Every finding on record at The Orchards at Douglas Cove

This citation pertains to intake #3092387 and 3117404.Based on interview and record review, the facility failed to provide adequate supervision to prevent accident hazards in 4 of 6 residents (R12, R18, R13, and R48) reviewed for accidents and hazards, resulting in R12 sustaining a fall with major injury.Findings include:R12Review of an admission Record revealed R12 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, anxiety, and restlessness.Review of R12's Kardex (summary of care needs), dated 8/26/2026, revealed R12 required supervision with transfers.In an interview on 8/26/2026 at 9:39 AM, the Director of Nursing (DON) reported staff were required to always monitor the locked dementia unit hallway as residents on the unit required constant supervision with ambulation and redirection to prevent resident to resident issues.Review of R12's Incident Report, dated 7/4/26 at 5:00 PM, revealed R12 had been walking unsteadily that day and later fell in the hallway, losing 3 artificial teeth, and was sent to the local hospital for further evaluation. Certified Nursing Assistant (CNA) M statement revealed, (R12) had been leaning backwards, stumbling around and closing her eyes, walking around all day. (R12) would not stay seated in recliner in the hall when I turned around and observed (R12) fall over on the floor. She was bleeding from right brow line and lip. Her false (artificial) teeth came out.Review of R12's Nurses Note, dated 7/4/26 at 8:26 PM, revealed R12 returned from the hospital and required dental follow up for tooth repair.In an interview on 8/25/26 at 3:30 PM, Licensed Practical Nurse (LPN) E reported R12 had been very unsteady all day on 7/4/26 to the point that he told the CNA She is going to fall 30 minutes before she fell. LPN E reported they did not place R12 into one-on-one supervision or otherwise increase supervision when they noticed that she was unsteady as staffing levels prevented this.In an interview on 8/25/26 at 3:45 PM, CNA M reported R12 had been unsteady all day, twirling around. CNA M reported he would have liked to be with her one-on-one because of her unsteadiness, but he had care to provide, and staff did not increase her supervision when they noticed her walking with abnormal unsteadiness.In an observation and interview on 8/26/26 at 2:18 PM in the locked unit office, the Director of Nursing (DON) reviewed R12's 7/4/26 fall and reported the teeth she lost were artificial. We observed these teeth together that were locked in the medication cart. The teeth were observed to be a dental bridge with roots visible and not false or artificial teeth as the facility had documented. The DON reported R12 should have been placed into one-on-one observation when staff noted her to be unsteady to prevent her from falling.R18Review of an admission Record revealed R18 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, agitation, and restlessness.In an interview on 8/24/26 at 3:25 PM, Family Member S reported R18 fell twice over the weekend, and she wondered what the facility was doing to prevent falls.Review of facility Incident Reports dated 8/21/26 at 2:45 PM and 3:30 PM revealed R18 fell two times that day within 45 minutes and was unwitnessed both times. The first fall was in the hallway, and the next fall was in his doorway.Review of the staff schedule for 8/21/26 revealed CNA J was the only CNA working on the locked dementia unit that day. In an interview on 8/25/26 at 9:57 AM, CNA J reported she was working alone on 8/21/26. CNA J reported it is very difficult to work alone on the locked unit because they have 4 residents who wander and many residents requiring the assistance of two staff and she was unable to supervise the hall adequately. CNA J reported she came out of resident room [ROOM NUMBER] into the unit hallway and found R18 on the floor in the hallway. CNA J reported no staff were supervising the hallway at the time.R13Review of an admission Record revealed R13 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety.Review of facility investigation of the facility reported incident (MI-FRI 65410) revealed at 6:20 PM on 7/15/26 while nurses were giving report in the office and the CNA was providing care in a resident room a resident-to-resident incident took place between R18 and R13 in which struck by R18 with a closed fist on the upper back and back of head. R13 was sent to the local hospital for further treatment and evaluation. In an interview on 8/26/26 at 12:21 PM, the Nursing Home Administrator reported the locked unit hallway was not being monitored by facility staff on 7/15/26 when the incident between R13 and R18 occurred. The NHA reported staff are required to continuously monitor the locked unit hallway to supervise at risk residents.R48Review of an admission Record revealed R48 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and agitation.Review of facility investigation of the facility reported incident (MI-FRI 65045) revealed on 6/13/26 at 4:20 PM a resident-to-resident incident occurred in which R48 was struck by R18 in the locked unit hallway while the hallway was unmonitored by facility staff.In an interview on 8/26/26 at 10:45 AM, CNA I reported she was working on 6/13/26 in another resident's room when she heard a commotion and came out into the hallway and saw R18 punch R48 in the face. CNA I reported no staff were supervising the hallway at the time of the incident.Review of facility policy/procedure Fall Management Guidelines, undated, revealed .Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision. to minimize the risk for falls. Residents identified at risk for falls will have a care plan developed and implement fall prevention interventions as needed based on their assessment.

This citation pertains to intake 3092525.Based on interview and record review, the facility failed to implement the facility abuse policies and procedures for reporting serious bodily injury in 1 of 3 residents (R49) reviewed for abuse. Findings include:Review of the facility investigation of MI-FRI 00065165 revealed R49 had an injury of unknown source that was reported to the state survey agency on 6/25/2026 at 4:23 PM. Review of R49's Progress Note dated 6/25/2026 at 10:22 AM revealed that (Name) Hospital had notified the facility at 10:22 AM that R49 had been admitted to the hospital with a hip fracture related to a recent fall. In an interview on 8/25/26 at 2:11 PM, the Nursing Home Administrator (NHA) reported that she was unsure why she did not report R49's serious bodily injury within the 2-hour period after being notified of the injury. The NHA reported that per the facility policy, R49's fracture should have been reported by 12:22 PM on 6/25/26. Review of facility policy/procedure Abuse and Neglect Prohibition Policy, reviewed 12/19/2025, revealed .the administrator or designee is responsible for reporting to the State Agency all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of property: Immediately but no later than 2 hours after the allegation is made if the allegation involves abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to notify the physician of a significant change in 1 (Resident #102) of 3 residents reviewed for notification, resulting in the physician not evaluating Resident #102 when she experienced a significant weight gain, swelling of her legs, decreased functional abilities, and hospitalization.Findings include:Review of an admission Record revealed Resident #102 was a [AGE] year-old female who was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified atrial fibrillation (a common, often rapid irregular heart rhythm where the heart's upper chambers beat chaotically which can cause blood clots, stroke and heart failure).Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 1/23/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. In an interview on 3/4/26 at 3:09pm, Resident #102 reported on 2/10/26 she insisted on going to the emergency room because she had experienced unresolved pain, swelling in both lower extremities and a loss of functional ability for more than a week. Resident #102 reported she told several staff members she wanted to be seen by the physician but was not evaluated. Resident #102 she became increasingly worried and frustrated when she lost the ability to transfer herself to her wheelchair and to the toilet. When further queried, Resident #102 reported she could tolerate a pain level of 5 on the pain scale of 0-10 and felt she could function as well as she'd like at that level. Resident #102 stated My pain was at an 8 before I went to the hospital and it was too much for me to handle.In an interview on 3/3/26 at 1:43pm, Family Member (FM) W reported Resident #102 struggled with swelling in her legs, pain and decreased mobility for more than a week when she went to the hospital on 2/10/26. FM W confirmed they spoke with a floor nurse on 2/2/26 and requested that a provider evaluate the resident. FM W reported they were told the resident (Resident #102) would be evaluated by a provider on 2/3/26 but that never happened. FM W reported when she asked the nurse what could be done to address Resident #102's severe pain, the nurse offered to provide the resident (Resident #102) with more over the counter pain medication but did not offer to contact a provider. FM W reported she witnessed Resident #102 crying from the pain she experienced. FM W reported during the week of 2/2/26, the staff began offering Resident #102 an over-the-counter cream for her pain, but the application of the cream intensified the pain in her legs, and she could not tolerate it.In an interview on 3/3/26 at 2:58pm, Certified Nursing Assistant (CNA) BB reported on 2/3/26 and 2/4/26 Resident #102 exhibited swelling in her legs, the left leg slightly more so than the right, complained of increased pain and needed more help getting her feet into bed and with transferring from one surface to another. CNA BB reported she told the nurse and therapy staff that something was off with Resident #102 because she felt Resident #102 needed to be evaluated.In an interview on 3/3/26 at 3:42pm, CNA K reported between 2/3-2/9/26 Resident #102 yelled out during cares and asked for pain medication. CNA K confirmed it was unusual for Resident #102 to complain of pain or request medication.In an interview on 3/4/26 at 3:50pm, CNA L reported between 2/3-2/9/26 she observed Resident #102's legs were swollen and painful. CNA L reported Resident #102 tried to be as independent as possible but during that time the resident needed physical assistance to lift her legs and for all transfers. CNA L reported Resident #102 yelled OHHH! and grabbed her legs as she was being assisted with moving them onto the bed. CNA L reported Resident #102's socks left indentations in her calves after they were removed. CNA L confirmed she reported Resident #102's swelling, increased pain and loss of functional abilities to the nurse. CNA L stated I told the nurse I thought the resident was retaining fluid.Review of a Weight Summary for Resident #102 revealed the resident gained 9 pounds from 12/30/25-2/1/26, a period of 32 days. Weight increase was documented by Licensed Practical Nurse (LPN) I. A weight gain of 4 pounds was documented by LPN I on 2/6/26.Review of a Weight Change Note for Resident #102 with a reference date of 2/5/26 revealed WEIGHT WARNING: .+7.5% (increase 7.5 percent) change.sig (significant) wt (weight) gain noted, resident has daily weights x7 days in place to monitor. No diuretics on board.In an interview on 3/4/26 at 1:54pm Director of Nursing (DON) B reported Resident #102 was supposed to have daily weights for 7 days because of her significant weight gain between 12/30/25-2/1/26. DON B confirmed Resident #102 continued to experience weight gain on 2/4-2/6/26. DON B confirmed the physician was not notified of the weight gain and Resident #102 was not evaluated by a provider between 2/1/26-2/10/26.Review of an Assessments listing revealed no nursing or physician assessments were completed on Resident #102 between 1/27/26-2/8/26.Review of progress notes revealed no documentation of a nurse contacting the provider regarding Resident #102's unexplained weight gain.In an interview on 3/6/26 at 7:15am, LPN J reported Resident #102 suddenly started complaining of leg pain in early February and had never previously had pain issues. LPN J reported she noticed swelling in Resident #102's left leg and was aware the resident was requiring additional physical assistance for mobility. LPN J reported she was not aware Resident #102 had gained 9 pounds in a little more than a month. LPN J confirmed a significant unexplained weight gain like the one Resident #102 experienced, along with her other symptoms were indicative of a need for further medical assessment and the physician should have been notified. When queried regarding how nurses contact the providers, LPN J reported in this situation, she would contact the provider via the use of Practitioner Communication form.Review of a Practitioner Communications form for Resident #102, with a reference date of 2/2/6, revealed Concern: Would like to see you and speak with you regarding swollen knees. A handwritten response from a provider, dated 2/3/26 read acetaminophen (over the counter pain medication) scheduled, diclofenac gel (anti-inflammatory drug applied topically) added.Review of a Practitioner Communications form for Resident #102, with a reference date of 2/9/26 revealed Concern: pain to all extremities but especially BLE (bilateral lower extremities) and knees. (acetaminophen) is not helping. *Family asking for ibuprofen and acetaminophen to be used intermittently. A handwritten response from a provider dated 2/17/26 read acetaminophen scheduled, PRN (as needed) (opioid analgesic, name omitted) added.In an interview on 3/4/26 at 2:20pm Physician's Assistant (PA) Y reported she was aware Resident #102 had complained of pain in her left knee prior to being hospitalized on [DATE]. PA Y reported she was not aware of any swelling in the resident's legs or of the resident's 9-pound weight gain in 32 days and that a provider should have been notified so the resident's needs would have been assessed. PA Y confirmed Resident #102 was not assessed by a provider between 2/1-2/10/26. When further queried, PA Y reported it was ineffective for staff to communicate with providers via communication sheets because they frequently got overlooked and the staff had been educated to contact the providers via telephone rather than place communication sheets in the provider's mailbox. PA Y reported providers were available via telephone 24 hours a day, 7 days a week.

Based on observation, interview, and record review, the facility failed to promptly identify a change in condition for 1 (Resident #102) of 3 residents reviewed for quality of care, resulting in Resident #102 experiencing unmanaged pain and swelling in her legs, decreased functional ability, frustration, and a 3-day hospitalization for treatment of her symptoms.Findings include:Resident #102Review of an admission Record revealed Resident #102 was a [AGE] year-old female who was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified atrial fibrillation (a common, often rapid irregular heart rhythm where the heart's upper chambers beat chaotically which can cause blood clots, stroke and heart failure).Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 1/23/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Review of section GG of the MDS revealed Resident #102 was independent for rolling her body while in bed and required only supervision for transferring from a lying to sitting/sitting to lying position, transferring from bed to chair/chair to bed, and transferring to/from the toilet.Review of a MDS assessment for Resident #102 with a reference date of 2/13/26 revealed the resident re-entered the facility on 2/13/26 following a hospitalization on 2/10/26. Section GG of the MDS revealed Resident #102 required supervision/light touching assistance for rolling her body while in bed and maximal assistance (helper does more than half the effort) for transferring from a lying to sitting/sitting to lying position, transferring from bed to chair/chair to bed, and transferring to/from the toilet.Review of a Care Plan for Resident #102 with a reference date of 10/17/25 revealed the following focus/goal/interventions: Focus: (Resident #102) has the potential for pain r/t (related to) AFIB (atrial fibrillation).Goal: (Resident #102) will not have an interruption in normal activities due to pain.Interventions: Administer analgesia (pain medication) as per orders, evaluate the effectiveness of pain interventions.resident satisfaction with results, impact on functional ability.monitor/record/report to Nurse any s/sx (signs and symptoms) of non-verbal pain:.vocalizations (grunting, moans, yelling out.). Further review of the care plan revealed no focus/goals/interventions related to monitoring of swelling, daily weights or use of cardiac monitor.During an observation on 3/4/26 at 3:00pm, Resident #102 sat in her wheelchair in her room, is was noted that her left leg appeared larger than her right.In an interview on 3/4/26 at 3:09pm, Resident #102 reported on 2/10/26 she insisted on going to the emergency room because she had experienced unresolved pain, swelling in both lower extremities and a loss of functional ability for more than a week. Resident #102 reported she told several staff members she wanted to be seen by the physician but was not evaluated. Resident #102 reported she became increasingly worried and frustrated when she lost the ability to transfer herself to her wheelchair and to the toilet. Resident #102 stated I like to be independent, and it was frustrating to me when I couldn't get in bed on my own. When further queried, Resident #102 stated my legs were so swollen and heavy, I just couldn't pick them up and the pain was more than I could deal with. Resident #102 described her pain as an 8 on the standardized pain scale of 0-10 (0 being no pain and 10 being the worst imaginable pain).In an interview on 3/3/26 at 1:43pm, Family Member (FM) W reported Resident #102 had been struggling with swelling, pain and decreased mobility for more than a week when she went to the hospital on 2/10/26. FM W confirmed they spoke with a floor nurse on 2/2/26 and requested that a provider evaluate the resident. FM W reported she was told the resident would be evaluated by a provider on 2/3/26 but that never happened. FM W reported when she asked the nurse what could be done to address Resident #102's severe pain, the nurse offered to provide the resident with more over the counter pain medication but did not offer to contact a provider. FM W reported she witnessed Resident #102 crying from the pain she experienced. FM W reported at some point during the week of 2/2/26, the staff began offering Resident #102 an over-the-counter cream for her pain, but the application of the cream intensified the pain in her legs, and the resident could not tolerate having it applied. Review of a History of Physical Report for Resident #102, from a local emergency department with a reference date of 2/10/26, revealed Patient is a 91 y.o (year old) female.brought to the emergency department.for left leg pain and swelling.daughter.states it has really been bothering her for the last week. Swelling is in both legs but the left is worse. Patient describes the pain as [NAME] horse.she has history of persistent atrial fibrillation.is tachycardic (has rapid heart rate) on arrival.presumed new congestive heart failure (heart condition in which the heart cannot pump blood efficiently causing fluid to build up in the lungs, legs and other tissues) possibly related to atrial fibrillation with RVR (Rapid Ventricular Response)(critical cardiac condition where the atrial fibrillation cause the heart's lower chambers to beat too fast which often leads to .reduced blood flow).Physical Exam:.Extremities: Bilateral (both sides of the body) pitting edema (type of swelling caused by fluid retention, typically in the legs or feet where pressing on the affected skin leaves a temporary indentation) to mid shin left greater than right.Review of Patient Discharge Instructions for Resident #102 with a reference to date of 2/13/26 revealed Your Diagnosis: Acute CHF (congestive heart failure), Atrial Fibrillation with RVR and bilateral lower extremity edema.discharge instructions: .daily weights, notify facility physician of weight gain of more than 2 pounds in a 1 day or more than 5 pounds in a week.cardiac monitor has been placed at time of discharge.In an interview on 3/3/26 at 2:58pm, Certified Nursing Assistant (CNA) BB reported on 2/3 and 2/4/26 Resident #102 had increased swelling in her leg, the left leg slightly more so than the right, complained of increased pain and needed more help getting her feet into bed and transferring from one surface to another. CNA BB reported she told the nurse and therapy staff that something was off with Resident #102 because she felt Resident #102 needed to be evaluated.In an interview on 3/3/26 at 3:38pm CNA Q reported during the week of 2/1-2/8/26, Resident #102 had swelling in both legs, complained of pain and yelled out with movement. When queried, CNA Q reported Resident #102 needed quite a bit more help with tasks she could normally complete on her own and described the resident as definitely different than her baseline.In an interview on 3/3/26 at 3:42pm, CNA K reported between 2/3-2/9/26 Resident #102 yelled out during cares and asked for pain medication. CNA K confirmed it was unusual for Resident #102 to complain of pain or request medication.In an interview on 3/3/26 at 3:48pm, CNA N reported Resident #102 complained of pain, needed more physical help to move and had a swollen left leg between 2/3-2/9/26. CNA N confirmed she reported her concerns to the nurse overseeing Resident #102's care. In an interview on 3/4/26 at 3:50pm, CNA L reported between 2/3-2/9/26 she observed Resident #102's legs were swollen and painful. CNA L reported Resident #102 tried to be as independent as possible but during that time the resident needed physical assistance to lift her legs and for all transfers. CNA L reported Resident #102 yelled OHHH! and grabbed her legs as she was being assisted with moving them onto the bed. CNA L reported Resident #102's socks left indentations in her calves after they were removed. CNA L confirmed she reported Resident #102's swelling, increased pain and loss of functional abilities to the nurse. CNA L stated I told the nurse I thought the resident was retaining fluid.Review of Weight Summary for Resident #102 revealed the resident gained 9 pounds from 12/30/25-2/1/26, a period of 32 days. Weight increase was documented by Licensed Practical Nurse (LPN) I. A weight gain of 4 pounds was documented by LPN I on 2/6/26.Review of a Nutrition Note for Resident #102 with a reference date of 2/4/26 revealed IDT (interdisciplinary team) met with NAR (nutritional at risk) meeting. Resident weight increase reviewed. Weight gain of 9lbs (pounds) in 2 months (sic) (period was actually 32 days). Resident placed on daily weights x7days (for seven days).Review of a Weight Change Note for Resident #102 with a reference date of 2/5/26 revealed WEIGHT WARNING: .+7.5% (increase 7.5 percent) change.sig (significant) wt (weight) gain noted, resident has daily weights x7 days in place to monitor. No diuretics on board.In an interview on 3/4/26 at 1:54pm Director of Nursing (DON) B reported Resident #102 was supposed to have daily weights for 7 days because of her significant weight gain between 12/30/25-2/1/26. DON B confirmed Resident #102 continued to experience weight gain on 2/4-2/6/26. DON B confirmed the physician was not notified of the weight gain and Resident #102 was not evaluated by a provider between 2/1/26-2/10/26.In an interview on 3/4/26 at 1:49pm LPN I reported she was aware on 2/3/26 that Resident #102 was experiencing increased pain in her legs. LPN I confirmed the resident was not further assessed.Review of an Assessments listing revealed no nursing or physician assessments were completed on Resident #102 between 1/27/26-2/8/26.Review of progress notes 2/1-2/10/26 revealed no documentation of a nurse contacting the provider regarding Resident #102's unexplained weight gain.In an interview on 3/6/26 at 7:15am, LPN J reported Resident #102 suddenly started complaining of leg pain in early February and had never previously had pain issues. LPN J reported she noticed swelling in Resident #102's left leg and was aware the resident was requiring additional physical assistance for mobility. LPN J reported she was not aware Resident #102 had gained 9 pounds in a little more than a month. LPN J confirmed a significant unexplained weight gain like the one Resident #102 experienced, along with her other symptoms were indicative of a need for further medical assessment and the physician should have been notified. When queried regarding how nurses contact the providers, LPN J reported in this situation, she would contact the provider via the use of Practitioner Communication form.Review of a Practitioner Communications form for Resident #102, with a reference date of 2/2/6, revealed Concern: Would like to see you and speak with you regarding swollen knees. A handwritten response from a provider, dated 2/3/26, read: acetaminophen (over the counter pain medication) scheduled, diclofenac gel (anti-inflammatory drug applied topically) added.Review of a Practitioner Communications form for Resident #102, with a reference date of 2/9/26 revealed Concern: pain to all extremities but especially BLE (bilateral lower extremities) and knees. (acetaminophen) is not helping. Family asking for ibuprofen and acetaminophen to be used intermittently. A handwritten response from a provider dated 2/17/26 read acetaminophen scheduled, PRN (as needed) (opioid analgesic, name omitted) added.In an interview on 3/4/26 at 2:20pm Physician's Assistant (PA) Y reported she was aware Resident #102 had complained of pain in her left leg prior to being hospitalized on [DATE]. PA Y reported she was not aware of any swelling in the resident's legs or of the resident's 9-pound weight gain in 32 days and that a provider should have been notified so the resident's needs would have been assessed. PA Y confirmed Resident #102 was not assessed by a provider between 2/1-2/10/26. When further queried, PA Y reported it was ineffective for staff to communicate with providers via communication sheets because they frequently got overlooked and the staff had been educated to contact the providers via telephone rather than place communication sheets in the provider's mailbox.In an interview on 3/4/26 at 12:05pm, Director of Rehabilitation (DOR) C reported due her loss of functional mobility, Resident #102 began therapy upon her return from the hospital. DOR C reported pain initially limited her ability to participate in lower extremity strengthening. DOR C reported as the swelling in her legs decreased, Resident #102 experienced less pain and was now tolerating therapy well and had begun to walk short distances again

