (company name) Service Standards, state, federal, local, CMS guidelines. Employee has had several complaints about customer services. Several resident concern forms have been submitted stating that resident have felt that employee does not want to provide care or would help them after nonemergent task was completed. There was nothing related to suspension pending investigation. CNA V quit without notice on [DATE]. 3) Abuse Allegation Questions dated [DATE] revealed R32 date of issue: ,[DATE], date of interview: ,[DATE]; issue in question: rude care giver What happened? she throws things around on the bed. She makes me feel like I am a bother to take care of. Who was involved? aid last night. When did this happen? last night .Do you feel scared of any staff? Just (CNA S) because she is loud (and) slams stuff around. Resident #32 (R32) Review of the Continuity of Care Document revealed R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R32 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the Resident Concern form dated [DATE] at 6:10 AM (This was provided with the concern forms that were requested and was not included in the abuse allegations not reported.) revealed (R32) stated Thank God it's you the aide what's her name .(CNA S name) she was really mean and rough with me .Resolution and Communication: met with resident to investigate any abuse/neglect that may have occurred. Interviewed staff and got a written statement .pertaining to the incident. Staff member will be educated to assure we are exceeding the (company service standards). Will follow up with resident to see if any other incidents have occurred. The form was initialed by NHAIT C as the executive director, however he was not the licensed administrator at the time. There was no date the ED reviewed this. A written statement from CNA S dated [DATE] that revealed To whom this may concern, I went in to (R32's room number) to change both men once I was done with bed two. I went on to bed 1. I asked him to roll toward the wall. I see him struggling so I tried to assist him and that's when he started screaming at me, I then let him be to roll over (and) did it just fine. I then was able to change him and he was fine afterwards. In an interview on [DATE] at 09:47 AM, DON B said R32's Abuse Allegation Questions dated [DATE] were asked in relation to the questions asked to R2 and R44. DON B stated that same night is when (CNA S) left a note saying R55 said a big black man hit him. When asked why CNA S was working with residents if R32 had brought up concerns about her earlier that day, DON B stated I would have to check. DON B reported CNA S worked the night of [DATE] since she left a note under NHA's door. When asked what the facility did to immediately protect residents from CNA S, DON B stated I would have to look back at that information. DON B did not provide the information prior to the exit of survey. On [DATE], the surveyor requested all resident concern forms. The surveyor was provided with all concern forms which included abuse allegations that were not provided to the survey team when abuse allegations were requested. The concern forms revealed the following abuse allegations that were not identified as abuse allegations by the facility: 1) Resident Concern Form dated [DATE] revealed (R77). Date of concern [DATE]. Time of concern: 4:00 pm and 5:30 pm. Does not like the way a CRCA (CNA) treats her. Wanted me to ask a charge nurse to switch her aide. Called her daughter (and) husband was very upset. Resolution and Communication revealed staff educated on customer service skills. The form was reviewed by the ED/Grievance officer on [DATE] by NHAIT C. Resident #77 (R77) R77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R77 scored 15 out of 15 (cognitively intact) on the BIMS. R77 was discharged on [DATE] On [DATE] at 03:59 PM, DON B could not provide the alleged perpetrator's name. On [DATE] at 10:16 AM, DON B still did not have the alleged perpetrator's name. On [DATE] at 01:42 PM, DON B reported she was still unsure of who the alleged perpetrator's name was and reported she would have to look on staffing sheets. On [DATE] at 02:55 PM, DON B reported the staff member referenced in R77's concern form was CNA V who was the same aide that R4 and R13 had allegations against on [DATE]. When asked if R77's allegation was investigated, DON B stated No, because if I remember correctly the resident did not give us specifics and just said she did not like her demeanor. DON B reported there was no counseling or suspension of CNA V until the counseling that was done after R4 and R13 made allegations against CNA V on [DATE]. 2) Resident Concern Form dated [DATE] at 3:50 PM revealed resident and family member expressed concern of missing cell phone-Kyocera (sprint) cell phone. color black w/silver top, flip phone. Has red sticker on bottom w/(res name) written. The form revealed the facility looked through resident's room and lost and found, but did not locate the phone. There was no additional investigation. Form was initialed by DON B on [DATE] Resident #76 (R76) Review of the CCD revealed R76 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R76 scored 10 out of 15 (moderate cognitive impairment) on the BIMS. R76 was discharged on [DATE]. In an interview on [DATE] at 09:54 AM, DON B reported she did not have any further information on R76's cell phone. 