This citation pertains to intake #2593174 and #2604697.Based on observation, interview and record review the facility failed to ensure residents received the necessary care and services (assessment, monitoring, and treatments) for PICC line (a long, thin tube inserted through a vein in the arm for long-term IV (intravenous) access to administer antibiotic medication) and non-pressure wounds for 2 of 6 residents (Resident #101 & #104) reviewed for quality of care, resulting in infection and the potential for worsening of medical conditions. Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: infective endocarditis (infection of the inside of the heart). Resident #101 transferred to a different skilled nursing facility on 8/28/25.In an interview on 9/2/25 at 11:00 AM, Nursing Home Administrator (NHA) A explained that they had recently discovered that Resident #101 had not received adequate care and services at the facility following his admission from the hospital on 8/5/25, specifically lack of wound care for his surgical wound on the right foot and management of his PICC line. In an interview on 9/3/25 at 2:07 PM, Registered Nurse (RN) N reported that she was part of a program that provided supplemental care to residents at a community day center. RN N reported that she had noticed concerns related to the care Resident #101 was receiving at the nursing home; his wound bandage was not being changed and his PICC line cap (cover) was not in place. RN N reported that when she saw the resident on 8/8/25 he still had the wound dressing that the hospital applied to his right foot on 8/5/25 and his PICC line was not capped. RN N communicated her concerns to the nursing home and was told that they would implement the care. RN N reported that the PICC line was a direct line to the resident's heart, and a cap was a standard order in place to prevent infection. On 8/11/25 Resident #101 was observed with the same wound dressing that RN N had applied on 8/8/25, his PICC line dressing had not been changed, and there was no cap on the PICC line. At that time RN N communicated with the nursing staff again to ensure that the resident received the proper treatments going forward. On 8/18/25 when the community day center arrived to transfer Resident #101 to the center, they noticed that his PICC line was no longer in place, so they transferred the resident to the hospital to have the PICC line reinserted. RN N reported that they had not been notified of the issue prior to arriving to pick the resident up that day. On 8/20/25 RN N observed that Resident #101 had the wound dressing on his right foot that she had applied on 8/11/25. RN N reported that management got involved at that time to ensure Resident #101's care improved and ultimately decided to transfer the resident to a different facility for skilled nursing care. Review of Resident #101's Hospital Discharge Orders dated 8/5/25 revealed, .Acute bacterial endocarditis.Cellulitis of right lower extremity.Right leg: non-weight bearing.Change Dressing daily as instructed: .Daily, apply 1/4 inch iodoform packing, gently packed to open area proximal incision leaving long tail laid flat over periwound at incision, then cover in stepwise nature with 4 x 4 inch gauze covering the wound, 4 inch kerlix (stretchy gauze) loosely wrap with figure 8 around ankle, 4 inch ACE (wrap) from toes to ankle, 1-3 inch paper tape to secure.you need IV antibiotics for weeks. The antibiotic will be given through the IV access line that was place in the hospital.Cefazolin (antibiotic).into a venous catheter every 8 hours for 20 days.Review of Resident #101's admission Assessment dated 8/6/25 indicated the resident had excoriation (missing the outer layer of skin) on left and right buttocks, swelling to groin, wound on right outer ankle, redness to right lower leg, and scattered scabbing to his left lower leg. The assessment also indicated that the resident was receiving IV medications, but it did not specify the location of the IV and/or PICC line. Review of Resident #101's Care Plan revealed, The resident has potential/actual impairment to skin integrity of the (specify location) r/t (related to). Date initiated 8/6/25. The care plan was not resident centered and did not include locations and/or relevant interventions. Review of Resident #101's Weekly Skin Review dated 8/11/25, 8/18/25 and 8/25/25 each revealed, Skin observation: Any new skin issues identified? No, Indicate sites below: (none listed), Progress note r/t (related to) current skin condition noted on assessment: no new concerns. Review of Resident #101's Care Plan revealed, .requires PICC line therapy r/t acute endocarditis. Date initiated: 8/6/25. Interventions: Dressing changed to PICC line as per MD orders. Dated initiated 8/6/25. The care plan was not resident centered and did not include the PICC line location and/or monitoring. Review of Resident #101's Treatment Administration Record (TAR) revealed, PICC line dressing change dressing weekly and PRN (as needed). Every day shift every Saturday for monitoring. Start date: 8/16/25. The resident admitted on [DATE] (10 days before) therefore missed one weekly PICC line dressing change. Review of Resident #101's Progress Note dated 8/18/25 at 5:02 AM revealed, .When attempting to give medication, PICC noted to be out. End tip under residents back. Spot of blood on sheet still wet to the touch. Resident states he was unaware of anything happening to the line. Line removed from bed. There is no further documentation regarding the status or outcome of the PICC line issue that day.Review of Resident #101's Progress Note dated 8/20/25 at 1:15 PM revealed, .spoke with (community day center) regarding concerns with wound dressing changes and missing CV caps (screw onto the end of PICC line to prevent infection and leakage) .concerned with resident's wound dressing being dated for 8/11, when it was changed at their day center. Writer looked into the order and noticed that wound order was placed into (resident's electronic record) incorrectly.They were also concerned with CV cap not on PICC upon arriving at day center.Dressing changes will be monitored. Plan of care is ongoing.Review of Resident #101's Physician Orders Start Date 8/22/25 (16 days after admission) revealed, To right lateral foot surgical site: Change M/W/F (Monday, Wednesday, Friday). Cleanse with wound cleanser, pat dry. Cover wound bed with iodoform gauze (for infected wounds), hydrofera blue (a dressing that provides wound protection and addresses bacteria) cut to fit wound bed and cover with foam border dressing. Cover with tubigrip (provides support and compression) size F. Remove tubigrip at bedtime and reapply in AM. Every day shift every M/W/F for wound changing. This was the first and only order implemented for the surgical wound on Resident #101's right foot; the hospital discharge orders indicated that the dressing needed to be changed every day beginning on 8/5/25. Review of Resident #101's Weekly Wound/Ulcer Observation dated 8/23/25 at 6:47 PM revealed, Weekly observation of surgical wound completed.rt (right) lateral foot. Light amount of serosanguinous drainage (thin watery light red fluid) noted, epithelial tissue (outer layer of skin), granulation tissue (new soft tissue present in wound healing), no signs/symptoms of infection noted. This was the only wound assessment for Resident #101.In an interview on 9/2/25 at 1:52 PM, Director of Nursing (DON) B reported that the facility did not assess, monitor and treat Resident #101's surgical wound on his right foot until 8/21/25 (16 days after admission), and did not enter orders into the computer for the resident's PICC line dressing change until 8/16/25 (10 days after admission). DON B reported that the initial admission's assessment was completed incorrectly and therefore did not trigger the proper wound assessments and care plans, and the original wound care orders were entered incorrectly and did not get transcribed to the TAR (treatment administration record), therefore were not visible to nursing staff. DON B reported that the interdisciplinary team had reviewed the resident's records but did not catch the issue and did not do a visual assessment. DON B reported that she oversaw wounds for the facility and that she did not perform a weekly wound assessment for Resident #101's wound until 8/23/25, after RN N (community day center nurse) reported on 8/20/25 that the wound dressings had not been changed in more than a week. DON B reported that nursing staff were expected to identify new skin issues and note the condition of the resident's current skin conditions on the weekly skin review assessment forms and in the daily skilled charting. DON B reported that the nursing documentation did not include observation notes related to the condition of Resident #101's right foot wound dressing. In an interview on 9/2/25 at 12:46 PM, Licensed Practical Nurse (LPN) G reported that when she went to administer Resident #101's antibiotic via the PICC line on 8/18/25 at about 5:00 AM, she observed that it was completely pulled out of his arm. LPN G did not notify the provider or the community day center nurse. LPN G reported the issue to the day shift nurse, LPN E at 6:00 AM so that Resident #101 could be scheduled to have the PICC line reinserted. LPN G reported that she remembered seeing a wound dressing on Resident #101's right foot but had never changed the dressing. LPN G reported that the nurses are only expected to document new skin issues on the weekly skin observations sheets. It was noted that DON B reported that all skin conditions should be noted on the weekly skin observation assessment, not just the new issues. In an interview on 9/2/25 at 1:39 PM, LPN E reported he did not notify the provider about Resident #101's PICC line being pulled out, nor did he assess it himself. LPN E reported that he called the community day center but they had already been to the facility to pick up Resident #101. LPN E reported that the community day center brought Resident #101 to the hospital to have his PICC line reinserted. LPN E reported that Resident #101 had a dressing on his right foot, but it didn't show up on the TAR, so he didn't know to change it. LPN E reported that the weekly skin assessment documentation only asks for new skin issues to be noted, therefore the condition of the dressing on Resident #101's right foot was not noted. Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes, dementia, unstageable pressure ulcer of left ankle, and stage 2 pressure ulcer of sacral region (tailbone). During an observation and interview on 9/3/25 at 9:21 AM in Resident #104's room, he was lying in bed. Resident #104 reported having multiple wounds on his left lower extremity but does not have any feeling in his leg or foot. Review of Resident #104's Wound Assessments indicated that the resident was being followed for pressure ulcers on left ankle, left lower leg front x 2, left 4th and left 5th toe. Review of Resident #104's TAR indicated wound treatments for pressure ulcers on left ankle, left lower leg, left 4th and 5th toes. In an interview on 9/3/25 at 2:41 PM, RN N from the community day center reported that she observed Resident #104 on 9/2/25 and he did not have any wound dressings in place on his left ankle, toes or the bottom of his foot. RN N reported that she identified signs of cellulitis (skin infection) and an antibiotic was ordered by the provider. RN N reported that Resident #104 doesn't ever complain about his wounds and has no feeling in his left lower extremity therefore he is extremely vulnerable to wounds. RN N reported that the facility staff are supposed to be completing all skilled care for the resident but that she is doing more lately because she noticed that the resident was not getting proper wound care. Review of Resident #104's Infection Note dated 9/3/25 at 10:16 AM revealed, .Wound infection. Medication Order: Cephalexin (antibiotic).In an interview on 9/5/25 at 11:11 AM, DON B reported that the facility received updated wound orders on 9/3/25 from the community day center provider and it was discovered that there was a wound that the facility did not have in their records. DON B reported that Resident #104 had a diabetic ulcer on the bottom of his left foot, that had not been assessed, monitored or had wound care treatments on record, and now the resident was diagnosed with a skin infection. DON B reported that the wound was not documented on the skin assessments, but that the community day center did have documentation of it in their visit records. DON B reported that the facility is responsible for the resident's care and should ensure that weekly wound assessments, weekly full skin observations, and wound treatments are completed as necessary.Review of Resident #104's Wound Assessments revealed, no wound assessments for the left plantar foot. Review of Resident #104's Weekly Skin Review dated 9/1/25 revealed, Skin observation: Any new skin issues identified? No, Indicate sites below: (none listed), Progress note r/t (related to) current skin condition noted on assessment: no new skin impairments observed.Review of Resident #104's Visit Notes from the community day center dated 8/18/25 revealed, .PI (pressure injury) on left lateral ankle with dressing intact, no other dressings on. Left plantar foot (bottom) diabetic ulcer with thick scab, peri wound warm to touch and pink. Left 5th toe also scabbed and open to air.(RN N) checked in with (LPN E) to inform of above as well as concern with slight redness to left foot, need to keep sock on to protect. (LPN E) verbalizes understanding and states they will assess left foot routinely. Review of Resident #104's Visit Notes from the community day center dated 8/25/25 revealed, .check in on wounds and skin status.Has dressing on LLE (left lower extremity) dated 8/23/25. (RN N) removed all dressings. Diabetic ulcer on left plantar foot. Wound care provided.

Based on observation, interview and record review, the facility failed to provide quality care and treatment for pressure ulcers, consistent with professional standards of practice for 1 resident (Resident #103) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the potential for worsening of pressure wounds, and overall deterioration in health status. Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: acquired absence (amputation) of left and right leg below the knee and fractures of the spine. In an observation and interview on 9/3/25 at 10:37 AM in Resident #103's room with CNA (Certified Nursing Assistant) I preparing to provided incontinence care. Observed a large dressing bordered with adhesive on the sacrum (tailbone) dated 9/2/25; the dressing was not fully intact on the bottom edge. Observed a bright red wound on the right buttock with a dark red center and active bleeding, with no dressing over it. There was a dressing covering Resident #103's right knee. After incontinence care was finished CNA I notified the nurse that Resident #103 would need new wound dressings. Review of Resident #103's Treatment Administration Record (TAR) for 9/3/25 revealed, Wound care to rt (right) posterior amputation site (knee): cleanse wound with wound cleanser, pat dry. Apply calcium alginate with silver to wound bed, cut to fit. Cover with bordered dressing. Change daily and PRN (as needed) every day shift for wound care.Review of Resident #103's TAR for 9/3/25 revealed, Coccyx (sacrum): cleanse wound with wound cleanser, pat dry. Apply calcium alginate with silver to wound bed, cut to fit. Cover with silicone super absorbent dressing. Change daily and PRN (as needed) every day shift for wound care.Review of Resident #103's TAR for 9/3/25 revealed, RT (right) buttock shearing: cleanse with wound cleanser, pat dry. May cover with hydroccoloid (moisture-retentive) dressing. Every day shift every Tuesday, Friday for wound care.In an observation on 9/3/25 at 11:34 AM in Resident #103's room with Licensed Practical Nurse (LPN) E to provide wound care to right knee, sacrum and right buttock. LPN E removed the dressing from the right knee, cleansed the wound, and applied a silicone foam dressing over the area. There was no calcium alginate topical applied to the wound and the dressing was not bordered. Next the resident was rolled onto her side, and there was bright red blood noted on the incontinence brief from the open wound on her right buttock. LPN E removed the dressing that was partially detached from the sacrum. Observed an open wound with a small area of slough on sacrum. LPN E cleansed the area and applied a silicone foam dressing over the wound. There was no calcium alginate topical applied to the wound. Lastly the open wound on the right buttock was cleansed and also covered with a silicone foam dressing. The dressing was not a hydrocolloid dressing as the physician order indicated. LPN E was not aware that the wound treatment orders indicated calcium alginate and reported that a hydrocolloid dressing was similar to the foam dressing. Review of Resident #103's Weekly Pressure Wound Observation tool dated 8/28/25 revealed, .sacrum.stage 2, .Date acquired: 8/22/25.40% necrosis (dead tissue) and/or slough (dead tissue) in the wound bed.unchanged.Review of Resident #103's Weekly Pressure Wound Observation tool dated 8/28/25 revealed, .right knee (rear). stage 2, Date acquired: 8/22/25.100% eschar/scab.unchanged.Review of Resident #103's Weekly Pressure Wound Observation tool dated 8/28/25 revealed, .right buttock. stage 2, Date acquired: 8/1/25.peri-wound red.unchanged.Review of Resident #103's Care Plan revealed, .has a stage 2 to right buttock with the potential for discomfort and infection. Date initiated: 8/15/25. Interventions: Administer treatments.Assess/record/monitor wound healing weekly.Follow facility policies/protocols for the prevention/treatment of skin breakdown.Monitor dressing every shift.Monitor/document/report PRN (as needed) any changes in skin status.Weekly treatment documentation.Date initiated: 8/15/25. There was no record of the resident's stage 2 pressure ulcer on her coccyx and/or her stage 2 pressure ulcer on her right knee. Review of Resident #103's Weekly Skin Observations with the most recent skin observation was documented on 8/12/25 revealed, Skin observation: Any new skin issues identified? No, Indicate sites below: (none listed), Progress note r/t (related to) current skin condition noted on assessment: no new concerns.In an interview on 9/5/25 at 11:11 AM, Director of Nursing (DON) B reported that LPN E had forgotten to apply Resident #103's calcium alginate and would be disciplined for not following physician orders. DON B reported that Resident #103's care plan did not include all of her wounds and the CNA's use that as their direct care reference. DON B also reported that Resident #103 did not have weekly skin observations documented for the past 3 weeks.

This citation pertains to intake #2593174 & 2604697. Based on observation, interview, and record review, the facility failed to provide necessary oxygen and CPAP (a device that delivers continuous positive airway pressure to ensure airway stays open during sleep) per physician orders and maintain oxygen tubing according to the standards of practice for 2 residents (Resident #101 & #104) of 4 residents reviewed for respiratory care, resulting in the potential for respiratory distress, the development and spread of respiratory infection and disease, and the exacerbation of respiratory conditions. Findings include: Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic obstructive pulmonary disease (blocks airflow and makes it hard to breathe).Review of Resident #101's admission Assessment dated 8/6/25 indicated that he used oxygen and a CPAP. The settings for these were not noted. Review of Resident #101's Physician Orders revealed, Resident may use CPAP from home. Settings should remain on APAP (automatic positive airway pressure) at 8-15 cm of water. At bedtime for OSA (obstructive sleep apnea). Start date 8/11/25 at 6:00 PM and CPAP; clean mask with soap and water daily. Allow to air dry. Every day shift for CPAP. Start date 8/12/25. This order was 6 days after the resident admitted . Review of Resident #101's Physician Orders revealed, Continuous O2 (oxygen) therapy via NC (nasal cannula) at 2-3L (liters) to maintain SPO2 (percentage of oxygen in your blood) of >90%. Please provide portable tank during activities and when visiting the day center. Every shift for respiratory monitoring. Start date: 8/11/25. This was 5 days after the resident admitted . Review of Resident #101's Care Plan revealed, The resident has oxygen therapy r/t (related to). Date initiated: 8/6/25. The care plan was not resident centered and did not include the resident's type and/or amount of oxygen. There was no care plan for CPAP. In an interview on 9/2/25 at 1:52 PM, Director of Nursing (DON) B reported that Resident #101 should have had orders in place upon admission to ensure his Oxygen and CPAP were being administered consistently. The orders were entered into the computer and TAR after the community day center expressed concerns. In an interview on 9/2/25 at 1:39 PM, Licensed Practical Nurse (LPN) E reported that Resident #101 required constant supplemental oxygen to ensure his blood oxygen level stayed in the mid 90's; if the oxygen was not positioned correctly on his nose, his blood oxygen level would drop quickly. In an interview on 9/3/25 at 2:07 PM, Registered nurse (RN) N reported that she was part of a community day center that provided supportive care for Resident #101. RN N reported that Resident #101 arrived at the day center on 8/13/25 short of breath, and it was discovered that his portable oxygen tank was not turned on and the tubing for his oxygen was kinked; he was without his supplemental oxygen for at least 25 minutes while he was driven to the day center. Resident #101's blood oxygen level was 80% and should be above 90%. Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure.During an observation and interview on 9/3/25 at 9:21 AM in Resident #104's room, he was lying in bed wearing oxygen via nasal cannula (NC) running via concentrator at 2 liters. Resident #104 reported that he wears his oxygen all the time. The oxygen tubing was observed with tape labeled with the date of 8/24/25. Review of Resident #104's Physician Orders revealed, .Oxygen at 1L (liter) as needed, wean off to keep O2 (oxygen) saturation >92%. Active date: 7/10/25. This order was not transcribed to the TAR to ensure nursing would administer and monitor. Review of Resident #104's TAR revealed, Change and date O2 tubing every Sunday NOC (night) every night shift every Sunday. Start date: 7/20/25. The administration record indicated that the tubing was changed on Sunday 8/31/25 but based on the observation made in Resident #104's room on 9/3/25 it was last changed on 8/24/25. Review of Resident #104's Oxygen Saturation Level record indicated, 96% on room air 9/1/25, 8/25/25, & 8/18/25. In an interview on 9/3/25 at 9:40 AM, LPN E reported that oxygen tubing should be replaced once a week on Sundays. LPN E was not sure what Resident #104's oxygen setting was supposed to be and it wasn't listed on the TAR.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings Include: On 07/15/2025 at 9:16 AM, An initial tour of the kitchen found an increased accumulation of spillage and white flakey debris on the back portion of the floor and floor juncture of the walk-in cooler. On 7/15/2025 at 9:26 AM, Observation of the ventilation hood over the cook line found an accumulation of dust and debris on the filters. When asked when the hoods were cleaned lasts, a sticker on the system stated it was last serviced in March of 2025. When asked if facility staff take them down and clean them, Certified Dietary Manager (CDM) E stated, we don't take them down. Further observation of the convection oven found an accumulation of debris on top of the oven. On 7/15/2025 at 9:38 AM, Observation of five clean utensil drawers found an accumulation of crumbs and debris inside of the drawers inside the back edge. When asked how often these areas get cleaned, CDM E stated she tries to clean them once a week. Further observation of the clean utensil drawers found two mechanical scoops with an accumulation of white food debris stuck in the scoop. On 07/15/2025 at 9:40 AM, Observation of the can opener blade found an accumulation of black and gunky debris on the blade and turning mechanism. When asked if it was used today [NAME] “II”, stated no. On 07/15/2025 at 10:01 AM, An interview with CDM “E” found that the slicer gets used about once a week to slice meats. Further observation found an accumulation of dried white meat debris on the back side of the slicer blade. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. “(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.” According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. “(A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean…” On 7/15/2025 at 9:18AM, Observation of the walk-in cooler found three boxes of individual cartons of nutritional shakes and juices with no date to indicate when the product should be discarded. An interview with CDM “E” found that staff should date the boxes when they are pulled from freezer to thaw. A review of the cartons found manufacture directions that state the products are only good “14 days from thaw”. On 07/15/2025 at 9:31 AM, Observation of the reach in refrigerator by the cookline, found a container of cooked carrots and a container of sliced cooked chicken, both items stored without a date of preparation or use by date on containers. On 07/15/2025 at 10:14 AM, Observation of the C hall pantry refrigerator found eight nutritional shakes and juices and an open gallon of milk. None of the items were marked with a date to indicate discard. On 07/15/2025 at 11:00 AM, Observation of the N Hall pantry refrigerator found a vanilla med pass supplement with an open date of 7/10. A review of the container storage directions states to use the product within 3 days upon opening. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 07/15/2025 at 9:14 AM, An interview with Certified Dietary Manager (CDM) E” found that the oven component to the Vulcan six burner stove top is not operational. When asked how this affects food service in the kitchen, CDM E stated that it's hard for staff to keep hot food items on hot hold before service, as the convection ovens are used for cooking and no other cooking or hot hold equipment is available. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. “(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2…” On 07/15/25 at 9:37 AM, An interview with CDM “E” found the kitchen uses “quat” (quaternary ammonium) based sanitizer from the three-compartment sink. When asked to see the test strips used to ensure proper concentration of sanitizer, CDM “E” gave the surveyors pH test strips and stated that is what staff use. Although the pH strips change color when used, pH test strips do not measure the concentration of quat in a solution. When asked if she had any other test strips, CDM “E” stated she only had more pH strips. On 07/15/25 at 9:40 AM, Observation of the floor under the three-compartment sink found a gallon container of bleach. An interview with CDM “E” found that staff sometimes use bleach sanitizer. According to the 2022 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.

This citation contains two deficient practice statements, A & B.Deficient Practice Statement (DPS) ABased on observation, interview, and record review, the facility failed to effectively implement effective infection control measures which included Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 5 of 5 residents (Resident #27, #51, #2, #19, & #17) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. DPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: Resident #27: Review of an admission Record revealed Resident #27 was a female with pertinent diagnoses which included pneumonia, PICC line (a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart), urinary tract infection, acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood and/or remove carbon dioxide) and asthma with acute exacerbation. Review of current “Care Plan” for Resident #27, revised on 6/21/25, revealed the focus, “…The resident is on IV medications ampicillin-sulbactam r/t (related to) infection . with the intervention .IV DRESSING: Right arm PICC line - Observe dressing every time Line is accessed. Change dressing and record observations of site weekly . Review of current Care Plan for Resident #27 revealed no focus or interventions for Enhanced Barrier Precautions. Review of Order dated 6/22/25, revealed, .Enhanced Barrier Precautions for PICC line use every shift for infection control . During an observation on 07/15/2025 at 10:45 AM CNA P was observed in Resident #27's room and she was stripping down her bed, she did not have a gown on. Observed an Enhanced Barrier Precautions sign on the wall outside of Resident #27's door. Resident #51: Review of an admission Record revealed Resident #51 was a female with pertinent diagnoses which included need for assistance with personal care, muscle weakness, skin tears on both forearms, and indwelling catheter. Review of current “Care Plan” for Resident #51, revised on 7/7/25, revealed the focus Resident #51 had an indwelling catheter (tube inserted into the bladder to drain urine). Review of Order dated 7/7/25, revealed, .Enhanced Barrier Precautions for foley . Review of Order dated 7/14/25, revealed, .Left forearm gently cleanse open area with wound wash, pat dry, cover with non adherent drsg and secure with rolled conforming gauze, avoid tape or adhesive to skin. Change every 3 days and PRN. Notify provider of s/s of infection or non healing. As needed for picking scabs if soiled or falls off . Review of current Care Plan for Resident #51 revealed no focus or intervention for Enhanced Barrier Precautions or a focus and interventions for Resident #51's skin integrity and skin tears. During an observation on 07/15/2025 at 1:13 PM, CNA U and Scheduler H entered Resident #51's room with the hoyer life machine to get her up for an activity. Both staff members did not don (put on) gloves or a gown prior to entering the room to transfer the resident. No personal protective equipment (PPE) was noted in the resident's room. In an interview on 7/17/25 at 10:26 AM, CNA W reported there was a sign on the wall to indicate a resident who was under precautions. For a resident on Enhanced Barrier Precautions, the staff would wear PPE, gown and gloves when transferring, providing personal care, repositioning, etc. CNA W reported to enter the room staff do not need to don PPE but any kind of personal care the staff were required to wear PPE. CNA W reported even to change linen a staff member would wear PPE. In an interview on 07/17/2025 at 10:33 AM, CNA LL reported the nurses updated the staff prior to caring for a resident if there were any changes such as implementation of enhanced barrier precautions (EBP). CNA LL reported staff would be able to tell as there was a PPE cart outside each door. CNA LL reported EBP would be in place for wounds, or new wounds, catheters, tube feeding residents. CNA LL reported staff would also be able to tell the care needs of a resident by reviewing their care plan and/or kardex. CNA LL reported the staff were to wear gown, gloves, sometimes a mask or eye protection. CNA LL reported PPE would need to be worn when transferring or any time when providing care, you would come into contact with the resident or care devices. In an interview on 07/17/2025 at 10:31 AM, Licensed Practical Nurse (LPN) I reported when a resident was on EBP the staff would wear a gown and gloves, and mask and/or eye protection. LPN I reported the staff would wear PPE when providing personal care, wound care, catheter care, transferring, strip the bed down, any time come in direct contact with them. LPN I reported the PPE needed to be worn when changing linen due to the possibility of germs on the bedding and bed. Resident #2: Review of an admission Record revealed Resident #2 was a female with pertinent diagnoses which included presence of functional implant, moderate severe oral and moderate pharyngeal dysphagia (noticeable and frequent swallowing difficulties with the potential for aspiration (food or liquid entering the airway). Review of current “Care Plan” for Resident #2, revealed no focus for Enhanced Barrier Precautions due to the PEG tube. Review of Order dated 7/8/25, revealed, .Enhanced Barrier Precautions for PEG Tube (A feeding tube inserted through the abdominal wall directly into the stomach) . Review of Discharge summary dated [DATE], revealed, .Moderate severe oral and moderate pharyngeal dysphagia .video swallow study on 3/29 with subsequent SLP (Speech Language Pathologist) recommendation for strict NPO (nothing by mouth) except for medications .Extended and prolonged goals of care discussions had with patient and family ultimately with patient and family request for evaluation of G tube placement, interventional radiology consulted and placed on 4/1 and patient tolerating tube feeds . Review of Order dated 4/26/25, .Change T-drain drsg (dressing) to peg tube insertion site, gently cleanse with wound cleanser and pat dry, cover with t-drain drsg secure as needed. Every night and prn (as needed) if soiled or loose .as needed if soiled or falls off . During an observation on 07/15/2025 at 9:39 AM, Certified Nursing Assistant (CNA) U was observed standing at the right side of Resident #2's bed, leaning over the side of the bed and she did not have on a gown. CNA [NAME] reported she was providing resident cares to Resident #2 who was naked. Resident #2 was observed lying flat in bed with another staff member (Scheduler H) standing on the left side of the bed with no gown on as well. Outside of Resident #2' door was an Enhanced Barrier Precautions sign on the wall which indicated .Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities .Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Device Care or Use: central line, urinary catheter, feeding tube, tracheostomy .Wound Care: any skin opening requiring a dressing . During an observation on 07/15/2025 at 9:46 AM, Resident #2 was observed lying in bed, CNA U hooked the sling to the hoyer arms. Scheduler H moved Resident #2 across the room to the wall over by the entry way. CNA U had tipped back the wheelchair and Scheduler H slowly lowered her into the wheelchair and she was slowly her to the wall by the door and then tipped the chair back and she as slowly lowered to the chair and then slowly lowered to the floor. During an observation on 07/15/2025 at 9:50 AM, Scheduler H went back into Resident #2's room grabbed the soiled bed pad and other linen used to clean her up and placed them in a plastic bag. Scheduler H was observed to only have gloves on, no gown. During an observation and interview on 7/16/2025 at 2:31 PM, Certified Nurse Aide (CNA) “HH” was inside Resident #2's room changing (removed soiled linens to replace with clean linens) the bed linens (sheets). During the changing of linens inside Resident #2's room CNA “HH” was observed wearing gloves as the only personal protective equipment and wiped the mattress down with a sanitizing wipe. No gown was observed being worn by CNA “HH” during the linen change. As CNA “HH” changed the linens CNA “HH”'s clothing directly contacted the pile of soiled linens on the bed. CNA “HH” reported he wore gloves for linen changes in enhanced barrier precaution rooms, but not a gown. CNA “HH” reviewed the enhanced barrier precaution signage at the entry to Resident #2's room, which indicated to wear gown and gloves during changing linens in an enhanced barrier precaution room and confirmed he wasn't wearing a gown during the linen change. The enhanced barrier precaution signage, undated, at the entrance to Resident #2's room was observed with staff CNA “HH. The enhanced barrier precaution signage was produced by the Centers for Disease Control and Prevention and stated, “Enhanced Barrier Precautions… Everyone Must: .Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing Linens . Resident #19 Review of an admission Record revealed Resident #19 was a male, with pertinent diagnoses which included heart failure, diabetes. In an observation and interview on 7/17/25 at 12:00 PM, Licensed Practical Nurse (LPN) K entered Resident #19's room to complete a blood sugar check and administer insulin. Observed LPN K check Resident #19's blood sugar level and administer insulin in his abdomen while he sat in a wheelchair beside his bed in his room. Noted LPN K did not put on gloves prior to completing Resident #19's blood sugar check/insulin administration. LPN K reported gloves were not required when performing blood sugar checks/insulin administration. Resident #17 Review of an admission Record revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder. Review of Resident #17's Orders revealed, Enhanced Barrier Precautions for chronic wound. Start date: 5/19/25. In an observation on 7/15/2025 at 10:17 AM, Certified Nursing Assistant (CNA) S was changing Resident #17's bed linens. It was noted that CNA S was not wearing a gown or gloves as she changed Resident #17 linens. Review of the policy/procedure Enhanced Barrier Precautions, dated 1/1/25, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .(EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . DPS B On 07/15/25 at 2:34 PM, an interview with Maintenance Director (MD) D, found that he has only been at the facility since the end of February (2025) and is unsure about all aspects of the facilities Water Management Program (WMP). On 07/15/25 at 2:35 PM, observation of the C hall shower room found a shower spigot capped off and the area that would be used for showering contained an open wire rack for storage, indicating the space was not used. When asked if there was water running to the shower fixture, Maintenance Director (MD) D was unsure. The faucet handle for the shower was turned on and could be heard with water servicing the line. When asked if this was something that gets flushed regularly MD D stated he didn't know about the stagnant line but can start flushing it. On 7/15/25 at 2:55 PM, observation of the soiled utility room off of N-hall found brown and discolored water dispense from the cold water tap over the hopper. When asked if he was able to see the brown and discolored water, MD D shook his head. At this time, an interview with Registered Nurse “JJ”, found that staff do not regularly use the hopper. On 7/15/25 at 3:18 PM, an interview with MD D found that he was unsure where paperwork for the Water Management Plan was and was only able to find a Risk Assessment of the facility that was done a few years ago. When asked if there is currently any sampling being performed to help reduce the risk of Legionella or other OPPP, MD D was unsure and wanted to learn more. Record review of the facility document entitled “Water Management Plan”, not dated, under section “2. Dead Legs” it stated “Tour building to find if any dead legs are present. This includes storage areas that use to have sinks/showers and toilets but are no longer used…”. Further review under section “3. Ensure Maintenance of less frequently used areas”, found “These areas include soiled linen rooms, medication rooms, shower stalls, private room showers, empty resident rooms, and eyewash stations. This task includes checking all the previously mentioned areas and running both hot and cold water for 8 minutes at each temperature. Only areas that change weekly are empty resident rooms.”

Based on interview and record review the facility failed to develop comprehensive resident focused care plans based on the comprehensive assessment for 4 residents (Resident #2, #36, #6 and #16) of 12 residents reviewed for care plans, resulting in the potential for unidentified care needs. Findings include:Resident #2: Review of an admission Record revealed Resident #2 was a female with pertinent diagnoses which included presence of PEG Tube (A feeding tube inserted through the abdominal wall directly into the stomach), moderate severe oral and moderate pharyngeal dysphagia (noticeable and frequent swallowing difficulties with the potential for aspiration (food or liquid entering the airway). Review of Order dated 7/8/25, revealed, .Enhanced Barrier Precautions for PEG Tube . Review of current “Care Plan” for Resident #2, revealed no focus or interventions for Enhanced Barrier Precautions due to the PEG tube, nor a care plan focus and interventions for Resident #2's peg tube. In an interview on 07/17/2025 at 10:33 AM, CNA LL reported the nurses updated the staff prior to caring for a resident if there were any changes such as implementation of enhanced barrier precautions (EBP). CNA LL reported staff would be able to tell as there was a PPE cart outside each door. CNA LL reported EBP would be in place for wounds, or new wounds, catheters, tube feeding residents, etc. CNA LL reported staff would also be able to tell the care needs of a resident by reviewing their care plan and/or kardex. Resident #36 Review of an “admission Record revealed Resident #36 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary tract infection (UTI), urinary calculus (kidney stone), obstructive uropathy (obstruction of urine flow), myelodysplastic syndrome (a group of disorders caused when something disrupts the production of bleed cells), anemia (deficiency of red blood cells), dysphagia (difficulty swallowing), anxiety, depression, and chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 6/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #36 was cognitively intact. Section I indicated Resident #36's Active Diagnoses with the primary medical condition category of medically complex conditions. In an interview on 07/16/2025 at 11:25 AM, Resident #36 reported that she had been in and out of the hospital a couple times recently and had a long history of recurrent UTI's, chronic bladder and kidney issues, and serious blood disorders. Review of Resident #36's Provider Visit Note dated 5/12/25 revealed, .PmHx (past medical history) significant for recurrent nephrolithiasis (kidney stone), hydronephrosis (fluid back up) R (right) kidney, recurrent UTI, CKD3 (chronic kidney disease), myelodysplastic syndrome, .chronic respiratory failure on 3L (liters) of O2 (oxygen), hx (history of) TIA (stroke), HTN (high blood pressure), collegenous colitis (inflammatory bowel), IBS (irritable bowel syndrome), chronic anemia with frequent blood transfusions, hypothyroidism (low thyroid), MDD (major depression), neuropathies (weakness, numbness, and pain due to nerve damage), chronic pain .seen today for general new admission follow-up .recently hospitalized for AMS (altered mental status) .found to have bilateral hydronephrosis and obstructing kidney stone on CT (x-ray) with UTI . Review of Resident #36's current Care Plan revealed no care plan related to the following medical conditions: anemia, myelodysplastic syndrome, obstructive uropathy, and/or her extensive history of UTI. In an interview on 07/17/2025 at 10:13 AM, MDS Nurse F reported that she was responsible for developing care plans. MDS Nurse F reported that Resident #36 had been hospitalized for low blood count, received blood transfusions, had a long history of UTI's, kidney stones, chronic pain and anemia. MDS Nurse F reported that Resident #36's care plan should include detailed diagnoses and personalized interventions. MDS Nurse F reported that Resident #36's basic care plan had been created in the record but was presently missing individual elements related to her problems and the interventions that were put in place. Resident #6 Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia, mild, with anxiety. Review of Resident #6's Orders revealed that Resident #6 was enrolled in Hospice services on 1/6/25. Review of Resident #6's current “Care Plan” did not reveal a focus related to hospice/end of life, or integration of hospice/end of life services into Resident #6's comprehensive plan of care. In an interview on 7/17/2025 at 11:44 AM, MDS Coordinator (MDS-C) F reported that she was responsible for creating resident care plans. MDS-C F confirmed that Resident #6 should have had a hospice care plan in place, and that this was missed. Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness, and difficulty in walking. Review of Resident #16 Orders revealed, Acetaminophen Oral Tablet 500 MG (Acetaminophen) (Tylenol) Give 2 tablet by mouth three times a day for leg pain. Start date: 6/19/25. Methocarbamol Oral Tablet 500 MG (Methocarbamol) (muscle relaxer). Give 1 tablet by mouth every 12 hours as needed for leg pain. Start date: 6/19/25 . Review of Resident #16's Physician Progress Note dated 3/13/25 revealed, . Resident #16 says he feels good, just weak with some leg pain .Visit DX (Diagnosis): Leg pain, bilateral . Review of Resident #16's Physician Progress Note dated 6/4/25 revealed, .(Resident #16) was seen last week with discussion of ongoing BLE (bilateral lower extremity) pain. He stated that his pain is mostly in his thighs at that time, but was unable to distinguish type of pain, exacerbating or alleviating features . He states that he is unsure if Tylenol has been helping but believes it has not been adequate in controlling his pain, with pt (patient) currently on 650 mg PRN (as needed). He was trialed on Methocarbamol 500 mg Q8H PRN (every 8 hours as needed) with nursing team, DON (sic) concern pt memory, needing frequent reminders of available medications . Review of Resident #16's Physician Progress Note dated 7/10/25 revealed, .Today he (Resident #16) reports ongoing bilateral pain constant dull in ache (sic) in feet up to knees with occasional sharp shocks that will last about 15 minutes. He has been experiencing the pain for about a year with an increase in pain 6 months ago. He reports that he used to walk around the building outside and down the halls, but now he just lays in bed. He states that he saw a vascular surgeon that told him that he needed vascular surgery on both legs to relieve the pain . Review of Resident #16's admission Elopement Risk assessment dated [DATE] revealed, Risk factors: 1. Physical Activity: Ambulatory and/or self-mobile in wheelchair. 2. Thinking/Awareness: Has frequent periods of altered perception and/or lack of awareness of surroundings-not of recent onset. 3. Mood/Behavior: Complacent. 4. Decision Making/Memory: Frequent periods of confusion and mental impairment, moderately impaired. 5. History of Wandering: Disoriented most of the time, wandering without attempts to leave the home/facility. 6. Communication: Expressive, understandable communication with others. 7. Diagnosis: Mild cognitive loss. 8.Based on the information gathered for this assessment and summary score, are elopement/wander risks precautions indicated for this resident? No . Review of Resident #16's Post admission Meeting dated 3/27/25 revealed, .Social Services: 4. Behavior Present? No . Nursing Notes: . He will at times wander to the front door. He is easily redirected . Review of Resident #16' Nursing Progress Note dated 3/15/2025 revealed, Writer observed (Resident #16) attempting to Exit front entrance. He was pushing buttons on keypad to get out. Writer asked how I could help him, and he states, I'm going to get matches to smoke a cigarette. Was able to redirect, and resident remained calm. Notified resident nurse of situation. (Resident #16) has been at N hall nurses' station today several times asking for matches. We have explained that this is a non-smoking facility, he verbalized understanding but continues to ask staff and visitors for matches .  Review of Resident #16's Behavior Notes dated 4/24/2025 revealed, (Resident #16) was up wandering in the front office. He was questioning about his lighter. Administrator had spoke with (Resident #16), stating that he was not admitted with a lighter. Inventory list was checked- nothing noted, no inventory assessment completed at admission. (Resident #16) started to become agitated. He stated he wanted to go out for a walk. At this time, Administrator had stated we need to (sic) permission from his guardian. Resident questioned that he had a guardian. He then asked for his lighter again. At this time, Administrator tried to redirect. (Resident #16) voice then got louder and was upset. DON (Director of Nursing) then went to seek out (Resident #16) nurse and social services director. (Resident #16) then left front office . Review of Resident # 16's Behavior Note dated 4/28/2025 revealed, (Resident #16) came into the front office this afternoon. He had asked for his lighter so he could go for a walk and smoke. Nursing staff had tried to talk redirect (Resident #16), and stated that he did not admit with a lighter. He had raised his voice to staff, stating that he had and he wants to go outside to smoke. Staff had stated that the facility has a no smoking policy. At this time, had stated that he would go for a walk. Nursing staff had stated that this would require a doctor's order. Resident had gotten upset and yelled. At this time, the administrator had entered the office and stated to (Resident #16) that they had this same conversation last week. (Resident #16) had then turned around to walk out of the office and stated, (expletive) this place . Review of Resident #16's Nursing Note dated 5/12/2025 revealed, Resident has been wandering and setting off door alarms. Has been placed on 15-minute checks x24 hr. Potential move to memory care unit on 5/13 has been discussed by IDT (Interdisciplinary team) . Review of Resident #16's History and Physical Note dated 5/20/25 and documented by Medical Director (MD) CC revealed, . He is on the unit (locked dementia unit) because he was restless and wandered outside the ECF . Review of Resident #16's current “Care Plan” did not reveal a focus/interventions related to Resident #16's leg pain or a focus/interventions addressing Resident #16's history of wandering/exit-seeking behaviors. In an interview on 7/17/2025 at 11:21 AM, Licensed Practical Nurse (LPN) K reported that Resident #16 frequently complained of leg pain, and that the facility had just started a muscle relaxer to help with his pain. LPN K was not aware of any non-pharmacological pain interventions that the facility had used for Resident #16. In an interview on 7/17/2025 at 11:44 AM, MDS Coordinator (MDS-C) F reported that she was responsible for creating resident care plans. MDS-C F reported that she was not aware of Resident #16's chronic leg pain and confirmed that his care plan did not address his leg pain. MDS-C F confirmed that Resident #16 should have had a care plan that addressed his leg pain, and that this was missed. MDS Coordinator (MDS-C) F reported that Resident #16 did not have a care plan related to his exit seeking/wandering. MDS-C F reported that the Social Services staff was responsible for creating that type of care plan. In an interview on 7/16/2025 at 10:22 AM, Social Services (SS) C reported that Resident #16 did not have a care plan in place for wandering/elopement. SSC reported that she was responsible for creating that type of care plan and that this was missed.