3) Resident Concern Form dated [DATE] at 11:30 AM (R75) reported aide working today on 1st shift is very rude to me (and) has a bad attitude, not very helpful when asked for help. The resolution and communication revealed [DATE] spoke to resident informed her that CRCA was no longer assigned to her. The executive director review dated was [DATE] and initialed by KM (the DON). Review of the Addendum to Resident Concern revealed (R75) reports 1st shift aid (sic) is evil. Not speaking kindly to her. Please f/u (follow up) Resident #75 (R75) R75 admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to prevent a fall for 1 of 3 residents (#6) reviewed for falls from a total sample of 15 residents, resulting in a left tibial metaphysis fracture for resident #6. Findings include: According to the admission record dated 9/10/2010, resident #6 was a [AGE] year old female admitted to the facility 9/30/2009. The facility form titled "Diagnose list" dated signed 6-12 reflected resident #6 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected resident #6 required extensive assistance for transfers with the assistance of 2 people. Resident #6 decision making skills were severely impaired and the ability to communicate concrete requests was limited. An incident and accident report dated 10/29/2013, reflected that 2 CNA's (certified nursing assistants) had transferred resident #6 using a mechanical Sara lift 3000. According to the incident and accident report resident #6 feet slipped out from under her and slid her knee to the base of the lift. The incident and accident report reflected resident #6 had no injury. Indicated measures to prevent reoccurrence was to inspect equipment for proper use and instruct staff that resident should have non-skid footwear on during all transfers. The root cause according to the report was resident #6 was wearing socks. According to the nurses notes dated 11/02/2013 resident #6's son was in the facility on 11/02/2013 and spoke with the physician due to resident #6's left lower extremity being bruised and painful with movement. An x ray of the left lower leg extremity along with the medication Tylenol was ordered for 325 milligrams 2 tablets twice daily. The radiology report dated 11/05/2013 with a date of service of 11/04/2013 revealed an acute tibia nondisplaced fracture. The physician was notified and resident #6 was sent to the hospital. On 12/18/2013 at 9:00 a.m., During an interview with the assistant director of nursing, staff "F" reported "I had the girls (the cna's that did the transfer) demonstrate what happened for me, right after it happened, I wrote a work order for maintenance and changed the resident to a different type of lift." On 12/18/2013 at 11:00 a.m., During an interview with CNA "E" she acknowledged that she was assisting in the transfer when resident #6 fell on [DATE]. CNA "E" reported that resident #6 had worn regular socks that day and that the lift they were using did not have anti skid tape on the platform "like the other lifts do." CNA "E" further reported that the knee support part of the lift that was used on 10/29/2013 was "loose and wobbly." CNA "E" demonstrated the lift and pointed out what corrections were done, i.e.: nonskid tape on the base and the knee support was observed to have some flex but not loose. "The guy from the lift company came out about a month ago and fixed it." On 12/19/2013 at 9:30 a.m., during an interview with CNA "D" whom was the other CNA present during the 10/29/2013 transfer, reported "I'm not going to lie, I was busy running my mouth, I didn't realize her feet slipped off until it was to late." There was no documentation in the incident and accident report or CNA "D" and "E" file that reflected they were distracted in conversation. According to the manufacturers guidelines for the mechanical Sara lift 3000 on page 13, after a diagram it states "Warning (in bold letters) The resident's feet shall always remain in full contact with the foot support. When raising, check to ensure that the resident's feet do not lift from the foot support. If they do, lower the resident immediately until resident's feet fully reach the foot support." During an interview with the head of maintenance staff "G" on 12/19/2013 at 10:20 a.m., he reported that he put anti slip tape on the platform of the lift on 10/29/2013 after he had received a work order, and contacted the manufacturer of the mechanical Sara lift 3000 and had them inspected and serviced the lift on 11/22/2013. When queried what prompted him to contact the manufacturer for service, he replied "the nursing staff must of reported something was loose, I can't remember when or what it was exactly." Resident #6's Acute Progress Note completed by the residents physician dated 11/08/2013 states, "Basically, this patient had a fall and basically developed some deformities about the left knee area. X-ray shows some metaphysical fracture. Basically, the patient was transferred to emergency room and x-ray was repeated once again, they shows (sic) nondisplaced fracture in the metaphysis below prosthesis." ( )