Based on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents in the facility.Findings Include: On 07/15/25 at 2:19 PM, observation of the boiler room, with Maintenance Director D, found outgoing hot water temperatures to the hall were observed at 118F, and the returning temperature was 110F. On 07/15/25 at 2:36 PM, observation and interview of the hand sink in the C hall shower room, found the hot water reached 130F while using a rapid read thermometer. When asked about taking regular water temperatures, MD D stated he has an assistant that takes the temperatures. On 07/15/25 at 2:40 PM, observation of the C hall dining room sink found the hot water reached 127.5F when tested with a rapid read digital thermometer. On 07/15/25 at 3:00 PM, observation of the N-hall spa found that both hand sinks had hot water that reached 127F when using a rapid read thermometer. When asked what type of thermometer is used by the facility to take hot water temperatures. MD D stated that a dial thermometer is used. On 07/15/25 at 3:13 PM, Observation of the boiler room found the outgoing temperature thermometer showing 122F and the return temperature at 115F.

Based on observation, interview, and record review, the failed to inform the resident's responsible party in advance and schedule meetings to participate in the formulation of care plans with relevant disciplines (nursing, dietary, social services, and activities) related to assessed healthcare needs for 1 (Resident #16) of 12 sampled residents reviewed for notification of care planning resulting in ineffective communication and the potential for unmet care needs. Findings include:Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE] with pertinent diagnoses which included wernickes encephalopathy (brain and memory disorder caused by lack of vitamin B1) and restlessness and agitation. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 7/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #16 was moderately cognitively impaired. Review of Resident #16's Care Conference notes did not reveal any record of a care conference completed by the facility since Resident #16 had been admitted to the facility. In an observation and interview on 7/15/2025 at 9:59 AM, Resident #16 was sitting in his room and reported feeling like he was in jail. Resident #16 reported that he was dealing with chronic leg pain, and he did not know if the facility had done anything about his pain. Resident #16 reported that he did not recall the facility staff meeting with him to discuss his care goals. In an interview on 7/16/25 at 12:46 PM, Guardian (G) GG reported that she was designated as Resident #16's legal guardian in April 2025. G GG reported that she had not been to the facility to visit Resident #16 since she had been appointed as his guardian. G GG reported that she had not attended a care conference for Resident #16, and she was not able to report any care goals for Resident #16. During an interview on 7/17/2025 at 11:56 AM, Social Services (SS) C reported that the facility was supposed to complete a care conference for a resident within 72 hours upon admission and quarterly. SS C reported that she was responsible for scheduling the 72-hour care conference, and that MDS Coordinator (MDS- C) F scheduled the quarterly care conferences for residents. SS C reviewed Resident #16's chart with this writer and confirmed that Resident #16 had not had a care conference since he was admitted in March 2025. In an interview on 7/17/2025 at 12:03 PM, MDS-C F confirmed that she had not scheduled a care conference for Resident #16. MDS-C F confirmed that Resident #16 was past due for a quarterly care conference and should have had a quarterly care conference completed in June 2025. Review of the facility's Care Planning- Resident Participation policy dated 1/25/25 revealed, Policy: This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: 1. The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status. 2. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. 3. The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. 4. The facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment options including a. Initial decisions about treatment b. Decisions about changes c. The right to refuse treatment. 5. In the case of a resident who has impaired decision-making ability (or has been declared incompetent by a court), the facility will, to the extent practicable, consult with and keep him or her informed .9. The facility will honor the resident's right to participate in establishing the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative, or document attendance in the medical record, after discussion or viewing of the care plan.11. If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record .

Based on observation, interview, and record review, the facility failed to assess the resident's need for the security of a locked unit and prevent involuntary seclusion for 1 (Resident #16) of 1 resident reviewed for involuntary seclusion resulting in resident frustration. Findings include: Resident #16 Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE] with pertinent diagnoses which included wernickes encephalopathy (brain and memory disorder caused by lack of vitamin B1) and restlessness and agitation. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 7/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #16 was moderately cognitively impaired. In an interview and observation on the locked dementia unit on 7/15/2025 at 9:59 AM, Resident #16 reported that he felt like he was locked up in his new room, and he did not know why he had to move rooms. Resident #16 reported that he never left his room and sometimes felt like he was going stir crazy being in his room all the time. Resident #16 became agitated when talking about being locked up in his new room. Review of Resident #16's admission Elopement Risk assessment dated [DATE] revealed, Risk factors: 1. Physical Activity: Ambulatory and/or self-mobile in wheelchair. 2. Thinking/Awareness: Has frequent periods of altered perception and/or lack of awareness of surroundings-not of recent onset. 3. Mood/Behavior: Complacent. 4. Decision Making/Memory: Frequent periods of confusion and mental impairment, moderately impaired. 5. History of Wandering: Disoriented most of the time, wandering without attempts to leave the home/facility. 6. Communication: Expressive, understandable communication with others. 7. Diagnosis: Mild cognitive loss. 8.Based on the information gathered for this assessment and summary score, are elopement/wander risks precautions indicated for this resident? No .Review of Resident #16's Care Plan did not reveal a wandering/elopement care plan for Resident #16. Review of Resident #16's Post admission Meeting dated 3/27/25 revealed, .Social Services: 4. Behavior Present? No . Nursing Notes: . He will at times wander to the front door. He is easily redirected .Review of Resident #16 Physician Progress Note dated 3/14/25, revealed, . Chief Complaint: . The patient is actively asking when he can leave, and staff report that he has been illegally smoking on campus. He was deemed incompetent by physician on 3/11/25, and staff are trying to orchestrate a court appointed guardian. He is otherwise compliant with staff, and can be successfully redirected without aggression .Review of Resident #16' Nursing Progress Note dated 3/15/2025 revealed, Writer observed (Resident #16) attempting to Exit front entrance. He was pushing buttons on keypad to get out. Writer asked how I could help him, and he states, I'm going to get matches to smoke a cigarette. Was able to redirect, and resident remained calm. Notified resident nurse of situation. (Resident #16) has been at N hall nurses' station today several times asking for matches. We have explained that this is a non-smoking facility, he verbalized understanding but continues to ask staff and visitors for matches . Review of Resident #16 Physician Progress Note dated 3/21/25 revealed, . The patient (Resident #16) is seen today in follow up to recheck behaviors after admission to the facility on 3/12/25. Staff report that he has not been agitated, nor aggressive, since admission. He is cooperative and easily redirected. He is also sleeping a lot during the day .Review of Resident #16 Physician Progress Note dated 3/31/25 revealed, . Although confused, and unable to make his own decisions, his behaviors have been compliant and cooperative since admission to SAR, and nightly Seroquel (psychotropic medication) has been gradually reduced. He is seen today in follow up to be sure he is tolerating GDR (gradual dose reduction). Staff report that he continues to need redirection, with confusion, but is sleeping well in the evening, without agitated nor disruptive behaviors .Review of Resident #16's IDT (Interdisciplinary Team) Note dated 4/3/2025 revealed, (Resident #16) continues with GDR of Seroquel with no adverse effects noted . (Resident #16) will come out of his room seeking snacks, but no exit seeking has been observed. IDT will continue to follow .Review of Resident #16's Behavior Notes dated 4/24/2025 revealed, (Resident #16) was up wandering in the front office. He was questioning about his lighter. Administrator had spoke with (Resident #16), stating that he was not admitted with a lighter. Inventory list was checked- nothing noted, no inventory assessment completed at admission. (Resident #16) started to become agitated. He stated he wanted to go out for a walk. At this time, Administrator had stated we need to (sic) permission from his guardian. Resident questioned that he had a guardian. He then asked for his lighter again. At this time, Administrator tried to redirect. (Resident #16) voice then got louder and was upset. DON (Director of Nursing) then went to seek out (Resident #16) nurse and social services director. (Resident #16) then left front office .Review of Resident #16's Physician Progress Note dated 4/25/25 revealed, . He (Resident #16) was on Seroquel post hospitalization, but behaviors have been stable. and GDR of Seroquel has been successful . Staff report that he has been doing well .Review of Resident # 16's Behavior Note dated 4/28/2025 revealed, (Resident #16) came into the front office this afternoon. He had asked for his lighter so he could go for a walk and smoke. Nursing staff had tried to talk redirect (Resident #16), and stated that he did not admit with a lighter. He had raised his voice to staff, stating that he had and he wants to go outside to smoke. Staff had stated that the facility has a no smoking policy. At this time, had stated that he would go for a walk. Nursing staff had stated that this would require a doctors order. Resident had gotten upset and yelled. At this time, the administrator had entered the office and stated to (Resident #16) that they had this same conversation last week. (Resident #16) had then turned around to walk out of the office and stated, F*ck this place .Review of Resident #16's Nursing Note dated 5/12/2025 revealed, Resident has been wandering and setting off door alarms. Has been placed on 15-minute checks x24 hr. Potential move to memory care unit on 5/13 has been discussed by IDT .Review of Resident #16's History and Physical Note dated 5/20/25 and documented by Medical Director (MD) CC revealed, . He is on the is unit (locked dementia unit) because he was restless and wandered outside the ECF .In an interview on 7/17/2025 at 11:16 AM, Certified Nursing Assistant (CNA) R reported that since moving to the dementia unit a few months ago, Resident #16 mostly stayed in his room. CNA R reported that she had not observed any behaviors with Resident #16, and she was not quite sure why he was on the locked unit, but maybe he was just more comfortable on the unit. CNA R was unable to report what interventions the facility staff had in place for Resident #16's exit seeking and wandering behaviors prior to moving him to the locked dementia unit. In an interview on 7/17/2025 at 11:35 AM, CNA W reported that when Resident #16 was first admitted to the facility, that they had observed Resident #16 attempt to exit the facility twice, but he was easily redirectable. CNA W reported that Resident #16 seemed to be confused that he could not smoke at the facility, but after he adjusted to being at the facility, he did not continue to exit seek. CNA W reported that Resident #16 wandered often, but that he was typically just looking for snacks. CNA W confirmed that the facility staff had placed Resident #16 on 15-minute checks during the two occasions where he attempted to exit the facility. CNA W was unable to report what interventions the facility staff had in place for Resident #16's exit seeking and wandering behaviors prior to moving him to the locked dementia unit. In an interview on 7/17/2025 at 11:21 AM, Licensed Practical Nurse (LPN) K reported that when Resident #16 was first admitted to the facility, he had attempted to exit the facility to smoke. LPN K reported that Resident #16 seemed confused as to why he was at the facility and did not understand the no smoking rule. LPN K reported that Resident #16 was always redirectable when he would wander. LPN K reported she did not know how many times Resident #16 had attempted to exit the facility, but that she knew that he did wander frequently, often looking for snacks. LPN K was unable to report what interventions the facility staff had in place for Resident #16's exit seeking and wandering behaviors prior to moving him to the locked dementia unit. LPN K reported that Resident #16 used to always walk around, but since moving to the locked unit, he mostly stayed in his room. LPN K confirmed that Resident #16 did not have any recent behaviors. In an interview on 7/17/2025 at 11:52 AM, CNA KK reported that when Resident #16 first admitted to the facility, he had attempted to exit the facility. CNA KK reported that Resident #16 seemed to want to exit the facility to smoke cigarettes, and once he was given nicotine patches, he did not seem as interested in leaving the facility, but he would still wander around looking for snacks. CNA KK reported that Resident #16 was usually easy to redirect. CNA KK was unable to report what interventions the facility staff had in place for Resident #16's exit seeking and wandering behaviors prior to moving him to the locked dementia unit. In an interview on 7/17/2025 at 11:41 AM, MDS Coordinator (MDS-C) F reported that Resident #16 did not have a care plan related to his exit seeking/wandering. MDS-C F reported that the Social Services staff was responsible for creating that type of care plan. MDS-C F reported that her office was near the room that Resident #16 resided in prior to being moved to the locked unit. MDS-C F reported that she had never observed Resident #16 attempting to exit the facility. MDS-C F reported that she did see Resident #16 occasionally wander the halls, but that Resident #16 was typically looking for a snack. MDS-S F reported that Resident #15 was easy to redirect and his wandering behavior seemed very manageable. MDS-C F reported that she did not observe Resident #16's wandering as affecting other residents. MDS-C F was unable to report what interventions the facility staff had in place for Resident #16's exit seeking and wandering behaviors prior to moving him to the locked dementia unit. In an interview on 7/17/2025 at 9:33 AM, Activity Director (AD) G reported that she had not been involved in meeting with Resident #16 to find activities for him to decrease his exit seeking. AD G reported that when he was first admitted , she met with him, and he was not interested in group activities. AD G reported that she had not been part of the IDT collaboration and decision to move Resident #16 to the locked dementia unit. In an interview on 7/16/2025 at 10:22 AM, Social Services (SS) C reported that the facility had moved Resident #16 to the locked unit because he was exit seeking. SS C reported that Resident #16 was not exit seeking a ton, but enough to need a more secure environment. SS C was unable to report how many times Resident #16 had attempted to exit the facility. SS C did confirm that Resident #16 would wander throughout the facility, usually looking for snacks. SS C was not able to report what alternative interventions the facility had attempted with Resident #16 to decrease his exit seeking/wandering prior to moving Resident #16 to the locked unit. SS C reviewed Resident #16's record with this writer and confirmed that Resident #16 did not have a care plan in place for wandering/elopement. SSC reported that she was responsible for creating that type of care plan and that this was missed. SS C confirmed that staff had not completed any additional elopement/wandering assessments for Resident #16 since his admission elopement assessment, in which he was not identified as an elopement risk. SS C reported that the criteria for a resident to be moved to the locked dementia unit included a dementia diagnosis and behaviors that affected others. SS C reported that the staff had tried to redirect Resident #16 but was not sure where the staff were documenting Resident #16's behaviors and failed redirection attempts. SS C reported that the facility IDT team had collaborated with the facility physician and determined Resident #16 would benefit from being moved to the locked dementia unit. SS C reviewed Resident #16's record with this writer and confirmed that there was no documentation of the IDT collaboration and decision to move Resident #16 to the locked dementia unit. SS C reported that she had re-assessed Resident #16 after he had moved to the locked dementia unit but was not able to provide documentation for any reassessments. SS C reported that she had obtained permission from Resident #16's guardian to move him to the locked dementia unit prior to moving him via email. This writer requested a copy of the email. Review of SS C email to Resident #16's guardian dated 5/12/25 revealed, (Guardian Name), Just wanted to update you on (Resident #16). He has been exit seeking more lately. He just pushed on the side door until it alarmed and walked out. Luckily, there was a staff member coming around the corner and saw him. He never left the front entrance, thankfully. We have a memory care bed opening up tomorrow and we are planning on moving him down there. If you have any questions, please let me know! In a follow up interview on 7/17/2025 at 1:02 PM Interview, SS C confirmed that Resident #16's guardian never responded to her email, and she had not spoke to Resident #16's guardian since he had been moved to the locked dementia unit. In an interview on 7/16/2025 at 10:48 AM, Director of Nursing (DON) B reported that the facility moved Resident #16 to the locked dementia unit because he was exit seeking. DON B reported that Resident #16 was exit seeking multiple times a shift and that his exit seeking had never improved. This writer queried where the facility staff were documenting Resident #16's frequent exit attempts, and DON B reported that staff had documented notes on 4/24/25, 4/28/25, and 3/15/25. DON B reported that Resident #16 was exit seeking much more often than staff had documented. DON B confirmed that Resident #16 did not have any additional elopement assessments completed after he began exit seeking, and that this was missed. DON B also confirmed that Resident #16 did not have an elopement or wandering care plan in place. DON B was unable to report what alternative interventions the facility had attempted prior to moving Resident #16 to the locked dementia unit. DON B reported that the IDT team had collaborated with the facility physician and determined Resident #16 would benefit from being on the locked unit. DON B was not able to provide documentation of the IDT collaboration, or the physician assessment of Resident #16. DON B reported that every time Resident #16 had attempted to exit the facility, that staff initiated 15-minute checks on him. This writer asked for documentation of the 15 minute checks. DON B was not able to provide documentation of the 15-minute checks for Resident #16 prior to survey exit. In an interview on 7/16/2025 at 12:08 PM, Medical Director (MD) CC reported that he was not involved in the collaboration and decision to move Resident #16 to the locked dementia unit. MD CC reported that he was not aware of what the facility process was for moving a resident to the locked dementia unit. This writer queried about MD CC 's progress note on 5/20/25 that noted (Resident #16) is on the is unit (locked dementia unit) because he was restless and wandered outside the ECF. MD CC reported that this was a documentation error, and that he had never been told by facility staff that Resident #16 had left the facility. In an interview on 7/16/2025 at 3:20 PM, Former Nurse Practitioner (FNP) FF reported that she worked at the facility until 5/1/25. FNP FF reported that she had not been involved in collaborating or assessing Resident #16 to move him to the locked dementia unit. FNP FF reported that she was aware that Resident #16 had been exit seeking when he was first admitted to the facility, but that she was under the impression that his behavior had resolved, and he was no longer exit seeking. FNP FF reported that the facility was able to discontinue Resident #16's Seroquel because of his improved behaviors. In an interview on 7/16/2025 at 12:46 PM, Guardian (G) GG reported that she was not aware that Resident #16 had been exit seeking or wandering throughout the facility. G GG confirmed that she had not been to the facility to visit Resident #16 since she was appointed his guardian in April, and that she was not aware of his current care goals. G GG was not aware that Resident #16 had been moved to the locked dementia unit. In an interview on 7/17/2025 at 12:08 PM, Nursing Home Administrator (NHA) A reported that the facility did not have a process or guidelines that they followed for determining the criteria to move a resident to the locked dementia unit. NHA A reported that the IDT felt that Resident #16 would benefit from having more attention, activities and being able to go outside on the locked unit, so they talked to Resident #16's guardian and moved Resident #16 to the unit. NHA A reported that the staff were worried that Resident #16 was becoming more depressed and secluded to his room, so they thought the locked unit would be better. NHA A reported that the IDT team contacted Resident #16's guardian 2-3 weeks before he was moved to the unit. NHA A did not know if anyone had re-assed Resident #16 after he was moved to the locked unit to see how he was adjusting. NHA A was not able to provide any documentation of the IDT meetings discussing Resident #16, and his move to the locked dementia unit.