This citation pertains to intake MI 249. Based on observation, interview, and record review, the facility failed to provide adequate supervision in 1 of 4 sampled residents (Resident #101) from a total sample of 4, who were identified as at risk for falls, when Resident #101 was left un-attended in the bathroom resulting in Resident #101 sustaining a laceration to the head requiring 6 staples. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated 2/16/12, revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #101 had severe cognitive impairments and required extensive staff assistance with activities of daily living (ADL's). The MDS documented that Resident #101 had a history of [REDACTED]. During the onsite investigation observations and an attempt to interview Resident #101 were made. On 3/19/12 at 1:59 PM, Resident #101 was observed sitting in a wheelchair near the nurse's station, alarm system in place. Resident #101 was unable to answer questions sensibly, asked by the Surveyor, due to the resident's cognitive impairments. Review of multiple facility "Accident/Incident" Reports revealed Resident #101 had a history of [REDACTED]. Review of the "At Risk for Fall/Injury" Care Plan dated 2/13/12, last updated 2/21/12, revealed Resident #101 was at risk for falls and/or injury due to a "history of falls, potential for falls, Dementia, and a functional problem of a right wrist fracture". Review of the "ADL Self-Care Plan Deficit or Potential for" Care Plan, dated 2/13/12, revealed Resident #101 required the assistance of two staff, cueing/prompting and hand-over-hand assistance with activities of daily living. Review of the "Accident/Incident Report' dated 2/22/12 at 7:05 AM, revealed Resident #101 was "observed on the floor" after an "un-assisted fall", "resident laying on bathroom, pool of blood on floor, laceration to back right side of head". Per the "Additional Information" on the report, the "resident stated she was trying to toilet self without assistance, lost her balance and fell ". Review of the "Fall Circumstance, Assessment and Intervention" Form, dated 2/22/12, revealed "prevention" interventions for Resident #101 that included "don't leave unattended while awake or out of bed". Review of the Facility Investigation Report, dated 2/29/12, revealed "the staff member (Certified Nurses Aide/CNA #8) involved was suspended for one day without pay and was interviewed and reeducated on 2/24/12. The employee did not realize she should not leave the resident unattended in the restroom to allow her to perform her own upper body adls..." Review of the typed interview statement of CNA #8, dated 2/24/12 at "about 6:00 PM", revealed the "reasoning for leaving her (Resident #101) alone in room: "because she had an alarm, she was washing her face, I went to get (another resident)..." Per statement CNA #8 "reported leaving the resident who fell sitting at the sink..." The Surveyor attempted to interview CNA #8, the staff member identified by the facility as the staff member who left Resident #101 un-attended in the bathroom. Contact was attempted via phone on 3/20/12 at 9:20 AM and 10:20 AM, and 3/21/12 at 8:12 AM without success. Surveyor was unable to leave a message. Review of the Physician order [REDACTED]. Review of the Hospital Records: ED (Emergency Department) Physician Notes, dated 2/22/12, revealed Resident #101 sustained a laceration to the head requiring 6 staples to "achieve adequate closer". Per Physician Note "the patient had a fall at her assisted living facility. She has a history of frequent falls, but unfortunately this time she did suffer laceration on the back of her head". During the onsite investigation, 3/19/12 through 3/20/12, observations were made of safety devices. All devices were in place as care planned for residents who required the need of safety devices. ( )

This citation pertains to intake numbers MI 073, MI 277, MI 328 Based on observation, interview, and record review the facility failed to prevent falls for 3 of 3 sampled resident (Resident #500, #501, & # 503) who were assessed to be a fall risk out of a total sample of 4 resulting in Resident #500 falling, after getting out of bed without assistance, and fracturing both of her lower legs, Resident #501 having three (3) falls that were not reported to Resident #501's nurse and who was identified to have a fractured right thumb of unknown origin within one day of her falls, and Resident #503 who fell on e day after her admission that resulted in a skin tear and another fall approximately one and a half months later, without injury. Findings include: Resident #500: Per the facility face sheet Resident #500 was a [AGE] year old female originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the "Minimum Data Set" ((MDS) dated [DATE] revealed that Resident #500 required extensive assistance with transferring and bed mobility. The MDS revealed that Resident #500 did not ambulate and required extensive assistance with toileting and hygiene. Record review of a facility "Accident/Incident Report" dated 5/19/2011 revealed that Resident #500 was found on her hands and knees next to her bed. The report revealed that Resident #500 was transferred to the