Based on interview, and record review, the facility failed to provide rationale for the continued use of, and adequate documentation of monitoring, for the use of psychotropic medications for 2 of 5 residents (Resident #27, #6) reviewed for unnecessary medications, resulting in the increased potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.Findings include: Resident #27: Review of an admission Record revealed Resident #27 was a female with pertinent diagnoses which included anxiety. Review of current “Care Plan” for Resident #27, revised on 6/21/25, revealed the focus, “…The resident uses psychotropic medications desvenlafaxine, bupropion HCl ER, anitriptyline (sic), and clonazepam r/t (related to) depression and anxiety . with the intervention .Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift) . Review of Consultant Pharmacist Recommendation to the Prescriber dated 4/10/25, revealed, .(Resident #27) has a PRN (as needed) psychotropic order for clonazepam 1 mg every 24 hours as needed for anxiety .All PRN psychotropics in this drug class should be DISCONTINUED after 14 days. Orders may be extended beyond 14 days if the physician or prescribing practitioner:1. Believes it's appropriate to extend the order- and-2. Document clinical rationale for extension -and-3. Provides a specific duration of use .Recommendation: Please consider a 14 day stop date for PRN clonazepam, unless all of the above items are addressed Physician/Prescriber Response: Disagree .Hospice pt (patient); no (delta sign - change or difference) . Review of Encounter dated 6/13/2025 at 00:00 AM, revealed, .Noted pt to have recently signed off from (Name of Hospice Agency) hospice on 4/25 d/t (due to) pt decision to pursue therapy and with general improvements to health . In an interview on 07/16/25 at 1:28 PM, Director of Nursing (DON) B reported the pharmacy medication reviews were sent to the Nursing Home Administrator (NHA) and she was included on the email as well. DON B reported she would print them out and give them to the provider for review and recommendations. The provider would enter their own orders usually if they agreed with the recommended changes by the pharmacist. Review of Order dated 8/2/24, revealed, .Clonazepam 1 mg (milligram) .1 tablet by mouth every 24 hours as needed for anxiety *Indefinite order* .Discontinued on 10/10/24 . Review of Medication Administration Record (MAR) for August 24 revealed Resident #27 received 10 doses of Clonazepam 1 mg as needed. Review of Medication Administration Record (MAR) for September 24 revealed Resident #27 received 10 doses of Clonazepam 1 mg as needed. Review of Medication Administration Record (MAR) for October 24 revealed Resident #27 received 1 dose of Clonazepam 1 mg as needed. Review of Order dated 3/7/25, revealed, .clonazePAM Oral Tablet 1 MG (Clonazepam) Controlled Drug .Give 1 tablet by mouth every 24 hours as needed for anxiety .Discontinued on 6/21/25 . (Note: this order was for greater than 14 days) Review of Medication Administration Record (MAR) for March 25 revealed Resident #27 received 3 doses of Clonazepam 1 mg as needed. Review of Medication Administration Record (MAR) for April 25 revealed Resident #27 received 0 doses of Clonazepam 1 mg as needed. Review of Medication Administration Record (MAR) for May 25 revealed Resident #27 received 4 doses of Clonazepam 1 mg as needed. Review of Medication Administration Record (MAR) for June 25 revealed Resident #27 received 3 doses of Clonazepam 1 mg as needed. Review of Order dated 6/21/25, revealed .Clonazepam 1 mg every 24 hours .Give 1 tablet by mouth as needed for anxiety daily as needed .Indefinite order .Discontinued on 7/17/25 . Review of Medication Administration Record (MAR) for June 25 revealed Resident #27 received 0 doses of Clonazepam 1 mg as needed. Review of Medication Administration Record (MAR) for July 25 revealed Resident #27 received 2 doses of Clonazepam 1 mg as needed. Review of Task Behavior Monitoring for the previous 30 days revealed no behaviors noted. Review of Resident #27's progress notes revealed no behavior notes or behavior observation notes. Review of Order dated 7/17/25 for Resident #27 revealed, .Clonazepam Oral Tablet 1 mg .Give 1 tablet by mouth as needed for anxiety for 2 weeks daily as needed .Start Date: 7/17/25 . In an interview on 07/17/25 at 12:04 PM, Certified Nursing Assistant (CNA) “W” reported the staff typically know from day one if a resident had behaviors and the CNAs would document those behaviors if there were more aggressive than the baseline in the electronic medical record. CNA W reported there was also a physical document they would complete in the binder for the resident. In an interview on 07/17/2025 at 10:42 AM, DON B reported a PRN (as needed) medication order should be reviewed every two weeks and if not needed further discontinued. DON B reported since Resident #27 was no longer on hospice and reported hospice made the decisions on the medications amount and duration as for the comfort of the resident so would leave the resident on it indefinite. The doses Resident #27 was receiving were hospice recommended doses. In an interview on 07/17/2025 at 11:32 AM, Social Worker (SW) C reported residents with new or existing behaviors were discussed in the behavior monthly meeting as well as during the IDT (Interdisciplinary team) meetings. SW C reported she had a spreadsheet for all the residents who were taking antipsychotics and psychotropic medications. SW C reported the facility would talk with the resident or family members to learn what non pharmacological interventions would be beneficial for the resident and those would be added to the care plan. SW C reported she completed an initial social work assessment at admission and annually. SW C reported the pharmacy recommendations would be given to the DON, the doctor reviewed and then changed in IDT. SW C list of everyone's medications, she keeps track of them, the team discussed potential GDRs (gradual dose reductions) for residents. SW C reported the facility followed the hospice orders and reported she didn't realize the provider was able to override them. Resident #6 Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia, mild with anxiety and muscle weakness. Review of Resident #6's Orders revealed, LORazepam Oral Tablet 0.5 MG (Lorazepam) (Anti-anxiety medication) Give 1 tablet by mouth every 2 hours as needed forrestlessness. Start date: 3/12/25. It was noted that there was not a stop date on the order. Review of Resident #6's Consultant Pharmacist Recommendation to the Provider note dated 4/10/25 revealed, (Resident #6) has a PRN (as needed) psychotropic order for lorazepam 0.5 mg every 2 hours as needed for restlessness. All PRN psychotropics in this drug class should be discontinued after 14 days. Orders may be extended beyond 14 days if the physician or prescribing practitioner: 1. Believes it's appropriate to extend the order and 2. Document clinical rationale for extension and 3. Provide a specific duration of use. Recommendation: Please consider a 14 day stop date for PRN lorazepam, unless all of the above items are addressed. Physician/Provider Response: Disagree: Hospice Pt (patient) cont (continue) at current dose. This was signed by the facility's provider on 4/15/25. In an interview on 7/16/2025 at 10:14 AM, Social Services (SS) C reported that the facility was responsible for evaluating the need for a PRN psychotropic medication every 14 days. SS C confirmed that Resident #6 had the PRN lorazepam order in place since March 2025. SS C was not able to provide evidence of rationale for the facility continuing the PRN lorazepam after 14 days. In an interview on 7/16/2025 at 10:48 AM, Director of Nursing (DON) B reported that Resident #6's hospice provider had ordered the PRN lorazepam, and she thought that hospice was responsible for evaluating the need for the continued use and documenting the rationale. DON B was unable to report if the facility's medical provider had evaluated the need for continued use of the PRN lorazepam. This writer asked for documentation to verify that the facility had evaluated the need and rationale for continued use of the PRN lorazepam. The facility was not able to provide requested documentation prior to survey exit. In an interview on 7/16/2025 at 12:08 PM, Medical Director (MD) CC reported that he had not monitored/evaluated Resident #6's order for PRN lorazepam. MD CC reported that this was an area that the facility could improve on.

Based on interview and record review, the facility failed to implement regular device checks, monitor battery status, and complete functionality tests for their AED (automatic external defibrillator) machine in 1 of 3 residents (Resident #101) reviewed for essential equipment in safe operating condition, resulting in an inoperable device at the time of Resident #101's critical cardiac arrest emergency and the potential for essential equipment to not be operable in a time of need. Findings include: Review of an admission Record revealed Resident #101 was a female, with pertinent diagnoses which included: atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), other pulmonary embolism (blood clot in the lungs) without acute cor pulmonale (right-sided heart failure), and malignant neoplasm of anterior mediastinum (cancer in the space between the lungs in the chest). Review of Resident #101's Nursing Note dated [DATE] at 6:22 PM revealed, Note Text: Around 1758 (5:58 PM) CNA (Certified Nurse Aide N and M) called out at the N Hall nurses station that resident is not breathing, not responding to any stimuli. Code Blue (medical emergency, cardiac or respiratory arrest) called, and 911 called. 1800 (6:00 PM) Chest compressions started. 1803 (6:03 PM) First responder arrived, 1807 (6:07 PM) Paramedic arrived. 1808 (6:08 PM) Attach to lucas (a chest compression machine), 1810 (6:10 PM) more paramedics arrived . Review of Resident #101's Nursing Note dated [DATE] at 7:12 PM revealed, Note Text: Around 1850 (6:50 PM) resident out to (hospital name omitted) with paramedics, EMS. Husband was following the ambulance going to the (hospital name omitted). In an interview on [DATE] at 1:45 PM, Director of Nursing (DON) B reported on [DATE] she had been in her office getting ready to leave for the day when she saw a CNA hurrying past the door. DON B reported Licensed Practical Nurse (LPN) G then called a Code Blue for Resident #101. DON B reported staff had confirmed that Resident #101 was a full code (cardio-pulmonary resuscitation (CPR) desired). DON B reported LPN Q had grabbed the crash cart (a cart with emergency supplies to respond to a medical emergency and code blue event) and LPN O grabbed the AED (a device used to shock the heart back into normal rhythm). DON B reported LPN Q and Registered Nurse (RN) F were performing CPR. DON B reported when they hooked the AED up to Resident #101, it did not turn on. DON B reported the first responding police officer had an AED that was then used on the resident. DON B reported the facility AED did not work because the battery was dead. DON B reported, at the time, the facility did not have a backup battery to install in the AED machine. DON B reported facility staff were supposed to check the AED machine every Sunday when they checked the crash carts and was not sure if there had been a disconnect on checking the AED machine. In an interview on [DATE] at 3:40 PM, RN F reported she had been performing CPR on Resident #101 with another nurse. RN F reported she and another nurse had put the AED contact pads on Resident #101 and when she (RN F) went to turn on the AED, it wouldn't turn on. In an interview on [DATE] at 12:55 PM, LPN O reported she was giving report around 6:00 PM on [DATE] when 2 CNAs yelled that Resident #101 was a Code Blue. LPN O reported another nurse had been performing CPR when she arrived and then she (LPN O) had switched off with that nurse and started performing CPR. LPN O confirmed that the facility AED machine did not work when they turned it on. On [DATE] at 1:47 PM, this surveyor requested evidence of AED functionality checks and backup battery availability from DON B. DON B looked at the Crash Cart Checklist (a listing of what items nursing staff was to check for the crash carts) and reported there was not a place on the checklist directing nurses to check the AED functionality. DON B suggested checking with the maintenance department to see if they had a record of the AED functionality checks. In an interview on [DATE] at 1:55 PM, Maintenance Director (MD) P reported he had been working at the facility for 3.5 months and had not been involved in checking the functionality of the AED and did not have evidence of functionality checks. In a follow-up interview on [DATE] at 2:03 PM, DON B confirmed that there was no documentation that the AED machine had been checked for functionality but assured this surveyor it would be added to the Crash Cart Checklist. In an interview on [DATE] at 2:39 PM, Nursing Home Administrator (NHA) A showed this surveyor an AED Inspection Log with the last entry of the AED being inspected on [DATE]. There was also a copy of a battery tag on the AED Inspection Log with the date of 3/2026 for the INSTL DATE and [DATE] for the EXP. DATE. NHA A reported she thought the date of [DATE] was when a battery had been installed in the AED machine and the date of 3/2026 was when the battery would be expired.

Based on observation, interview, and record review, the facility failed to maintain the facility dishwasher in an operable manner. This deficient practice had the potential to affect all 47 residents within the facility. Findings include: This writer observed resident being served their lunches in Styrofoam containers. There was no mention of the facility having an outbreak of COVID in the building. In an interview on 3/11/25 at 12:29 PM, Certified Nursing Assistant (CNA) K reported the sink was not working and she believed that was why the facility was using Styrofoam containers for meals. She reported she worked last Friday, and they used the Styrofoam containers then as well. In an interview on 3/11/25 at 12:33 PM, Dietary Manager (DM) E reported the dish machine had been out over 30 days, not sure how long exactly, reported she first ordered the Styrofoam containers mid-February. She reported their Current Chemical Supplier/[NAME] N came in to check on their need, reported he could get them a dishwasher on lease through them. DM E reported this was approximately two weeks ago. She reported the facility had to obtain approval from corporate but once they did, the facility would lease the dishwasher. DM E reported she was unsure why the dishwasher was not at the facility yet. She reported she had provided all the information she had to the Administrator. DM E reported the previous Maintenance Director F had gotten quotes from Chemical Supplier/[NAME] M who could provide them with a dishwasher, but the facility had decided to go with Current Chemical Supplier/[NAME] N for the dishwasher. In an interview on 3/11/25 at 2:50 PM. Administrator A reported the facility was required to obtain 3 quotes for corporate office. She had reached out to obtain a quote from Food and Service Supplier L which took about 3 weeks, and they still had no quote yet. She reported Current Chemical Supplier/[NAME] N connected them with Account Representative O who informed them last week, 3/7/25, the facility did not have enough credit history and needed a guarantee from corporate owner. This writer requested documentation of quotes, invoices, etc. to support interview. In an interview on 3/12/25 at 4:03PM, Previous Maintenance Director F' reported the dish machine stopped working last month, February, some time. Previous Maintenance Director F' reported before he left, he had been working on getting a replacement as the one they had was so old the cost for repair would be at the least half amount of a new one and the were parts not available as the machine was [AGE] years old. Previous Maintenance Director F' reported when he left, he understood the facility was still waiting on quotes as they were required to obtain three quotes by corporate. Review of the submitted documentation revealed on 1/29/25 the facility had obtained a quote to have the dishwasher fixed. 1/29/25 had reached out to Food and Service Supplier L about obtaining a dishwasher. Informed they do no provide dishwashers, they utilized Chemical Supplier/[NAME] M. On 2/11/25, Chemical Supplier/[NAME] M came to the facility for a walk through. On 2/20/25, Chemical Supplier/[NAME] M had reached out and were informed the facility was going with Current Chemical Supplier/[NAME] N. On 2/14/25, Current Chemical Supplier/[NAME] N supplied the facility with the type and model of dishwasher (High Temperature Single Rack Straight dishwasher) the facility would need and the cost for replacement. On 2/20/25, Account Representative O requested additional information from corporate owners. On March 7, 2025, Account Representative O informed the facility they were not approved due to credit history was not extensive and required a guarantee from the owner. In an interview on 3/12/25 at 08:58 AM, Resident #104 had reported she was sick and tired of being served her meals on Styrofoam and was over it. Resident #104 reported this had been happening for far too long and as much as she paid as a resident at the facility, she shouldn't be served Styrofoam for months and the dishwasher should have been addressed long ago. Resident #104 reported the Styrofoam didn't maintain heat for the food as well so she was getting cold or luke warm food. In an interview on 3/12/25 at 12:46 PM, Administrator A reported she had spoken to Account Representative O who was the financing specialist. Administrator A reported she was informed by the financing specialist the company had to run the additional information requested on 3/7/25 and indicated to the facility she was 90% sure the credit would be approved for a leased dishwasher. Administrator A reported she was informed the replacement dishwasher could take 4-6 weeks once the credit approval was granted. Administrator A reported the facility would continue to use Styrofoam containers until the dishwasher was replaced due to the concern for maintaining infection control and the cross contamination of the tableware.

This citation pertains to Intake: MI00149459 Based on interview and record review, the facility failed to ensure 3 of 22 nurse aides reviewed for nurse aide certification license became certified within four months of nurse aide training before continuing to provide resident care, resulting in the potential for inadequate or inappropriate resident care. Findings include: This writer reviewed the Nurse Aide Public Registry on 03/12/25 for all 22 nurse aides employed by the facility and was unable to locate a Certified Nursing Assistant (CNA) license for Nursing Assistant (NA) G, NA H, and NA I. In an interview on 3/12/25 at 12:25 PM, Human Resources (HR) D reported NA G did not pay the extra fee to have her license placed in the licensing system. HR D reported she contacted NA G via telephone to inform her of the need for the license to be placed in the system as well as to provide the facility with a copy of her CNA license. In an interview on 3/12/25 at 12:30 PM, HR D reported NA I was hired on 3/29/24, took the nursing assistant class, which was paid for by the facility, from 4/22/24 - 5/3/24. HR D reported NA I had taken her test on Friday, March 7, 2025, and had failed the test. HR D reported she continues to work at the facility full time on the night shift from 6 PM - 6 AM. In an interview on 3/12/25 at 12:35 PM, HR D reported NA H had worked for the assisted living before moving to long term care. HR D reported the facility had paid for NA H' to take the nursing aid class and did not have a copy of her CNA license. Review of Posted Timecard Report dated 3/12/25, revealed for NA H .06/05/24 Attending CNA School .06/18/2024: Position transfer from ALF Tech Aide to Nursing Dept. CNA . In an interview on 3/12/25 at 12:37 PM, HR D reported Scheduler J placed the staff in the CNA training class when they were hired or moved from a different area of the facility. HR D reported she was unsure who was responsible for keeping track of the licensing for those nursing assistants the facility had paid for their classes. In an interview on 3/12/25 at 12:42 PM, Administrator A reported those responsible for maintaining the records for certified nursing assistants licenses when they completed the CNA class was a combination of human resources staff and the scheduler.

Based on observation, interview, and record review, the facility failed to ensure residents received the correct foods as outlined on the planned, posted menu resulting in the potential for dissatisfaction with meal service and feelings of frustration. This deficient practice has the potential to affect all residents who consume food from the kitchen, out of a total census of 49. Findings include: Review of the Resident Meal Menu for 7/16/24 revealed: Breakfast - Juice of Choice, Bacon, Cereal of Choice, French Toast, Milk of Choice, 8 oz (ounces), Coffee, Syrup / Margarine / Creamer Lunch - Ravioli Baked, Italian [NAME] Beans, Bread Sticks, Apple Crisp, Beverage of Choice Supper - Tuna Melt Grilled Sandwich, Sweet Potato Fries, Creamy Cucumbers, Mandarin Oranges, Beverage of Choice, Milk of Choice, 8 oz During a dining observation on 7/16/24 at 12:40 PM on the A Hall, noted that none of the meal trays contained breadsticks as was outlined on the posted menu for that meal. In an interview on 7/16/24 at 4:03 PM, Dietary Manager (DM) H confirmed that residents had not been served breadsticks at lunch because the breadsticks hadn't gotten pulled from the freezer. DM H also reported that a tuna melt sandwich was on the menu for the supper meal that evening but because those sandwiches didn't hold up well on meal trays, they were going to make tuna noodle casserole instead. (It should be noted that at the time of the interview, the posted menu had not been updated to reflect the planned change to tuna noodle casserole.) In an interview on 7/16/24 at 9:22 AM, Resident #39 reported he did not get bacon on his breakfast tray that morning but that the menu had listed bacon as part of the meal. Resident #39 reported he had received his French toast and oatmeal, but no bacon and he was concerned because he had not gotten a protein source for that meal. In a follow-up interview on 7/17/24 at 2:49 PM, Resident #39 reported he had not received milk for lunch the day before even though that had been his beverage of choice. Resident #39 reported staff had said there was only a little bit of milk left and they needed to conserve it for the breakfast the following morning. Resident #39 reported it was frustrating when he did not receive what he ordered and when he did not receive what was on the menu. In an interview on 7/17/24 at 2:53 PM, Resident #16 reported the kitchen had run out of things at times resulting in residents not being served what was on the menu. Review of Resident Council Meeting Minutes of 7/12/24, Comment revealed, The menu and food we are served are completely different. In a follow-up interview on 7/17/24 at 10:54 AM, DM H was queried on resident report of not receiving bacon for breakfast on 7/16/24 per the posted menu. DM H reported the cook had burned the bacon on Monday and, as a result, there was not enough bacon for breakfast on Tuesday. DM H was queried on resident report of staff needing to conserve milk for breakfast. DM H reported they were unable to purchase single-serve pints of milk and had to purchase gallons instead. DM H reported because he was new to the position, he was still trying to determine how many gallons of milk to purchase to have enough while not over-purchasing and wasting it. DM H reported he had told the staff if there was only enough milk for one meal service before the next milk delivery came, to save it for breakfast.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen, at 9:15 AM on 7/16/24, it was found that the walk in coolers were dark and hard to see, especially in the back of the unit. When a flashlight was used, heavy accumulation of black debris was evident on the floor perimeter and especially around the wheels and rack legs of the storage shelves. When asked if he was aware of the black accumulation, Dietary Manager (DM) H stated it was hard to see until the flashlight was used. During the initial tour of the kitchen, at 9:50 AM on 7/16/24, it was observed that the clean utensil drawers, located under the preparation table, were found with excess crumb debris on the inside of the drawer. Staff were using parchment paper as a bottom barrier in the drawer. The paper looked old and discolored with no date to indicate when it was changed last. DM H was unsure when it had been changed. During a revisit to the kitchen, at 3:00 PM on 7/16/24, a Digital [NAME] meter was used to determine the amount of visible foot candles of light register in the walk-in cooler and freezer. Putting the Digital [NAME] meter 30 inches off of the floor, directly under the walk in cooler and freezer light, found they produced between 10.3-14.2 foot candles. When moved to the back of each walk-in unit and measured 30 inches off of the floor (near the condenser), the digital lux meter read between 0.5-2.1 foot candles of light. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (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. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . According to the 2017 FDA Food Code section 6-303.11 Intensity. The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning . During an interview with DM H, at 9: 18 AM on 7/16 24, it was found that the facility does not cool food very often. At this time, observation of a gallon container of apple crisp was found stored in the walk-in cooler, tightly covered with a top, with heavy condensation on the inside of the container. Upon seeing the item cooling DM H opened the top to allow it to vent. When asked what the item was used for, DM H stated it was apple crisp from Breakfast this morning. A temperature was taken at this time and found the item to be 95.5F. A return visit to the kitchen, at 12:01 PM on 7/16/24, found the apple crisp in the same position in the walk-in cooler with no apparent additional ways to help rapidly cool the product. At this time a temperature was taken with a rapid read thermometer and found the item to be 69.8F. An interview with DM H at this time found the item should have reached 70F within two hours of cooling. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During the initial tour of the kitchen, at 9:22 AM on 7/16/24, observation found that ice accumulation in the walk-in freezer door impedes the doors ability to fully close. An interview with DM H found that ice tends to building up around the door and inside the unit some. Staff must watch for and break down the ice in the corner of the door in order to get it to close properly. During the initial tour of the kitchen, at 9:44 AM on 7/16/24, it was observed that the gasket to the single door True cooler was found with large rips and tears in the gasket seal along the top and side of the door. During the initial tour of the kitchen, at 10:00 AM on 7/16/24, it was observed that the atmospheric vacuum breaker, on the back of the dish machine, was missing its top cap which compromises the integrity of the vacuum breaker. According to the 2017 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on observation, interview, and record review the facility failed to properly implement enhanced barrier and contact isolation precautions and the use of personal protective equipment for 4 of 4 residents (Resident #33, Resident #8, Resident #9, and Resident #41) reviewed for infection control, resulting in the potential for cross contamination and spread of infection. Findings include: Resident #33 Review of an Admission Record revealed Resident #33, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia (loss of movement on one side of the body). Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 6/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #33 was cognitively intact. Review of a Care Plan for Resident # 33, with a reference date of 5/24/24 , revealed a focus/goal/interventions of: Focus: (Resident #33) has an eye infection, conjunctivitis(common but very contagious infection) of left eye. Goal: (Resident #33's) infection will be resolved with complications. Interventions: Educate resident and direct care staff that the infection is contagious . Review of physician orders for Resident #33 revealed an order placed on 7/14/24 for the resident to be in contact isolation precautions due to conjunctivitis (a common but very contagious infection of the conjunctiva of the eye). During an observation on 7/16/24 at 12:57pm a sign that read: Stop. Contact Precautions, Providers and Staff must .: Put on gloves before room entry. Put on gown before room entry hung outside Resident #33's room. During an observation on 7/18/24 at 9:39am, Activity Director (AD) J stood against Resident #33's bed, wore no personal protective equipment (PPE), held Resident #33's electronic device with her left hand and used her right index finger to tap on the touch screen of the device. AD J then handed the device back to Resident #33, exited the room and completed hand hygiene with hand sanitizer. In an interview on 7/18/24, at 9:41am, AD J reported while in Resident #33's room, she took his electronic device from him and assisted him with completing a task on it. AD J reported she thought staff only needed to wear PPE when performing cares for Resident #33, but she was not really sure. When further queried, AD J confirmed she did not wear any PPE while in Resident #33's room, handled his electronic device that he uses frequently and cleansed her hands with hand sanitizer upon exiting. In an interview on 7/18/24 at 10:03am, Assistant Director of Nursing/Infection Preventionist (ADON) D reported Resident #33 was in contact precautions for conjunctivitis and all staff who entered his room and handled his belongings or performed care were required to wear a gown, gloves, and a mask to reduce the risk of infection. ADON D added that staff who handled Resident #33's belongings with their bare hands would need to wash their hands with soap and water to reduce the risk of cross contamination. When further queried, ADON D reported that failure to use the proper personal protective equipment while caring for Resident #33, or handlings items in his room, could result the potential spread of infection to other residents. Review of a facility policy titled Transmission Based Precautions with a reference date of 3/24 revealed: Contact Precautions- Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 47659 Resident #8 Review of an Admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease (COPD). Review of Resident #8's Orders did not reveal current or discontinued orders for enhanced barrier precautions. During an observation on 7/16/24 at 10:03 AM, Resident #8's room had a sign outside of the door that stated, enhanced barrier precautions. Inside of Resident #8's room, there was a cart full of personal protective equipment (PPE). During an observation on 7/17/24 at 9:09 AM, Resident #8's room had a sign outside of the door that stated, enhanced barrier precautions. Inside of Resident #8's room, there was a cart full of personal protective equipment (PPE). During an interview on 7/17/24 at 12:10 PM, Certified Nursing Assistant (CNA) U reported that Resident #8 was on enhanced barrier precautions because she had a catheter, but the catheter had recently been removed. CNA U reported that she did not know if staff were still following the enhanced barrier precautions for Resident #8. During an interview on 7/17/24 at 3:04 PM, Licensed Practical Nurse (LPN) L reported that he had removed Resident #8's catheter the previous week, and that Resident #8 no longer required enhanced barrier precautions. LPN L reported that he did not know who was responsible for initiating or discontinuing enhanced barrier precautions for residents. LPN U reported that he did not know if staff were still following enhanced barrier precautions for Resident #8. During an interview on 7/18/24 at 8:40 AM, LPN R reported that Resident #8 remained on enhanced barrier precautions. LPN R confirmed that she was aware that Resident #8 no longer had a catheter. During an interview on 7/18/24 at 11:00 AM, Registered Nurse (RN) P reported that the facility process for initiating and discontinuing enhanced barrier precautions was not clear and it caused confusion among the staff. RN P reported that nurses were able to initiate and discontinue enhanced barrier precautions, but not all nurses were aware of the process. During an interview on 7/18/24 at 11:43 AM, Assistant Director of Nursing (ADON) D reported that the nursing staff were responsible for initiating and discontinuing enhanced barrier and transmission-based precautions. ADON D reported that nurses were also responsible for communicating the precautions to the environmental services department so that they could place and/or remove the sign and cart from the resident's room. ADON D reported that all residents on enhanced barrier or transmission-based precautions should have an order in their electronic health record (EHR). ADON D reported that Resident #8 did not have an order in their EHR for initiating or discontinuing enhanced barrier precautions. ADON D reported that the staff missed completing initiation and discontinuation of enhanced barrier precautions for Resident #8. During an interview on 7/18/24 at 12:19 PM, Maintenance/Environmental Director (MD) G reported that he was responsible for communicating with nursing staff to know which residents were on enhanced barrier or transmission-based precautions. MD G reported that he had reviewed all residents the prior week to ensure that the correct signs and PPE were placed and removed as ordered. MD G reported that he could not recall if he had been notified that Resident #8 was no longer on enhanced barrier precautions. Resident # 9 Review of an Admission Record revealed Resident #9 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #9's Orders did not reveal current or discontinued orders for transmission-based precautions. Review of Resident #9's Nursing Note dated 6/14/24 revealed, .Resident also to be on contact isolation . During an observation on 7/16/24 at 9:35 AM, Resident #9's room had a sign that stated Contact Precautions on the door. It was noted that there was not a PPE cart located outside or inside of Resident #9's room. During an interview on 7/16/24 at 10:18 AM, CNA T reported that staff were required to wear gloves and gowns when providing direct care to Resident #9. CNA T did not know why Resident #9 did not have a PPE cart in her room or how staff were putting on PPE when there was not a cart available. During an interview on 7/17/24at 12:10 PM, CNA U reported that Resident #9 was not on contact precautions anymore. CNA U was unaware of when the precautions were discontinued for Resident #9. During an interview on 7/17/24 at 3:04 PM, LPN L reported that he worked with Resident #9 regularly, but he did not know if Resident #9 was currently or had been on contact precautions. During an interview on 7/18/24 at 8:40 AM, LPN R reported that Resident #9 was removed from contact precautions on 6/24/24. LPN R did not know why Resident #9's room still had a sign that stated they were on contact precautions. During an interview on 7/18/24 at 11:43 AM, ADON D reported that Resident #9 did not have orders in their EHR for the initiation or discontinuation of contact precautions. During an interview on 7/18/24 at 12:19 PM, Maintenance/Environmental Director (MD) G reported that he could not recall when he was notified that Resident #9 was removed from contact precautions or when the PPE cart was removed from Resident #9's room. Resident #41 Review of an Admission Record revealed Resident #41 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of Resident #41's Orders did not reveal current or discontinued orders for enhanced barrier precautions. During an observation on 7/16/24 at 9:17 AM, A PPE cart was sitting in Resident #41's room. It was noted that Resident #41 did not have a sign on the door of their room to indicate what kind of precautions Resident #41 was on. During an interview on 7/18/24 at 11:43 AM, ADON D reported that Resident #41 was on enhanced barrier precautions. ADON D reported that Resident #41 was missing an order for the enhanced barrier precautions in their EHR. ADON D confirmed that Resident #41 should have had a sign on their door to indicate to staff what kind of precautions Resident #41 was on, as that would determine when and how staff should don and doff PPE when caring for Resident #41. During an interview on 7/18/24 at 12:19 PM, Maintenance/Environmental Director (MD) G reported that he did not know why Resident #41 was missing a sign on their room door to indicate what precautions staff should take when caring for Resident #41. During an observation and interview on 7/18/24 at 1:19 PM, Resident #41's room door was noted to have a sign that stated Contact Precautions on the door. LPN R reported that the sign was incorrect, and that Resident #41 was not on contact precautions. During an observation and interview on 7/18/24 at 1:54 PM, LPN R prepared medication to administer to Resident #41 via Resident 341's peg tube (a feeding tube that goes directly to the stomach). LPN R was observed entering Resident #41's room with the prepared medication. LPN R placed the medication on a tray table and applied gloves. After applying gloves, LPN R administered the medication to Resident #41 via the peg tube. It was noted that LPN R did not have any other form of PPE on during the medication administration. LPN R reported that staff were only required to wear gowns when caring for wounds. LPN R reported that she never wore PPE when administering medications via peg tubes. Review of the Facility's Enhanced Barrier Precautions last reviewed 9/2023 revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: A. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. B. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions .2. Initiation of Enhanced Barrier Precautions: A. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC but may be considered epidemiologically important. B. An order for enhanced barrier precautions will be obtained for residents with any of the following: I. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). B. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room . 4. High-contact resident care activities include: a. Dressing. b. Bathing C. Transferring D. Providing hygiene E. Changing linens F. Changing briefs or assisting with toileting. G. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters H. Wound care: any skin opening requiring a dressing .

This citation pertains to intake #MI00127465. Based on interview and record review, the facility failed to implement appropriate safety measures were followed to ensure safe transfer of 1 (Resident #100) of 3 residents reviewed for falls resulting in an actual fall for Resident #100 who sustained a fractured right leg. Findings include: Review of an Admission Record revealed Resident #100 was a female with pertinent diagnoses which included dementia, poliomyelitis (infectious viral disease that affects the central nervous system and can cause paralysis), post polio syndrome (group of potentially disabling signs and symptoms that appear decades after the initial polio illness), repeated falls, history of stroke, muscle weakness, cognitive communication deficit, need for assistance with personal care, hemiplegia, and difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/25/22 revealed a Staff Assessment for Mental Status was completed which indicated Resident #100 was severely cognitively impaired. Review of MDS dated [DATE], revealed, Resident #100 was an extensive assistance of one person with transfers with lower extremity impairment on one side .Moving from a seated to standing position .2. Not steady, only able to stabilize with staff assistance .Surface to surface transfer (transfer between bed and chair or wheelchair) 2. Not steady, only able to stabilize with staff assistance . Review of current Care Plan for Resident #100, initiated on 5/31/21, revealed the focus, .(Resident #100) is risk for falls r/t (related to) gait/balance problems secondary to CVA (cerebral vascular accident) and post-polio syndrome; Poor communication/comprehension secondary to dementia and mild cognitive impairment .Goal: (Resident #100) will not sustain serious injury through review date . with the intervention .(Resident #100) is at risk for falls .Follow facility fall protocol . Review of UDA Note dated 1/19/22 at 12:05 AM, revealed, MORSE Fall Risk Scale .(Resident #100) is at high risk for falling . Review of Progress Notes dated 2/5/22 at 2:55 PM, revealed, .Resident is noted to have decreased upper body strength. Is NOT able to hold herself up in a sitting position on the side of the bed. Also, noted to have more difficulty with transfers, and standing up with assist bar in shower room with care . Review of Nursing Referral Form dated 2/5/22, revealed, .Reason for Referral of decline observed: Decreased upper body strength with difficulty transferring .Seating/Positioning: poor postural control during daily activities .difficulty repositioning self .Self care: increased assistance with toileting hygiene .Mobility: decreased bed mobility . Review of Incident Report dated 3/18/22, revealed, .CNA reported that resident fully dressed and back in wheelchair that he had to lower her to the floor during the transfer from shower chair to WC (wheelchair) d/t (due to) lower extremity weakness. He did call for another CNA to assist the reposition once into wheelchair. Noted to have redness to right scapula (shoulder blade) d/t (due to) the slide on the shower chair. Will monitor every shift until resolved. CNA states resident did NOT hit her head in any manner .Just freshly out of shower and naked during attempted transfer. CNA educated to dry off top half and dress upper body. Then proceed to towel off lower legs and feet and dress as much as possible before attempting a transfer. Will call for assistance when needed . Review of Incident Report dated 3/18/22, revealed, .3/18/2022: Notes: While assessing back it was noted to have a 8cm red line on right scapula. Denies any pain. Will monitor every shift until resolved . Review of Progress Notes dated 3/19/2022 at 7:52 AM, revealed, .STAT XR 2 view to Right knee for pain and swelling post fall one time only for 1 Day Start Date: 3/19/2022 End Date: 3/20/2022 Ordered via (Xray company), #36675423, online at 0745, notified (Guardian) . Review of Progress Notes dated 3/19/2022 at 9:24 PM, revealed, .2000, RLE XR completed. continues to have pain , unable to straighten LE. +CMS. edema below knee. Pending result . Review of Progress Notes dated 3/19/2022 at 11:01 PM, revealed, .2245 XR resulted with likely RLe proximal tibia fracture. Recc for CT f/u to confirm. Notified on call provider, (First Name) NP ,request to send to ED for CT and pain control. Writer notified (Guardian) and she agrees to have (Resident #100) sent to (Local Hospital) for eval and tx. Writer notified on call admin (DON B) of transfer .Last pain medication provided at 6:30 PM per order. Ice and ace wrap were provided at that time and removed before transfer. Report given to EMS staff along with document for transfer. Out of building via stretcher with AMR at 2301 . Review of Emergency Documentation dated 3/19/22, revealed, .History of Present Illness: Patient is a pleasant [AGE] year-old female, history significant for polio, previous stroke, right sided hemiparesis, significant aphasia, here for evaluation of knee pain and swelling .Staff reports assisted fall to the ground .causing patient to strike her right knee on the ground. X-ray imaging was obtained yesterday, and result came back today, questioning possible right proximal tibial fracture .Patient brought to the emergency department for further evaluation. Staff reports no head injury .Musculoskeletal: No gross deformity. Soft tissue edema noted diffusely across anterior aspect of right knee with tenderness along proximal tibia . Review of Progress Notes dated 3/20/2022 at 5:17 AM, revealed, .Writer spoke with (First Name) RN at (Local Hospital) ED. (Resident #100) had a CT scan to RLE that resulted a Right displaced proximal tibia fracture . The ED DR consulted with in house DR and concluded that she would not be a surgical candidate RT risk outweighs benefits. She will be place in a knee immobilizer that will extend to the portion of tibia fracture. (Resident #100) will need a follow up with (Orthopedics office). Her transport back to (Facility) is scheduled for around 0800. No further report will be called from ED unless have further questions . Review of Progress Note dated 3/20/2022 at 9:27 AM, revealed, .At 0920, AMR arrived with resident on stretcher. Resident alert and sleepy. Assisted into bed x3 assist. Knee immobilizer to right knee. Toes are blanchable, foot cool with redness compared to left foot. VS obtained, tachycardia at 105. AMR did NOT have any discharge paperwork, stated report was called in earlier .Medications given as previously ordered . In an interview on 11/29/22 at 1:29 PM, Certified Nursing Assistant (CNA) K reported they went to the shower room to answer the shower room call light. When CNA K went into the shower room, Resident #100 was already placed in the wheelchair, and they helped to reposition Resident #100 in the wheelchair. CNA K reported Resident #100 did not demonstrate expressions of pain at that time. CNA K reported the next day (3/19/22) Resident #100's knee had swollen and did complain of pain to her knee. CNA K reported Resident #100 wasn't easy to transfer as she was losing her strength in her upper body and was having a hard time using the transfer pole next to her bed and you would need two people there to get her into/out of the bed. CNA K reported they would take the resident back to her room in the shower chair, get the resident in the bed, and dress the resident there. In an interview on 11/29/22 at 3:44 PM, CNA H reported they would leave the resident on the floor, use the call light or yell for help and wait for the nurse to come and assess the patient. CNA H reported the resident would never be picked up off the floor even if they were lowered them to the floor, as you never know they could be injured and this is standard practice. In an interview on 11/29/22 at 4:12 PM, CNA I reported they would leave the resident on the floor. CNA I stated, .As I don't know if they are hurt, and I don't want to hurt myself trying to get them back up .I would pull the cord in the shower room or yell for help to get someone to assist .have the nurse assess them in case they are hurt before getting them up from the floor . In an interview on 11/29/22 at 1:43 PM, Certified Nursing Assistant (CNA) C reported performed a shower with Resident #100 and when he went to transfer her from the shower chair to the resident's wheelchair she slipped. CNA C stated when he lifted her, Resident #100 .slipped out of my hands and I lowered her to the floor . CNA C reported her right leg went under her when she went down. CNA C reported Resident #100 was gesturing with her arms to for him to pick her up off the floor. CNA C reported he made sure she was okay, picked her up and transferred her in the wheelchair. CNA C demonstrated he assisted the resident from the shower chair to the wheelchair by reaching under her arms and lifting her up from the wheelchair without the use of a gait belt. CNA C reported when the resident was lifted up out of the wheelchair, the resident had went limp and she slipped out of his hands. CNA C reported he informed the nurse Resident #100 had been lowered to the floor and the resident did not hit her head. CNA C reported the nurse on duty came and assessed the resident. In an interview on 11/30/22 at 09:00 AM, Licensed Practical Nurse (LPN) G reported if staff lowered a resident to the floor, it is considered a fall at that point and the staff member would leave the resident on the floor until the nurse can come and complete a head to toe assessment. LPN G reported the nurse would start the fall protocol which would include ROM, pain, neuro, ask the resident questions about pain, where it hurts, and also perform interviews with staff to determine what happened, and complete an incident report. In an interview on 11/30/22 at 9:14 AM, CNA C reported they did not have a gait belt on the resident, and they should have had one on her. CNA C reported Resident #100 was a one person transfer but there were days the resident was a two person assist. In an interview on 11/30/22 at 1:05 PM, Director of Nursing (DON) B reported nursing would be able to increase the number of staff needed for assistance to transfer a resident or if the resident required the use of a hoyer. The nursing staff would request a screening be performed on the resident and if deemed necessary the therapy department would pick up the resident for therapy. DON B stated, .Therapy department would provide nursing a sheet with the current recommendations .For (Resident #100), the support of the transfer pole for transfers .She was post CVA (cerebral vascular accident) .A gait belt should have been used with a transfer .