hospital. Record review of a "Fall Circumstance, Assessment and Intervention" dated 5/19/2011 revealed that Resident #500 was sent to the hospital for a possible knee/leg fracture. The report revealed that Resident #500 complained of severe pain to her right leg after her fall. The report also revealed that Resident #500's activity at the time of the fall was unknown and that it was unknown as to whether or not Resident #500's bed alarm was on and functioning at the time of her fall. Record review of hospital "ED (emergency department) Physician Notes" dated 5/19/2011 revealed that Resident #500 presented to the hospital after she was found on the floor, beside her bed, by nursing staff at the facility. The note revealed, "It was unknown how long the patient actually had been fallen on the floor." The note revealed that Resident #500 was not able to straighten out her right knee and there was significant swelling to her right knee area. The note revealed that an X-ray report revealed a fracture of Resident #500's right femur bone (thigh bone). Record review of an X-ray report dated 5/19/2011 revealed a fracture of Resident #500's femur bone. Review of an "Operative/Procedure Report" dated 5/19/2011 revealed that Resident #500 underwent surgery to repair the fracture of her right femur. Although review of hospital physician "Progress Notes" dated 5/25/2011 revealed a notation from the physician, "his case was discussed with the daughter (Resident #500's daughter) ...We explained to her that this is a fall with fracture, it is like signs of frailty of an elderly person and it is like more pathological (spontaneous) fracture without any signs of abuse or neglect. Severe osteoporosis is the major reason for this fracture." Resident #500 sustained a fall and there is no evidence which supports that the fracture of her femur happened prior to her fall at the facility. Record review of the "Treatment Record" dated for the month of March 2011 revealed that nursing staff initialed the "Treatment Record" every shift indicating that Resident #500 had her bed alarm on. Review of the "Treatment Record" for the months of April and May 2011 revealed no initials for the entire two months and FYI (for your information) was written on the "Treatment Record" next to where it was written, low bed, floor mat, and bed side alarm. Record review of a "Resident Care Plan" dated 10/17/2009 and updated 11/16/2010 revealed that Resident #500 was at risk for falls. Under the "Interventions" dated 12/1/2009 it stated, "Pressure alarm to bed to alert staff of attempts to get up unassisted' check placement and function every shift and PRN (as needed)." Record review of "Nurse's Notes" dated 5/19/2011 revealed a notation from Staff Member #1, a Registered Nurse (RN), "Entered resident's room upon prompting from (Certified Nurse Aid #2) to find resident on floor parallel to bed, facing the front of the bed on hands and knees. No bed alarm sounding at this point ...small reddened area noted on right inner knee, which had been resting on floor ...resident had been reported to have been attempting to climb out of bed a couple of times during shift." Review of Resident #500's medical record revealed no documentation of frequent checks of Resident #500 as an intervention, or any other intervention based on her attempts to get out of bed unassisted prior to her fall. RN #1, Resident #500's primary nurse, was interviewed on 6/9/2011 at 10:00 AM. He said that nursing was responsible to check resident alarms every shift for functioning and placement and document that the check was done on the "Treatment Record" every shift." He said that it was facility policy and procedure to check and document alarms on residents every shift. He said that he believed that the Unit Managers were responsible for implementing resident care plans, such as if a resident was assessed to be a fall risk then the resident would require a fall risk care plan. He said that when he entered Resident #500's room he found her on her hands and knees on the floor. He said that he was called into Resident #500's room by Certified Nurse Aid #2 (CNA). He said that Resident #500's bed alarm was not sounding when he entered her room. He said CNA #2 entered before him, but by the way Resident #500 was on the floor he could not see that CNA #2 could have or would have shut the alarm off before calling out for help. RN #1 said that he was four (4) rooms away from Resident #500's room when CNA #2 called him in there. He said that the alarms where loud and if Resident #500's bed alarm had sounded then he would have heard it from where he was standing and he did not hear the alarm sound. He said that CNA #2 told him that she had left Resident #500's room 5 minutes prior to her fall. RN #1 said that the bed alarm was either not on or not placed under Resident #500 correctly after CNA #2 assisted her prior to her fall. He said that Resident #500 was not able to get herself up from the floor and that was when he assisted her up from the floor. Resident #500 complained of pain and said that her leg was broken. He said again at the end of the interview that per facility policy and procedure nursing was to check the placement and functioning of