Based on interview and record review, the facility failed to implement its policy for staff to resident abuse for 2 (Resident #13 and Resident #8) of 8 residents reviewed for abuse, from a total sample of 12 residents, resulting in an Immediate Jeopardy when a Certified Nurse Aide (CNA E) grabbed Resident #13's wrists across his body and forcefully pushed Resident #13 across the hall, and when Licensed Practical Nurse (LPN H) made derogatory and disparaging statements to Resident #8, placing Resident #13, Resident #8, and all other residents living in the facility at risk for serious psychosocial and physical harm, injury, and or death. Findings include: According to the State Operations Manual, Section 483.13 (c) (2) The facility must ensure that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law with established procedures (including the state survey and certification agency). Section 483.13 (c) (3) reads The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. Section 483.13 (c) (2) and (4) reads The facilities reporting requirements include reporting both alleged violations and the results of investigations to the State survey agency. Injuries of Unknown source- An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the incidence of injuries over time. Immediately means as soon as possible, but ought not exceed 24 hours after the discovery of the incident, in the absence of a shorter State time frame requirement. The phrase in accordance with State law modifies the word officials only. As such, State law may stipulate that alleged violations and the results of the investigations be reported to additional State officials beyond those specified in Federal regulations. This phrase does not modify what types of alleged violations must be reported or the time frames in which the reports are to be made. As such, States may not eliminate the obligation for any of the alleged violations (i.e., mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property) to be reported, nor can the State establish longer time frames for reporting than mandated in the regulations at 483.13(c)(2) and (4). No State can override the obligation of the nursing home to fulfill the requirements under 483.13(c), so long as the Medicare/Medicaid certification is in place. Resident #13 was a [AGE] year-old male who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 was severely cognitively impaired. Review of the facility Resident Incident Report, dated 8/5/2015 at 6:30 PM, revealed that an incident occurred in the C Hall near rooms [ROOM NUMBERS]. The report revealed Resident (#13) was forced against the was by (CNA). The report revealed Resident #13 was oriented to person only and walks unassisted. The documentation in the report indicated that the incident was reported by LPN D and that the perpetrator was CNA E. The facility investigation interview Form completed by LPN D and dated 8/5/2015 at 6:45 PM, was reviewed. the form revealed LPN D documented, CNA E was noted to have (Resident #13) by the wrists with arms crossed across chest pushing Resident #13 backward toward the opposite wall, upon running toward (Resident #13) this nurse grabbed a hold of CNA E's hands and stated you cannot grab him like that CNA E let go of hands. In a telephone interview on 9/4/2015, at 10:10 AM, LPN D reported on 8/5/2015 she was in C unit when she observed Resident #13 being walked backward by CNA E with CNA holding the wrists of the Resident across his body. LPN D reported the resident was backed into the opposite side of the hall wall. LPM D reported she immediately ran toward the Resident and had to physically remove the CNA's hands from Resident #13. I grabbed her wrists and said, let go. LPN D reported she escorted Resident #13 to a safe area and removed CNA E from C hall. The facility Investigation Interview Form, completed by LPN F dated 8/5/2015 at 6:30 PM, was reviewed. The for revealed LPN F documented, I observed CNA E to be holding Resident #13 arms like an X and pushed him to the other side of the hallway. The documentation revealed LPN F observed LPN D run toward Resident #13 and separated the Resident and CNA E. The report indicated LPN F contacted the Director of Nursing (DON) G. In a telephone interview on 9/3/2015 at approximately 4:00 PM, LPN F stated that she observed Resident #13 backing out of a room. LPN F reported when the resident cleared the door she noted CNA E was holding the Residents wrists and pushed him across the hall and stopped at the wall. LPN F was asked if Resident #13 was being forced across the hall. LPN F stated, very much so. In a telephone interview on 9/4/2015, DON G reported on 8/5/2015, she was notified of the incident involving Resident #13 and she immediately came to the facility and initiated and investigation. DON G reported she notified Nursing Home Administrator (NHA) A of the indicant. DON B reported the following day that the NHA A told her the incident was not reported to the State Agency because CNA E was defending herself. On 9/3/2015 at 4:15 PM. , CNA E reported she continues to work at the facility. Resident #8 is an [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the Resident was cognitively intact. During the Confidential Group Interview conducted on 9/2/2015 at 11:00 AM, Resident # 8, reported a recent encounter during which LPN H was accusatory and ridiculed her. Resident #8 reported she felt insulted. Resident #8 reported she complained in writing to the head nurse. During a follow up interview on 9/4/2015 at 8:40 AM Resident #8 again described the incident that took place on 7/22/2015 with LPN H. Resident #8 stated she (Resident #8) and LPN H were having a conversation when LPN H asked about how the residents doctor appointment went, Resident #8 replied, I don't know, I don't really remember, must not have been that important LPN H replied you must have dementia if you cant even remember what your doctor said, that's a first sign of dementia. Resident #8 replied I Don't have dementia LPN H laughed at her. This surveyor asked Resident #8 how that made her feel, Resident #8 stated I felt insulted, ridiculed, and upset mostly because LPNH' laughed at me. In a telephone interview on 9/4/2015 at 11:11 AM , DON G denied ever seeing a written complaint from Resident #8, but did admit to knowing of a concern. DON G denied following up with the Resident to ensure her well-being and to rule out abuse. DON G admitted she knew LPN H had a history of [REDACTED]. DON G stated that she did not interview other residents who could have been affected by LPN H. In an interview on 9/4/2015 at 11:50 AM, NHA A acknowledged that a written statement had been submitted by Resident #8 to DON G. NHA A reported she did not report an allegation of abuse to the state agency because Resident #8 indicated she felt safe at the time of the follow up and was ok with LPN H being educated on her bedside manner. The written statement from Resident #8 along with the resident concern form and education for LPNH were requested from DON B and NHA A and they both admitted they could not find it in the facility. On 9/4/15, at 2:29 PM, an interview was conducted with Licensed Practical Nurse F. LPN F reported on 8/5/15, at about 6:30 PM, she was in C hall and observed Certified Nurse Aide (CNA) E holding the hands of Resident #13 in an X across his front and pushed the Resident across the hall to the far wall. LPN F reported the push appeared, forceful. LPN F reported she did not hear CNA E call out or ask for assistance. LPN F reported LPN D intervened and CNA E was removed from the area. LPN F reported she contacted Director of Nursing (DON) G to inform of the incident. LPN F reported CNA E had a history of [REDACTED]. LPN F stated, If that happens in the open around people, what goes on behind closed doors?. LPN F reported she did not like that CNA E was allowed to return to work the following day. LPN F reported both she and LPN D spoke with DON G and DON B regarding the final outcome of the facility actions on the incident. LPN F reported they were told, it was being handled. CNA E and LPN H were not suspended and continue to work at the facility. Review of facility policy reveals: Policy Statement: This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property, by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Though it cannot guarantee that such occurrences will not occur, this facility will take preventative steps to reduce the potential for such occurrences. As defined in the facility policy Physical abuse: The infliction of physical pain or injury, includes but is not limited to slapping, pinching, hitting, kicking or shoving. It also includes controlling behavior through corporal punishment. Mental abuse: The inflicition of mental anguish, includes but is not limited to: humilation, intimidation, harassment, and threats of punishment of deprivation. Verbal abuse: Any use of oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance, regardless of their age, ability to comprehend or infirmities. Examples of verbal abuse include but are not limited to: saying or doing something with intent to frighten a resident or otherwise make him/her feel unsafe or insecure; gesturing a slit throat, passing a note that reads you talk to much! Be careful what you say about me. On 9/4/2015 at 4:00 PM The Administrator and Director of Nursing were informed of the Immediate Jeopardy that was identified on 9/3/15 and began on 7/23/2015 for Resident # 8 who was verbally abused by LPN H and for Resident #13 who was pushed by CNA E on 8/6/2015 placing them at risk for serious injury (physical or emotional), harm and or death. On 9/8/2015 The survey team confirmed the facility implemented the following to remove the Immediate Jeopardy: On 9/4/15 at approximately 12:00 p.m. the Administrator began two abuse investigations following the facility's abuse reporting and investigation policy including utilization of the Notification Checklist and Investigation File Checklist. 1. Resident #13 · LPN D immediately protected Resident #13 on 8/5/15 at approximately 6:30 p.m. by removing CNA E from the unit Resident #13 resides on. · DON G assessed Resident #13 on 8/5/15 at 6:45 p.m. no reported injuries or distress from the resident. · On 9/4/15, Resident #13 was reassessed by the (current) DON B at approximately 6:30 p.m. · On 9/4/15, CNA E was re-suspended from duty. · On 9/4/15, at approximately 7:30 p.m. the responsible party and the Medical Director were again notified of the abuse that occurred on 8/5/15. · On 9/4/15, The Administrator reported the allegation of physical abuse that occurred on 8/5/15 with Resident #13 to the State Agency, Adult Protective Services, Local Police and Ombudsmen were notified of the abuse for Resident #13. · On 9/4/14 A full investigation was initiated by the Administrator, Director of Nursing and Regional Director of Clinical Services for further review of the abuse that occurred on 8/5/15 involving Resident #13 and CNA E. · On 9/4/15, the Administrator was in-serviced by the Regional Director of Operations on the facility's policy for abuse reporting and investigation the Administrator then initiated all staff in-service. All staff currently working have been re-educated on the facility's policy and procedure for abuse investigation and reporting. No employee will be allowed to work until they have completed the in-service. · On 9/5/15, Human Resources Director started an audit and will audit 100% of employee files to ensure that background checks. 2. Resident #8 · On 7/22/15, Resident #8 turned in a written complaint alleging verbal abuse on 7/22/15 by LPN H. · On 9/4/15, the accused individual, LPN H was immediately suspended once the Administrator was made aware of the allegation. · On 9/4/15 at approximately 11:20 a.m. SSD J re-interviewed Resident #8. · The current Director of Nursing (DON) B assessed Resident #8 on 9/4/15 at approximately 7:09 p.m. and no suspicious areas indicating any type of abuse were noted and Resident #8 had no signs or symptoms of mental distress. · On 9/4/15, the Medical Director and Responsible party were notified of the allegation of verbal abuse. · The allegation of verbal abuse was reported to the State of Michigan on 9/4/15 at approximately 12:11 p.m. by the Administrator. The local police department was notified on 9/4/15 by the Director of Nursing with police officer arriving to the facility at 7:55 p.m. The Ombudsmen was notified 9/4/15 of the allegation of verbal abuse by the Administrator at 8:45 p.m. · Effective 9/4/15, all investigation files will be reviewed by the Regional Director of Clinical Services and/or Regional Director of Operations to ensure a complete and through investigations are completed per facility policy. · On 9/4/15, The facility implemented an in-serviced manager or RN to be present at facility around the clock to round and make sure any unusual events are immediately investigated and the residents are protected. This will occur until all staff are educated on the abuse policy and procedure process. · On 9/4/15, the Administrator was in-serviced by the Regional Director of Operations on the facility's policy for abuse reporting and investigation the Administrator then initiated all staff in-service. All staff currently working have been re-educated on the facility's policy and procedure for abuse investigation and reporting. No employee will be allowed to work until they have completed the in-service. · On 9/4/15 the facility had 79 employees and as of 9/4/15 at 11:00 p.m. the facility had in-serviced 45 out of 88 employees. On 9/5/15 at 10:30 a.m. the facility had in-serviced 63 out of 88 employees. On 9/5/15 at 4:00 p.m. 68 out of 88 employees had completed the inservice. Resident 13 and Resident 8 were offered psychological services as a result of the alleged events. This action will ensure residents reporting alleged abuse are treated for [REDACTED]. Resident interviews were conducted for all cognitive residents. This action helps us to identify any additional abuse that has not been reported. The Social Services Director conducted resident interviews starting on 9/4/15 and completed the interviews on 9/4/15 at approximately 4:30 p.m. No residents interviewed alleged any new, unreported abuse. A Resident Council Meeting was held on 9/4/15 from 6:45 p.m. - 7:30 p.m. This council meeting educated our residents on abuse, neglect, and resident rights. This education will help ensure resident safety by ensuring residents understand the process of how to report abuse, neglect and concerns along with giving them options of who to report these concerns to. Resident Council President was educated and verbalized understanding of facility's process. Although the Immediate Jeopardy (IJ) was removed on 9/4/2015, the facility remained out of compliance at a scope of Pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy Due to all staff had not been inserviced on the abuse policy and sustained compliance has not been verified by the state agency. ( )

Based on interview and record review, the facility failed to prevent staff to resident abuse for 2 (Resident #13 and Resident #8) of 8 residents reviewed for abuse, from a total sample of 12 residents, resulting in an Immediate Jeopardy when a Certified Nurse Aide (CNA E) grabbed Resident #13's wrists across his body and forcefully pushed Resident #13 across the hall, and when Licensed Practical Nurse (LPN H) made derogatory and disparaging statements to Resident #8, placing Resident #13 and Resident #8 at risk for serious psychosocial and physical harm, injury, and or death. Findings include: Resident #13 was a [AGE] year-old male, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], revealed Resident #13 was severely cognitively impaired. Review of the facility Resident Incident Report, dated 8/5/2015 at 6:30 PM, revealed that an incident occurred in the C Hall near rooms [ROOM NUMBERS]. The report revealed Resident (#13) was forced against the wall by (CNA). The report revealed Resident #13 was oriented to person only and walks unassisted. The documentation in the report indicated that the incident was reported by LPN D and that the perpetrator was CNA E. The facility Investigation Interview Form completed by LPN D and dated 8/5/2015 at 6:45 PM, was reviewed. the form revealed LPN D documented, CNA E was noted to have (Resident #13) by the wrists with arms crossed across chest pushing Resident #13 backward toward the opposite wall, upon running toward (Resident #13) this nurse grabbed a hold of CNA E's hands and stated you cannot grab him like that CNA E let go of hands. In a telephone interview on 9/4/2015, at 10:10 AM, LPN D reported on 8/5/2015 she was in C unit when she observed Resident #13 being walked backward by CNA E with CNA holding the wrists of the Resident across his body. LPN D reported the resident was backed into the opposite side of the hall wall. LPN D reported she immediately ran toward the Resident and had to physically remove the CNA's hands from Resident #13. I grabbed her wrists and said, let go. LPN D reported she escorted Resident #13 to a safe area and removed CNA E from C hall. The facility Investigation Interview Form, completed by LPN F dated 8/5/2015 at 6:30 PM, was reviewed. The form revealed LPN F documented, I observed CNA E to be holding Resident #13's arms like an X and pushed him to the other side of the hallway. The documentation revealed LPN F observed LPN D run toward Resident #13 and separate the Resident and CNA E. The report indicated LPN F contacted the Director of Nursing (DON) G. In a telephone interview on 9/3/2015 at approximately 4:00 PM, LPN F stated that she observed Resident #13 backing out of a room. LPN F reported when the resident cleared the door she noted CNA E was holding the Resident's wrists and pushed him across the hall and stopped at the wall. LPN F was asked if Resident #13 was being forced across the hall. LPN F stated, very much so. In a telephone interview on 9/4/2015, DON G reported on 8/5/2015, she was notified of the incident involving Resident #13 and she immediately came to the facility and initiated and investigation. DON G reported she notified Nursing Home Administrator (NHA) A of the incident. DON G reported the following day that the NHA A told her the incident was not reported to the State Agency because CNA E was defending herself. On 9/3/2015 at 4:15 PM. , CNA E reported she continues to work at the facility. Resident #8 is an [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the Resident was cognitively intact. During the Confidential Group Interview conducted on 9/2/2015 at 11:00 AM, Resident # 8, reported a recent encounter during which LPN H was accusatory and ridiculed her. Resident #8 reported she felt insulted. Resident #8 reported she complained in writing to the head nurse. During a follow up interview on 9/4/2015 at 8:40 AM Resident #8 again described the incident that took place on 7/22/2015 with LPN H. Resident #8 stated she (Resident #8) and LPN H were having a conversation when LPN H asked about how the residents doctor appointment went, Resident #8 replied, I don't know, I don't really remember, must not have been that important LPN H replied you must have dementia if you cant even remember what your doctor said, that's a first sign of dementia. Resident #8 replied I Don't have dementia LPN H laughed at her. This surveyor asked Resident #8 how that made her feel, Resident #8 stated I felt insulted, ridiculed, and upset mostly because LPN 'H' laughed at me. In a telephone interview on 9/4/2015 at 11:11 AM, DON G denied ever seeing a written complaint from Resident #8, but did admit to knowing of a concern. DON G denied following up with the Resident to ensure her well-being and to rule out abuse. DON G admitted she knew LPN H had a history of [REDACTED]. DON G stated that she did not interview other residents who could have been affected by LPN H. In an interview on 9/4/2015 at 11:50 AM, NHA A acknowledged that a written statement had been submitted by Resident #8 to DON G. NHA A reported she did not report an allegation of abuse to the state agency because Resident #8 indicated she felt safe at the time of the follow up and was ok with LPN H being educated on her bedside manner. The written statement from Resident #8 along with the resident concern form and education for LPN H were requested from DON B and NHA A and they both admitted they could not find it in the facility. On 9/4/15, at 2:29 PM, an interview was conducted with Licensed Practical Nurse F. LPN F reported on 8/5/15, at about 6:30 PM, she was in C hall and observed Certified Nurse Aide (CNA) E holding the hands of Resident #13 in an X across his front and pushed the Resident across the hall to the far wall. LPN F reported the push appeared, forceful. LPN F reported she did not hear CNA E call out or ask for assistance. LPN F reported LPN D intervened and CNA E was removed from the area. LPN F reported she contacted Director of Nursing (DON) G to inform of the incident. LPN F reported CNA E had a history of [REDACTED]. LPN F stated, If that happens in the open around people, what goes on behind closed doors?. LPN F reported she did not like that CNA E was allowed to return to work the following day. LPN F reported both she and LPN D spoke with DON G and DON B regarding the final outcome of the facility actions on the incident. LPN F reported they were told, it was being handled. CNA E and LPN H were not suspended and continue to work at the facility. Review of facility policy reveals: Policy Statement: This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property, by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Though it cannot guarantee that such occurrences will not occur, this facility will take preventative steps to reduce the potential for such occurrences. As defined in the facility policy Physical abuse: The infliction of physical pain or injury, includes but is not limited to slapping, pinching, hitting, kicking or shoving. It also includes controlling behavior through corporal punishment. Mental abuse: The infliction of mental anguish, includes but is not limited to: humiliation, intimidation's, harassment, and threats of punishment of deprivation. Verbal abuse: Any use of oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance, regardless of their age, ability to comprehend or infirmities. Examples of verbal abuse include but are not limited to: saying or doing something with intent to frighten a resident or otherwise make him/her feel unsafe or insecure; gesturing a slit throat, passing a note that reads you talk to much! Be careful what you say about me. Further review of the policy for Reporting/Investigation/Response: Indicated: Any complaint of, allegation of, observation of or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented immediately. On 9/4/2015 at 4:00 PM, the Administrator and Director of Nursing were informed of the Immediate Jeopardy that was identified on 7/3/15 and began on 7/23/2015 for Resident #8 who was verbally abused by LPN H and for Resident #13 who was pushed by CNA E on 8/6/2015 placing them at risk for serious injury (physical or emotional), harm and or death. On 9/8/2015 The survey team confirmed the facility implemented the following to remove the Immediate Jeopardy: Resident #13 · LPN D immediately protected Resident #13 on 8/5/15 at approximately 6:30 p.m. by removing CENA E from the situation. · DON G assessed Resident #13 on 8/5/15 at 6:45 p.m. · On 9/4/15, Resident #13 was reassessed by the DON. · On 9/4/15, CENA E was suspended from duty. · On 9/4/15, the responsible party and the Medical Director were notified of the abuse. · On 9/4/15, The Administrator reported the allegation of physical abuse that occurred on 8/5/15 with Resident #13 to the State Agency. · On 9/4/15 the local police and Ombudsmen were notified of the abuse for Resident #13. Resident #8 · On 7/22/15, Resident #8 turned in a written complaint alleging verbal abuse on 7/22/15 by LPN H. · Social Services Director (SSD) J and DON B spoke to the resident following turning the written complaint in to DON G on 7/23/15. · On 9/4/15 at approximately 11:20 a.m. SSD J re-interviewed Resident #8. · The current Director of Nursing (DON) B assessed Resident #8 on 9/4/15 at approximately 7:09 p.m. and no suspicious areas indicating any type of abuse were noted and Resident #8 had no signs or symptoms of mental distress. · On 9/4/15, the accused individual, LPN H was immediately suspended once the Administrator was made aware of the allegation. · On 9/4/15, the Medical Director and Responsible party were notified of the allegation of verbal abuse. · The allegation of verbal abuse was reported to the State of Michigan on 9/4/15 at approximately 12:11 p.m. by the Administrator. · On 9/4/15, the Administrator was in-serviced by the Regional Director of Operations on the facility's policy for abuse reporting and investigation. · Effective 9/4/15, all investigation files will be reviewed by the Regional Director of Clinical Services and/or Regional Director of Operations to ensure a complete and through investigations are completed per facility policy. · On 9/4/15 at approximately 12:00 p.m. the Administrator began two abuse investigations following the facility's abuse reporting and investigation policy including utilization of the Notification Checklist and Investigation File Checklist. · On 9/4/15 at approximately 5:30 p.m. the Administrator initiated all staff in-service regarding facility's policy on abuse prevention and reporting. All staff currently working has been reeducated on the facility's policy and procedure for abuse investigation and reporting. No employee will be allowed to work until they have completed the in-service. All new staff will be trained by the Administrator and/or Director of Nursing on the day of hire and prior to working the floor on the facility's policy for abuse reporting and investigation. On 9/4/15 the facility had in-serviced 45 out of 88 employees. On 9/5/15 at 10:30 a.m. the facility had in-serviced 63 out of 88 employees. On 9/5/15 at 4:00 p.m. 68 out 88 employees had been in-serviced. The remaining 20 employees will be sent in-service material via certified mail with signature required and will be inserviced prior to them working the floor. · On 9/4/15, Resident interviews were conducted by the Social Services Director for all cognitive residents. This action helped the facility to identify any additional resident concerns that has not been reported. No residents interviewed alleged any new, unreported abuse. · On 9/4/15, the MDS Coordinator C and Assisted Living (AL) RN conducted skin assessments on all non-cognitive residents on 9/4/15. Shower sheets were used to document results of the skin assessments. Any areas of unknown origin related to bruising or other skin conditions will be fully investigated per our Incident Report Policy. No resident assessments resulted in signs of obvious physical abuse. · Resident #13 and Resident #8 were offered psychological services as a result of the alleged events. Both Resident #13 and Resident #8 will be seen by Behavioral Care Solutions at the next schedule visit. · On 9/4/15, The facility implemented an in-serviced manager or RN to be present at facility around the clock to round and make sure any unusual events are immediately investigated and the residents are protected. This will occur until all staff are educated on the abuse policy and procedure process. · On 9/4/15, Responsible parties of residents will be notified of the definition of abuse and neglect, will be notified how to report abuse/neglect/concern. · On 9/4/15, A Resident Council Meeting was held to educate residents on abuse, neglect, and resident rights. This education will help ensure resident safety by ensuring residents understand the process of how to report abuse, neglect and concerns along with giving them options of who to report these concerns to. Resident Council President was educated and verbalized understanding of facility's process. · On 9/4/15, the SSD or Designee will meet one to one with all other residents who did not attend the Resident Council Meeting on 9/4/15 to ensure education was provided on abuse, neglect, and resident rights. · On 9/4/15, the Administrator initiated all staff in-service regarding facility's policy on abuse prevention and reporting. All staff currently working have been re-educated on the facility's policy and procedure for abuse investigation and reporting. No employee will be allowed to work until they have completed the in-service. Although the Immediate Jeopardy (IJ) was removed on 9/4/2015, the facility remained out of compliance at a scope of Pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy Due to all staff had not been inserviced on the abuse policy and sustained compliance has not been verified by the state agency. ( )