resident alarms every shift. He said that the Certified Nurses' Aid did not document on the "Treatment Record" that the alarms had been checked; only nursing did. RN #1 said that alarm checks were never to be just an FYI when written on the "Treatment Record". CNA #2, Resident #500's primary CNA, was interviewed on 6/9/2011 at 12:00 PM. She said that she had changed Resident #500 at about 5:15 AM. She said that she then went into another resident's room, two rooms away, and changed her. She said that when she had come out of the other resident's room she heard Resident #500 yell "help, I'm stuck". She said that she found Resident #500 on her knees facing her nightstand. She said that she called RN #1 into the room and the two of them were able to get Resident #500 up off the floor. She said that Resident #500 did have a pressure alarm on her bed. She said the alarm sounded; she was not sure if RN #1 heard the alarm or not. CNA #2 said that when she had changed Resident #500, prior to her fall, the bed alarm sounded and she pushed the reset button. She said that there was no way to tell if the alarm was functioning when she left the room, she only knew because the alarm had sounded while she assisted Resident #500 with changing 5 minutes before her fall. CNA #2 said that the bed alarm used for Resident #500 was a "Secure Pad 2 Alarm". CNA #2 showed the surveyor the "Secure Pad 2 Alarm". Observation of the audibility of the "Secure Pad 2 Alarm" four (4) rooms away, and where RN #1 was standing when called into Resident #500's room by CNA #2, was conducted on 6/9/2012 at 1:00 PM. The bed alarm was placed on the exact bed (room 219-A) that Resident #500 was residing in at the time of her fall. The bed alarm was turned on so it sounded the alarm. The surveyor began at room 219-A, and could hear the alarm sounding. The surveyor walked to room 213, four rooms away, and could still hear the alarm sounding. Beyond room 213 the alarm was audible, although faint. The Assistant Director of Nursing (ADON) was asked for the facility policy and procedure specific to resident alarms on 6/8/2011 at 1:00PM. On 6/8/2011 at 3:00 PM the ADON stated that the facility did not have a policy and procedure specific to alarms but only a policy for falls. Review of the falls policy and procedure revealed no guidance for resident alarms. Resident #501: Per the facility face sheet Resident #501 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an MDS dated [DATE] revealed that Resident #501 required assistance with ambulation, dressing, toilet use, and personal hygiene. Record review of an incident report dated 6/1/2011 revealed that Resident #501 was found to have a swollen thumb on 5/30/2011. An X-ray dated 5/30/2011 revealed that Resident #501 had a fracture of her thumb. Staff Member #4, a Licensed Practical Nurse (LPN), was interviewed on 6/9/2011 at 9:11 AM. She said that CNA #5 brought to her attention of a bruise to Resident #501's right thumb. She said the bruise was dark purple and the swelling extended from her wrist to the top of her thumb. She said that Resident #501 had a fall a few days prior to the discovery of the bruising and swelling. She said that she did not know any of the details of Resident #501's fall. She said that Resident #501's thumb appeared to be broken so she phoned the physician and received an order for [REDACTED]. She said that Resident #501 was unpredictable with her attempts to get up on her own. She said that Resident #501 required frequent observation. She said that a care plan was to be initiated on admission of a resident if a resident was identified to be a fall risk. LPN #4 said that the nursing staff was responsible to check fall alarms every shift and document on the "Treatment Record". LPN #4 said that the CNA's could document that a resident had an alarm, but could not document that the alarm was functioning. Staff Member #6, a CNA, was interviewed on 6/9/2011 at 11:09 AM. She said that on 5/29/2011 around 9:00 PM, she heard Resident #501's fall alarm sound. She said that she did not go into Resident #501's room but just looked in the door. She said that she did not want to agitate Resident #501. CNA #6 said that Resident #501 was on her hands and knees next to her bed, with her hands on her wheelchair attempting to get herself up from the floor. CNA #6 said that she called out to CNA #7, who she saw in the hallway, and told her that Resident #501 was on the floor. CNA #6 said that CNA #7 starting walking towards Resident #501's room. She said that she told CNA #7 that she was going to answer other call lights and left Resident #501. She said that she did not know if CNA #7 ever went into Resident #501's room or who got her off the floor, because she left the hall. CNA #6 said that also on 5/29/2011, between 7:30 and 8:00 PM, she was with Resident #501 in the television room. She said Resident #501 stood up from her wheelchair and CNA #6 asked her to sit back down. CNA #6 said that Resident #501 sat back down but missed her wheelchair and sat on the floor instead. CNA #6 said that she did not consider that a fall and that she was not aware that the definition of a fall was an unintentional coming to rest on the ground. CNA #6 said that she was on weight restriction and could not pick Resident #501 up. Staff Member #7, a CNA and Resident 501's primary CNA, was interviewed on 6/9/2011 at 2:20 PM. She said that on Sunday 5/29/2011 CNA #6 came to her, while she was in another resident's room, and asked her to help her get Resident #501 off the floor. She said that she told CNA #6 that she needed to finish with the resident she was with first. She said that CNA #6 told her that Resident #501 had slid out of her wheelchair. She said that she questioned whether Resident #501 had fallen, but CNA #6 insisted that Resident #501 slid out of her wheelchair and had not fallen. CNA #7 said that she took Resident #501 to her room, put her into bed, and took her vital signs. She said that Resident #501 complained of pain in her right arm. CNA #7 said that she reported the arm pain and situation to Resident #501's primary nurse, LPN #8, who in return told her that Resident #501 always complained of arm pain. CNA #7 said that CNA #6 had not told her at anytime that Resident #501 was on the floor in her room on Sunday 5/29/2011. She said that she knew nothing about this and that CNA #6 never summoned her to Resident #501's room, as she was walking to the hall. Staff Member #8, an LPN and Resident #501's primary nurse from Saturday 5/28 through Sunday 5/29/2011 on the 7:00 AM to 3:00 PM shift, was interviewed on 6/9/2011 at 1:50 PM. She said that she was not told about any falls that Resident #501 may have had until after the bruising and swelling was discovered on Resident #501's right thumb. Staff Member #9, a CNA who cared for Resident #501 on Saturday 5/29/2011 on the 3:00 PM to 11:00 pm shift, was interviewed on 6/9/2011 at 1:25 PM. She said that when she left on Saturday at 11:00 PM Resident #501 did not have any type of injury nor did she complain of any type of pain. She said that it was on Monday in the evening she went to hold Resident #501's hand and noticed that it was swollen and bruised. She said that staff were already aware of the injury to Resident #501's thumb when she noticed it swollen and bruised. Staff Member #10, an LPN who cared for Resident #501 on Sunday 5/29/2011 on the 3:00 PM to 11:00 PM shift, was interviewed on 6/9/2011 at 3:00 PM. She said that it was never reported to her that Resident #501 had any falls in her room or in the T.V. room. Staff Member #11, a CNA, was interviewed on 6/10/2011 at 8:50 AM. She said that CNA #6 was watching Resident #501 while she was in the T.V. room on Sunday 5/29/2011. She said that CNA #6 and CNA #7 argued over whether Resident #501 had fallen while in the T.V. room. She said that CNA #6 said Resident #501 just sat down apposed to falling. CNA #11 said that CNA #7 commented that the fall needed to be reported to Resident #501's nurse. She said that she did hear CNA #7 tell someone (did not know who), while in Resident #501's room, that Resident #501 had complained of arm pain. LPN #8 was interviewed again on 6/10/2011 at 9:40 AM. She said that no one ever told her that Resident #501 had a fall or that she complained of any arm pain. Staff Member #12, a CNA, was interviewed on 6/10/2011 at 10:45 AM. She said that she had worked 11:00 PM to 7:00 AM on 5/29/2011. She said that she noticed the swelling and bruising to Resident #501's right thumb. She said that when she asked about it CNA #6 said that Resident #501 had fallen. Observation of Resident #501's bed in her room was conducted on 6/9/2011 at 3:35 PM. The bed was noted to be in the lowest position, with a bed alarm, and a pad on the floor next to the bed. Record review of the "Nursing Admission Assessment and Data Collection" dated 4/28/2011 revealed that upon admission Resident #501 was identified to be at a high risk for falls. A safety plan of care, only documented on the admission assessment form revealed that a pressure alarm was initiated for safety and to alert staff of attempts to get up without assistance. A permanent care plan with interventions and goals was not found to have been initiated at the time of the investigation. Record review of the "Treatment Record" for the month of May 2011 revealed that nursing staff was to initial every shift that Resident #501 had a pressure alarm to her bed and wheelchair, with a mat on the floor next to her bed. No shifts were initialed until 5/22/2011. Record review of a "Fall Circumstance, Assessment, and Intervention" form dated 5/20/2011 revealed that Resident #501 had slid out of her bed onto the floor. No care plan was found related to falls. Resident #503: Per the facility face sheet Resident #503 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an "Accident/Incident Report" dated 4/2/2011 and another dated 5/14/2011 revealed that Resident #503 had two falls. Both falls Resident #503 was found on the floor in her room. No injury was noted. Record review of the "Treatment Record" dated for the month of April 2011 revealed that no alarm was documented as in place until 4/13/2011. Record review of a physician order dated 4/12/2011 revealed that Resident #503 was to have a pressure alarm to her bed and chair and the alarm was to be checked every shift for functioning. Record review of a care plan dated 4/25/2011 titled "Falls" revealed no fall alarms as part of Resident #503's plan of care. The ordered pressure alarm was not on the care plan. Review of the facility policy and procedure titled "Falls Management Program" dated 1/2006 revealed, under procedure, "care plan interventions should be implemented that address the resident's risk factors." Staff Member #13, an LPN, was interviewed on 6/10/2011 at 8:20 AM. She said that Resident #503 had another fall on 5/14/2011. She said that Resident #503's fall pressure alarm did not sound. Observation of Resident #503 was conducted on 6/10/2011 at 9:50 AM. A bed alarm was in place and observed to be functioning. A family member was visiting with Resident #503 and stated that Residents #503 would take the alarm apart at times. Review of the facility audit tool for compliance with, "Alarms in place per care plan and functioning" revealed that the audit had not been done since 4/21/2011. Staff Member #14, a Registered Nurse and the Assistant Director of Healthcare Services, was interviewed on 6/10/2011 at 10:15 AM. She said that since the Director of Nursing had left her employment, no one had been completing the fall alarm audit tool. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE FOR 1 RESIDENT (#4) AND HOSPICE SERVICES FOR 3 OF 3 SAMPLED RESIDENTS (#2, #3 #7) AND 1 OFF-SAMPLE RESIDENT (#40) REVIEWED FOR HOSPICE CARE FROM A TOTAL SAMPLE OF 16 RESIDENTS, RESULTING IN A MAJOR SKIN INJURY AND UNRELIEVED PAIN FOR RESIDENT #4 AND A LACK OF COORDINATION OF HOSPICE CARE FOR RESIDENTS #2, 3, 7 AND 40. FINDINGS INCLUDE: RESIDENT #4 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS ALSO RECEIVING [MEDICATION NAME] (BLOOD THINNER) THERAPY DAILY. BOTH "FALLS" AND "SKIN" CARE PLANS DATED 7/2/09 REFLECTED THAT THE RESIDENT WAS AT RISK FOR FALLS AND SKIN BREAKDOWN RELATED TO LIMITED MOBILITY, [MEDICAL CONDITION] OF THE LOWER LEGS, STASIS [MEDICAL CONDITION] WITH CHRONIC STASIS ULCERATIONS IN THE SHINS, LIMITED SENSORY PERCEPTION, [MEDICAL CONDITIONS] AND HAND CONTRACTURES. THE RESIDENT WAS TO BE TRANSFERRED WITH A MECHANICAL LIFT AND HAD BED BOLSTERS TO PREVENT HER FROM FALLING OUT OF BED. THE NURSING NOTE DATED 10/6/10, 2300, STATED THAT THE RESIDENT WAS SENT TO THE emergency room (ER) AT 10:45 P.M. AFTER A FALL. THERE WAS NO DESCRIPTION OF HOW THE FALL OCCURRED OR UNDER WHAT CIRCUMSTANCES. THE NEXT NURSING NOTE ENTRY DATED 10/7/10 STATED, " RESIDENT RETURNED FROM ER AT 0030 WITH NEW ORDER OF ANTIBIOTIC ...TO BE SEEN BY WOUND CLINIC..." THE INCIDENT REPORT DATED 10/6/10 DESCRIBED THE RESIDENT AS BEING LOWERED FROM BED TO THE FLOOR BY A CERTIFIED NURSING ASSISTANT (CNA), SCRAPING HER ARM AND CAUSING A LARGE SKIN TEAR. THE PHYSICIAN'S PROGRESS NOTE DATED 10/7/10 STATED THAT THE SKIN HAD BEEN PEELED OFF FROM THE LOWER FOREARM TO ALMOST THE ELBOW, COULD NOT BE APPROXIMATED DUE TO EXTENSIVE LOSS OF SKIN TISSUES. THE SURGEON'S REPORT FROM THE HOSPITAL RECORD DATED 10/7/10 REFLECTED " ...THE RESIDENT fell OUT OF BED LAST NIGHT AND INJURED THE LEFT FOREARM SUSTAINING A LARGE LACERATION...SHE VISITED ER, BUT NOTHING WAS DONE AND SENT HOME...WHEN SHE WAS EXAMINED THERE IS A LARGE LACERATION EXPOSING PART OF HER FASCIA AND THE MUSCLES AND WAS DECIDED TO REPAIR THE WOUND ON 10/8/10... " ON 2/25/11 AT 9:30 A.M., DURING A BED BATH ASSISTED BY 2 NURSING AIDES, (STAFF "D" AND "L") IN THE RESIDENT'S ROOM, THE RESIDENT WAS OBSERVED TO HAVE MULTIPLE BRUISES AND SKIN TEARS (OLD AND NEW) OVER HER ENTIRE BODY; BACK OF RIGHT UPPER ARM, RED AND BLACK SCABS ABOVE RIGHT KNEE, DRESSED AREA ON RIGHT LOWER LEG AND LEFT ELBOW AND FOREARM, GASH WOUND OVER LEFT UPPER ARM, RED/BRUISED RIGHT FORE ARM, BOTH LOWER LEGS WERE RED, SWOLLEN AND COVERED WITH TINY BLISTERS AND INDURATIONS. THE BUTTOCKS WERE MACERATED WITH DARK RED COLOR. THE ENTIRE SKIN SURFACE WAS SHINY, FRAGILE AND THIN CAUSED BY A LONG TERM STEROID USE. TWO NURSING AIDES WASHED THE RESIDENT WITH WASH CLOTHES AND A TOWEL (ABRASIVE TO FRAGILE SKIN) FOR APPROXIMATELY 20 MINUTES AND ANOTHER 10 MINUTES DURING A TRANSFER FROM BED TO A WHEEL CHAIR. THE RESIDENT WAS YELLING AND SCREAMING LOUDLY FOR THE ENTIRE PERIOD, COMPLAINING OF PAIN AND HOLLERING, "QUIT IT! QUIT IT!" BOTH STAFF "D" AND "L" STATED THAT THE RESIDENT WOULD YELL AND SCREAM EVERY TIME SHE WAS TOUCHED AND HER YELLING WAS 5-6 TIMES WORSE DURING A SHOWER. ON 2/25/11 AT AT 1:00 P.M., THE UNIT MANAGER, (STAFF "I") STATED THAT THE RESIDENT WAS NOT PRESCRIBED NARCOTICS BECAUSE OF HER POOR RENAL FUNCTION. HOWEVER, SHE DID NOT KNOW THE EXACT CAUSE OF THE RESIDENT'S PAIN AND HAD NO INTERVENTIONS TO MANAGE THE PAIN. THE PAIN CARE PLAN DATED 2/14/11 FAILED TO DEMONSTRATE RECOGNITION OF THE RESIDENT'S PAIN RELATED TO SPECIFIC CIRCUMSTANCES AND DID NOT INCLUDE AN EVALUATION OF EXISTING PAIN OR THE CAUSES AND REALISTIC GOALS IN MANAGING THE PAIN. ON 2/25/11 AT 3:00 P.M., THE NURSING AIDE, (STAFF "Y") WHO ASSISTED THE RESIDENT AT THE TIME OF ACCIDENT WAS INTERVIEWED. STAFF "Y" STATED THAT SHE HAD TAKEN CARE OF THE RESIDENT FOR ALMOST 2 YEARS, WORKING ALWAYS ON EVENING SHIFT. SHE STATED THAT SHE HAD ROLLED THE RESIDENT ON TO HER RIGHT SIDE TO PUT A NIGHT GOWN ON. THE RESIDENT GRABBED THE FRONT PART OF STAFF "Y'S" CLOTHING AND THE NIGHT STAND. SHE ATTEMPTED TO BREAK AWAY FROM THE RESIDENT, BUT THE RESIDENT PULLED HARD FORWARD TOWARD THE BED. STAFF "Y" SAID SHE LOST HER BALANCE AND HAD TO LOWER THE RESIDENT TO THE FLOOR. STAFF "Y" STATED THAT THE RESIDENT DID NOT WEAR "GERI SLEEVES (THICK CLOTH)" AT THAT TIME BECAUSE THOSE WERE ORDERED ONLY FOR RESIDENTS WITH BRUISES. STAFF "Y" ADDED THAT SHE SHOULD HAVE HAD ANOTHER CNA TO HELP HER BECAUSE THE RESIDENT WAS MUCH LARGER (5 FEET 6 INCHES TALL, 208 POUNDS) THAN SHE WAS (4 FEET TALL, 99 POUNDS). HOWEVER, SHE DID NOT WISH TO IMPOSE ON OTHER NURSING AIDES, BECAUSE SHE KNEW THEY WERE BUSY AND SHE NEVER HAD ANY INCIDENTS WITH THIS RESIDENT BEFORE. HOWEVER, SHE ALSO NOTICED THAT THE RESIDENT'S PHYSICAL AGGRESSION AND BEHAVIORS HAD GOTTEN WORSE AS HER DEMENTIA ADVANCED. THE NURSING NOTES DATED 8/5/10 THROUGH 10/6/10 (DATE OF INCIDENT) REFLECTED THAT THE RESIDENT WAS EXHIBITING MULTIPLE EPISODES OF BEHAVIOR ISSUES AS WELL AS HAVING NUMEROUS AREAS OF SKIN BREAKDOWN. THE NURSING NOTE DATED 8/5/10 STATED, " ...NOTED SKIN TEAR ON BACK OF RIGHT LOWER LEG... " NOTE DATED 8/9/10 STATED, " ...1.5 CM X 1.5 CM FLUID FILLED BLISTER ON LEFT LOWER LEG... " NOTE DATED 8/20/10 STATED, " ...BLISTER ON LEFT LOWER CALF... " NOTE DATED 10/2/10 STATED, " ...MULTIPLE EPISODES OF YELLING THIS SHIFT KEEPING OTHERS AWAKE... " NOTE DATED 10/3/10 STATED, " ...BEGAN YELLING AFTER DINNER FOR 2 HOURS, KEEPING OTHERS FROM GOING TO SLEEP... " THE CARE PLANS FOR "FALLS" AND "SKIN BREAKDOWN" DATED 7/2/09 HAD NO UPDATED PROVISIONS REGARDING THE RESIDENT'S SKIN CARE OR NUMBER OF STAFF SHE MAY NEED ASSISTING DURING PERSONAL CARE, ALTHOUGH THE NURSE AIDE GUIDE, PRINTED 2/23/11, REFLECTED: "2 PEOPLE ASSIST FOR CARE AT ALL TIMES." DESPITE THE RESIDENT'S REPEATED INCIDENTS OF SKIN BREAKDOWNS AND INCREASING BEHAVIORAL ISSUES DOCUMENTED IN THE NURSING NOTES, THE CARE PLAN FAILED TO DEMONSTRATE REVISED INTERVENTIONS OR EVALUATION OF THE INTERVENTIONS BASED ON ASSESSMENT TO PREVENT FURTHER SKIN INJURIES AND FALLS. ( ) RESIDENT #3 WAS AN [AGE] year OLD FEMALE admitted TO THE FACILITY WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS ALSO DEPENDENT ON OXYGEN AND HAD CHRONIC NON-HEALING VASCULAR ULCERS ON HER LOWER EXTREMITIES. THE CARE AREA ASSESSMENT SUMMARY (CAAS) DATED 10/28/10 REFLECTED THAT THE RESIDENT REQUIRED EXTENSIVE TO TOTAL ASSIST WITH ALL OF HER ACTIVITIES OF DAILY LIVING (ADLS). SHE WAS admitted TO THE HOSPICE SERVICE ON 10/15/2010. THE HOSPICE CARE NOTE DATED 10/18/10 REFLECTED THAT THE RESIDENT WAS TO BE VISITED BY A NURSE TWICE A WEEK, A SOCIAL WORKER ONCE A MONTH, HOSPICE AIDES TWICE A WEEK AND A CHAPLAIN ONCE A MONTH. THE NOTE INCLUDED A LIST OF PROBLEMS BUT NO INTERVENTIONS OR GOALS COULD BE FOUND. THE FACILITY CARE PLANS HAD NO DOCUMENTATION REGARDING COORDINATION OF HOSPICE SERVICE. ON 2/24/11 AT 9:00 A.M., THE UNIT MANAGER ON 200 WING, (STAFF "I") STATED THAT THE NURSING AIDES WERE INFORMED BY READING THE DAILY PRINTED NURSING AIDE GUIDE AS TO WHO THE HOSPICE RESIDENTS WERE. HOWEVER, THE NURSING AIDE GUIDE PRINTED ON 2/23/11 DID NOT INDICATE THE RESIDENT WAS RECEIVING HOSPICE CARE. ON 2/25/11 AT 10:30 A.M., THE CERTIFIED NURSING ASSISTANT (CNA), (STAFF "L") STATED THAT SHE USUALLY COMMUNICATED WITH THE HOSPICE AIDE ABOUT WHAT HAD BEEN PROVIDED BY THE HOSPICE AIDE, BUT SHE DID NOT KNOW WHICH HOSPICE AIDE CAME ON WHICH DAYS OF THE WEEK OR WHAT TIME OF DAY OR EVENING. ( ) RESIDENT #7 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE NOTE CONTINUED SAYING, " THE PATIENT IS ON HOSPICE CARE AT PRESENT TIME AND AGGRESSIVE MEASURES WILL BE ABORTED." THE RESIDENT HAD NOT BEEN IDENTIFIED AS BEING A HOSPICE RESIDENT ON THE NURSING AIDE GUIDE PRINT-OUT DATED 2/23/11 AS THE UNIT MANAGER (STAFF "I") CLAIMED ON 2/24/11 AT 9:00 A.M. STAFF "I" STATED THAT SOME OF THE HOSPICE AIDES CAME EARLY TO HELP OUT WITH FEEDING AND BATHING AND SOME CAME LATER IN THE DAY TO ASSIST WITH OTHER CHORES. HOWEVER, STAFF "I" DID NOT KNOW THE EXACT SCHEDULES OF THE HOSPICE CARE STAFF AND WHAT TASKS THEY WERE ASSIGNED TO CARRY OUT. THERE WAS NO COORDINATION OF CARE PLANS BETWEEN THE FACILITY AND HOSPICE CARE SERVICE. ( ) ACCORDING TO THE FACE SHEET, RESIDENT #2 WAS A [AGE] year OLD MALE WHO HAD RESIDED IN THE FACILITY SINCE 4//1/08 AND REadmitted [DATE]. THE [DIAGNOSES REDACTED]. ON 2/23/11 AFTER REVIEWING ALL OF RESIDENT #2'S CARE PLANS NO HOSPICE OR COORDINATION OF HOSPICE AND FACILITY CARE PLAN WAS FOUND. ON THE MORNING OF 2/24/11 THE DIRECTOR OF NURSING (DON) "K" WAS ASKED WHERE WAS THE HOSPICE CARE PLAN, SHE LOOKED THROUGH THE CLINICAL RECORD AND COULD NOT FIND ONE. THE NURSE'S NOTES DATED 12/31/10 REFLECTED A "HOSPICE NURSE CALLED US WITH NEW ORDERS CALLED IN TO (PHARMACY NAME) ..." THERE WAS NO EVIDENCE FOUND IN THE CLINICAL RECORD TO REFLECT WHY NEW ORDERS WERE NEEDED, OF IF THE HOSPICE NURSE OR ANY OTHER NURSE SPOKE TO THE DOCTOR TO JUSTIFY NEW ORDERS. ON 2/24/11 AT 1:40 PM A HOSPICE NURSE FROM ANOTHER HOSPICE AGENCY WAS OBSERVED AT THE NURSE'S STATION ON THE 200 UNIT GETTING A SIGNATURE FROM UNIT MANAGER "I", WHICH REFLECTED WHAT WAS DONE WITH RESIDENT #40 THAT DAY. THE HOSPICE NURSING STAFF TOLD THE UNIT MANAGER "I" THAT RESIDENT #40 HAD BEEN ON HOSPICE SINCE 2/11/11, UNIT MANAGER "I" REPLIED SHE WAS NOT AWARE RESIDENT #40 WAS ON HOSPICE. ( )