Based on interview and record review, the facility failed to identify, immediately report , and thoroughly investigate staff to resident abuse for 2 (Resident #13 and Resident #8) of 8 residents reviewed for abuse, from a total sample of 12 residents, resulting in an Immediate Jeopardy when a Certified Nurse Aide (CNA E) grabbed Resident #13's wrists across his body and forcefully pushed Resident #13 across the hall, and when Licensed Practical Nurse (LPN H) made derogatory and disparaging statements to Resident #8, placing Resident #13, Resident #8, and all residents living at the facility at risk for serious psychosocial and physical harm, injury, and or death as a result of continued violations involving mistreatment, neglect, or abuse to go undetected due to not being thoroughly investigated or reported. Findings include: Resident #13 was a [AGE] year-old male, who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 was severely cognitively impaired. Review of the facility Resident Incident Report, dated 8/5/2015 at 6:30 PM, revealed that an incident occurred in the C Hall near rooms [ROOM NUMBERS]. The report revealed Resident (#13) was forced against the wall by CNA E. The report revealed Resident #13 was oriented to person only and walks unassisted. The documentation in the report indicated that the incident was reported by LPN D . The facility investigation interview form completed by LPN D and dated 8/5/2015 at 6:45 PM, was reviewed. The form revealed LPN D documented CNA E was noted to have (Resident #13) by the wrists with arms crossed across his chest pushing Resident #13 backward toward the opposite wall, upon running toward (Resident #13) this nurse grabbed a hold of CNA E's hands and stated you cannot grab him like that CNA E let go of hands. In a telephone interview on 9/4/2015, at 10:10 AM, LPN D reported on 8/5/2015 she was in C unit when she observed Resident #13 being walked backward by CNA E with CNA holding the wrists of the Resident across his body. LPN D reported the resident was backed into the opposite side of the hall wall. LPN D reported she immediately ran toward the Resident and had to physically remove the CNA's hands from Resident #13. I grabbed her wrists and said, let go. LPN D reported she escorted Resident #13 to a safe area and removed CNA E from C hall. The facility Investigation Interview Form, completed by LPN F dated 8/5/2015 at 6:30 PM, was reviewed. The form revealed LPN F documented, I observed CNA E to be holding Resident #13 arms like an X and pushed him to the other side of the hallway. The documentation revealed LPN F observed LPN D run toward Resident #13 and separate the Resident and CNA E. The report indicated LPN F contacted the Director of Nursing (DON) G. In a telephone interview on 9/3/2015 at approximately 4:00 PM, LPN F stated that she observed Resident #13 backing out of a room. LPN F reported when the resident cleared the door she noted CNA E was holding the resident's wrists and pushed him across the hall and stopped at the wall. LPN F was asked if Resident #13 was being forced across the hall. LPN F stated, very much so. In a telephone interview on 9/4/2015, DON G reported on 8/5/2015, she was notified of the incident involving Resident #13 and she immediately came to the facility and initiated an investigation. DON G reported she notified Nursing Home Administrator (NHA) A of the incident. DON G reported the following day that the NHA A told her the incident was not reported to the State Agency because CNA E was defending herself. On 9/3/2015 at 4:15 PM. CNA E reported she continues to work at the facility. Resident #8 is an [AGE] year-old female who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the Resident was cognitively intact. During the Confidential Group Interview conducted on 9/2/2015 at 11:00 AM, Resident # 8, reported a recent encounter during which LPN H was accusatory and ridiculed her. Resident #8 reported she felt insulted. Resident #8 reported she complained in writing to the head nurse. During a follow up interview on 9/4/2015 at 8:40 AM, Resident #8 again described the incident that took place on 7/22/2015 with LPN H. Resident #8 stated she (Resident #8) and LPN H were having a conversation when LPN H asked about how the residents doctor appointment went, Resident #8 replied, I don't know, I don't really remember, must not have been that important LPN H replied you must have dementia if you cant even remember what your doctor said, that's a first sign of dementia. Resident #8 replied I Don't have dementia LPN H laughed at her. This surveyor asked Resident #8 how that made her feel, Resident #8 stated I felt insulted, ridiculed, and upset mostly because LPN 'H' laughed at me. In a telephone interview on 9/4/2015 at 11:11 AM , DON G denied ever seeing a written complaint from Resident #8, but did admit to knowing of a concern. DON G denied following up with the Resident to ensure her well-being and to rule out abuse. DON G admitted she knew LPN H had a history of [REDACTED]. DON G stated that she did not interview other residents who could have been affected by LPN H. In an interview on 9/4/2015 at 11:50 AM, NHA A acknowledged that a written statement had been submitted by Resident #8 to DON G. NHA A reported she did not report an allegation of abuse to the state agency because Resident #8 indicated she felt safe at the time of the follow up and was ok with LPN H being educated on her bedside manner. The written statement from Resident #8 along with the resident concern form and education for LPN H were requested from DON B and NHA A and they both admitted they could not find it in the facility. On 9/4/15, at 2:29 PM, an interview was conducted with Licensed Practical Nurse F. LPN F reported on 8/5/15, at about 6:30 PM, she was in C hall and observed Certified Nurse Aide (CNA) E holding the hands of Resident #13 in an X across his chest and pushed the Resident across the hall to the far wall. LPN F reported the push appeared, forceful. LPN F reported she did not hear CNA E call out or ask for assistance. LPN F reported LPN D intervened and CNA E was removed from the area. LPN F reported she contacted Director of Nursing (DON) G to inform of the incident. LPN F reported CNA E had a history of [REDACTED]. LPN F stated, If that happens in the open around people, what goes on behind closed doors?. LPN F reported she did not like that CNA E was allowed to return to work the following day. LPN F reported both she and LPN D spoke with DON G and DON B regarding the final outcome of the facility actions on the incident. LPN F reported they were told, it was being handled. CNA E and LPN H were not suspended and continue to work at the facility. Review of facility policy reveals: Policy Statement: This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property, by any facility staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Though it cannot guarantee that such occurrences will not occur, this facility will take preventative steps to reduce the potential for such occurrences. As defined in the facility policy Physical abuse: The infliction of physical pain or injury, includes but is not limited to slapping, pinching, hitting, kicking or shoving. It also includes controlling behavior through corporal punishment. Mental abuse: The infliction of mental anguish, includes but is not limited to: humiliation, intimidation, harassment, and threats of punishment of deprivation. Verbal abuse: Any use of oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance, regardless of their age, ability to comprehend or infirmities. Examples of verbal abuse include but are not limited to: saying or doing something with intent to frighten a resident or otherwise make him/her feel unsafe or insecure; gesturing a slit throat, passing a note that reads you talk to much! Be careful what you say about me. On 9/4/2015 at 4:00 PM The Administrator and Director of Nursing were informed of the Immediate Jeopardy that was identified on 9/3/15 and began on 7/23/2015 for Resident # 8 who was verbally abused by LPN H and for Resident #13 who was pushed by CNA E on 8/6/2015 placing them at risk for serious injury (physical or emotional), harm and or death. On 9/8/2015 The survey team confirmed the facility implemented the following to remove the Immediate Jeopardy: On 9/4/15 at approximately 12:00 p.m. the Administrator began two abuse investigations following the facility's abuse reporting and investigation policy including utilization of the Notification Checklist and Investigation File Checklist. 1. Resident #13 · LPN D immediately protected Resident #13 on 8/5/15 at approximately 6:30 p.m. by removing CNA E from the unit Resident #13 resides on. · DON G assessed Resident #13 on 8/5/15 at 6:45 p.m. no reported injuries or distress from the resident. · On 9/4/15, Resident #13 was reassessed by the (current) DON B at approximately 6:30 p.m. · On 9/4/15, CNA E was re-suspended from duty pending the investigation. · On 9/4/15, at approximately 7:30 p.m. the responsible party and the Medical Director were again notified of the abuse that occurred on 8/5/15. · On 9/4/15, The Administrator reported the allegation of physical abuse that occurred on 8/5/15 with Resident #13 to the State Agency, Adult Protective Services, Local Police and Ombudsmen were notified of the abuse for Resident #13. · On 9/4/14 A full investigation was initiated by the Administrator, Director of Nursing and Regional Director of Clinical Services for further review of the abuse that occurred on 8/5/15 involving Resident #13 and CNA E. · On 9/4/15, the Administrator was in-serviced by the Regional Director of Operations on the facility's policy for abuse reporting and investigation the Administrator then initiated all staff in-service. All staff currently working have been re-educated on the facility's policy and procedure for abuse investigation and reporting. No employee will be allowed to work until they have completed the in-service. 2. Resident #8 · On 7/22/15, Resident #8 turned in a written complaint alleging verbal abuse on 7/22/15 by LPN H. · On 9/4/15, the accused individual, LPN H was immediately suspended once the Administrator was made aware of the allegation. · On 9/4/15 at approximately 11:20 a.m. SSD J re-interviewed Resident #8. · The current Director of Nursing (DON) B assessed Resident #8 on 9/4/15 at approximately 7:09 p.m. and no suspicious areas indicating any type of abuse were noted and Resident #8 had no signs or symptoms of mental distress. · On 9/4/15, the Medical Director and Responsible party were notified of the allegation of verbal abuse. · The allegation of verbal abuse was reported to the State of Michigan on 9/4/15 at approximately 12:11 p.m. by the Administrator. The local police department was notified on 9/4/15 by the Director of Nursing with police officer arriving to the facility at 7:55 p.m. The Ombudsmen was notified 9/4/15 of the allegation of verbal abuse by the Administrator at 8:45 p.m. · Effective 9/4/15, all investigation files will be reviewed by the Regional Director of Clinical Services and/or Regional Director of Operations to ensure a complete and through investigations are completed per facility policy. · On 9/4/15, The facility implemented an in-serviced manager or RN to be present at facility around the clock to round and make sure any unusual events are immediately investigated and the residents are protected. This will occur until all staff are educated on the abuse policy and procedure process. · On 9/4/15, the Administrator was in-serviced by the Regional Director of Operations on the facility's policy for abuse reporting and investigation the Administrator then initiated all staff in-service. All staff currently working have been re-educated on the facility's policy and procedure for abuse investigation and reporting. No employee will be allowed to work until they have completed the in-service. A Resident Council Meeting was held on 9/4/15 from 6:45 p.m. - 7:30 p.m. This council meeting educated our residents on abuse, neglect, and resident rights. This education will help ensure resident safety by ensuring residents understand the process of how to report abuse, neglect and concerns along with giving them options of who to report these concerns to. Resident Council President was educated and verbalized understanding of facility's process. On 9/5/15, Human Resources Director started an audit and will audit 100% of employee files to ensure that background checks. Responsible parties of residents will be notified of the definition of abuse and neglect, will benotified how to report abuse/neglect/concern, and will be provided with phone numbers to the facilities Compliance Hotline phone number, Ombudsman phone number, and State Complaint Hotline phone number via letter. Although the Immediate Jeopardy (IJ) was removed on 9/4/2015, the facility remained out of compliance at a scope of Pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy Due to all staff had not been inserviced on the abuse policy and sustained compliance has not been verified by the state agency. ( )

Based on observation, interview, and record review, the facility failed to prevent the development of a heel pressure ulcer for 1 of 2 (#2) sampled residents reviewed with wounds from a total sample of 12 residents resulting in increased pain and the potential for wound infection [MEDICAL CONDITION]. Findings include: According to the admission face sheet (not dated) and the Medication Administration Record [REDACTED]. Review of the admission minimum data assessment (MDS, resident assessment form) dated 3/20/2014 for Resident #2, she was coded 3 out of 15 on the brief interview for mental status section, which indicated severe cognitive impairment (reasoning and decision making abilities). Review of the 6/19/2014 MDS indicated Resident #2 scored a 6 out of 15 in the same area which continued to indicate severe cognitive impaired. Review of the 3/20/2014 MDS for Resident #2 revealed she required the total assist of two staff members for bed mobility and transfers. She also was not able to walk, required total assistance of two staff members for locomotion, dressing, and toilet use. Review of the 6/19/2014 MDS revealed she required extensive assistance of one staff members for bed mobility and two staff members for transfers. She also was not able to walk, required extensive assistance of one staff member for locomotion, dressing, and toilet use. Also, according to the 3/20/2014 MDS, Resident #2 was identified as not having any pressure ulcers or wounds on admission but was identified as "being at risk" of developing pressure ulcers. According to the same MDS, a "pressure reducing device for bed" was put into place. A physician's orders [REDACTED]." Review of the nursing care plan for Resident #2 created on 3/15/2014 (admission) revealed the identified problem, "I am at risk for impaired skin r/t (related to) impaired mobility, contracture of my left hand and incontinence of bowel and bladder. I have a history of poor nutritional intake, and non-compliance with positioning. I am able to alert staff after I have been incontinent. I have the following Diagnoses: [REDACTED]. I am dependent on staff for transfers and mobility..." The nursing goal for this problem was "I will not experience any skin conditions from incontinence or preventable pressure through next review." The next review was dated 10/17/2014. The only preventative intervention identified on 3/15/2014 was to "turn and reposition me (every) two hours as I allow. The care plan failed to include any devices for pressure relief such as the air mattress or any device to elevate the heels of the mattress. Review of a physician's orders [REDACTED]. Skin intact." On that same date, (6/12/2014), a "Pressure Sore Risk Assessment" was completed. The directions at the bottom indicated that Resident #2 remained at risk and to proceed to the "Pressure Ulcer Prevention Checklist" form and implement care plan for treatment or prevention. The clinical record failed to review the prevention checklist. During an interview with Director of Nursing (DON), "B" on 8/13/2014, she stated the "nurse's didn't realize they had this checklist to follow." DON "B" delivered a blank "Pressure Ulcer Prevention Checklist (not dated) to the survey team. The form contained preventative Measures such as: Preventative mattress Preventative seat cushion Pressure point protectors Heels elevated off bed Turn and reposition Head of bed elevated less than 30 degrees Prevent skin to skin contact with the use of pillows and padding Left and turn with bed sheet Schedule time out of bed as appropriate Application of skin products Nutritional Assessment Lab Assessment According to a list of pressure ulcers in the facility presented to the survey team on 8/12/2014, Resident #2 developed a left heel pressure ulcer (blister) while a resident of the facility on 7/18/2014. "Wound Healing Progress Report" for Resident #2 identified a "3.00 X 4.00 X 0.00 (unstageable due to slough/eschar)" pressure ulcer of the left heal on 7/18/2014. The most recent measurements for the wound were taken on 8/18/2014 and were recorded as "2.50 X 2.80 X 0.00" and were "unstageable due to slough/eschar." The wound was measured every week. According to the "Weekly Skin Integrity Review" sheet for Resident #2, blisters on the right heel were identified on 8/6/2014. According to the same form, on 7/17/2014, (the day the heel blisters were first identified for resident #2), the "Weekly Skin Integrity Review" form had the area, "skin intact" checked but also had the box checked for "open area" with a notation for an error on the entry. The entry was not signed or dated on the bottom and did not indicated in writing where the open area was and did not indicate on the human diagram where the open area was. A review of the "risk of impaired skin" care plan for Resident #2 dated 3/15/2014 indicated several new interventions added on 7/17/2014 (the day the heel ulcer was identified) including: Position me with pillows and/or positioning divisive as I will allow to pad boney prominences..... Elevate and bridge my heels up while in bed and in Geri-chair as I allow Blue plush boots as I allow, and use a heels up in my bed as I allow. Check blister left heel every shift Skin Prep to bilateral heels every shift Observation of the wound took place on 8/13/2014 with Assistant Director of Nursing (ADON) "C" on 8/13/2014 in the residents room. ADON "C" verified ahead of time that the wound would not need a dressing change because it was not open and it would be able to be visualized any time as she was lying in bed. ADON attempted to take the stocking off and it was stuck to the wound. The wound was open and measurements were taken. The wound measured 2.0 X 3.0, had foul odor and and pinpoint bleeding in the wound bed. The wound was a stage two at that time. A small amount of yellow drainage was noted inside the stocking. ADON "C" stated that she did not know the wound was open and no dressing was noted covering the wound. Resident #2 was heard yelling "it hurts, it hurts" over and over again. This survey asked Resident #2 what hurts and she stated, "my heel". An interview with Administrator "A" and DON "B" took place at 9:00 am on 8/14/2014 in the conference room. When asked why Resident #2 developed a heel pressure sore, DON "B" stated that Resident #2 "is noncompliant and she wants to lay in bed all the time." Administrator "A" presented a time line of development of the wound. A review of all nursing notes from admission (March 2014 through August 2014) reviewed that even though the nurses documented that Resident #2 was noncompliant with wearing a hand brace for a contracture, no documentation in the clinical record revealed Resident #2 to be noncompliant with any interventions concerning prevention a heel pressure sore. An interview with the facility physician, DO "H" took place at 9:30 am on 8/14/2014 in the conference room. When asked why the pressure relieving mattress (air mattress) was discontinued on 6/12/2014, DO "H" stated that the resident had a change of status. DO "H" stated that her (Resident #2) protein levels had returned to a normal range and she was not having any skin issues. ( )

Complaint Intake Numbers: MI 033, MI 343 & MI 368 Based on observation, interview, and record review the Facility failed to prevent resident-to-resident abuse for 1 of 5 residents in the sample (#103) resulting in actual harm bruises to her head, arm and hand, and a hematoma to her head. Findings include: 3/22/12 Per the Incident Report dated 3/22/12 Resident #104 "shoved" Resident #103 "out of his doorway causing her to first land on buttocks then fall back and hit head." In the Nurses' Notes dated 3/23/12 referring to 3/22/12, "At 6:40 p.m. Resident (#103) was in doorway of room (Resident #104's room number). That resident became angry and was yelling at (Resident #103). He then shoved her backwards causing her to first land on her buttocks then on her back bumping the back of her head...Small bump noted to back of head where she bumped the floor. Area red, no bruising. Not open....Resident (#103) did start to complain of pain in her left wrist but able to move it without difficulty." In a telephone interview on 4/15/12 at 2:05 p.m. Nurse Aide #27 said on 3/22/12 he was "down the hallway by the dining room" (at the north end of the corridor on the locked dementia unit) and "half the residents were up wandering in the hall or in the dining room. I heard yelling from (Resident #104)'s room (near the south end of the hall). I looked in that direction. (Resident #103) came flying out. She fell out. (Resident #103) wandered into (Resident #104)'s room and he shoved her out." In a telephone interview on 4/15/12 at 7:06 p.m. LPN #33 said on 3/22/12, "I could hear (Resident #104) yelling. I was running down the hall. I saw (Resident #103) coming backwards (through Resident #104's bedroom doorway). They were both in the doorway. She fell backwards onto her butt and then hit her head. You could see his hands. He pushed her." In an observation on 4/5/12 at 2:08 p.m. Resident #103 was seated in a chair in her room. A yellowing bruise was visible on the back of her head. 3/24/12 Per the Incident Report dated 3/24/12 Resident #103 was "walking down the hallway when another resident approached her and grabbed her arm and pulled on it. Resident startled pulled back and lost her balance and fell to the ground on her left elbow...x-ray of left elbow...no acute fracture or dislocation." Per the x-ray report dated 3/24/12 no acute fracture or dislocation was noted to Resident #103's left elbow. Per the Nurses' Notes dated 3/25/12 referring to 3/24/12 at 8:40 p.m. Resident #103 was walking in the hall when another resident "grabbed her arm and pulled on it, (Resident #103) started pulled back losing her balance and fell to the floor on her left elbow..." In a telephone interview on 4/15/12 at 11:00 a.m. Nurse Aide #26 said on 3/24/12, "I was standing at the other end of the hall. I saw it happen. (Resident #103) walked out of her room. Nothing was said (between the 2 residents). (Resident #105) grabbed (Resident #103)'s arm, spun her around and knocked her to the floor. (Resident #105) kept walking. (Resident #103 fell on to her right side. She tried to get up. She said something hurt. I told her not to get up (and called for help). She said her arm hurt. They had x-rays done. (Resident #105) is always hitting, pulling hair, pinching staff and residents. She's done it to me." In a telephone interview on 4/15/12 at 2:29 p.m. LPN #30 said on 3/24/12 he was at the nurses' station when he heard Nurse Aide #26 call for help. LPN #30 said Nurse Aide #26 told him she saw Resident #105 grab Resident #103's arm whereupon Resident #103 "pulled back and fell down." In an observation on 4/05/12 at 4:05 p.m. Resident #103 was seated in a chair in her room on the locked dementia unit. Her left elbow was discolored purple black and appeared fluid filled and a large purple bruise extended below her left elbow. 4/04/12 1:10 p.m. Per the Incident Report dated 4/04/12 at 1:10 p.m. Resident #104 was observed to "swat" Resident #103's arm with a soft shell helmet. Per the written statement signed by Activity Aide #20, "On 4/4/12...I witnessed (Resident #103) walking (in the corridor of the locked dementia unit) and (Resident #104) come up next to her and say, 'Stay out of there!' At the same time he had a helmet in his hand and swung the helmet around at (Resident #103) connecting with her left arm. (Resident #103) grabbed her arm and stepped to the side. As soon as I saw this I ran down the hall and yelled for (Resident #104). I was too far away to get to them before he swung the helmet." In an interview on 4/15/12 at 2:50 p.m. Activity Aide #20 said on 4/04/12 she saw Resident #103 at the south end of the hall on the locked dementia unit facing Activity Aide #20 who was at the north end of the same hall. Resident #104 "came out of his room behind her. He already had the helmet. He walked behind her and to her left. He said, "She shouldn't have thrown it in here.' He swung his arm around and connected the helmet to her left arm. I said, "'(name of Resident #104)' and he threw the helmet to the floor. (Resident #103) grabbed her arm. I asked her if she was 'OK' and she said, 'Yeah.' I told the Charge Nurse and got staff" to stay with Resident #104. In an observation on 4/05/12 at 4:05 p.m. a dime sized purple bruise was approximately 2 inches above Resident #103's left elbow on the back of her arm. 4/04/12 Per the Incident Report dated 4/04/12 at 5:40 p.m. Residents #103 and #105 were walking in opposite directions in the hall on the locked dementia unit when Resident #105 "struck" Resident #103 "in the left arm." Per the written statement dated 4/04/12 Nurse Aide #25 saw Resident #105 "walking toward the nurses' station when passing (Resident #103) she punched her with closed hand. There was no signs verbal or physical before she punched her." In a telephone interview on 4/15/12 at 10:45 a.m. Nurse Aide #25 said on 4/04/12 she was in the hall on the locked dementia unit when she saw Residents #103 and #105 walking in opposite direction. As the two residents met "there were no comments. (Resident #105) flung and hit (Resident #103). There was nothing I could have done" due to the distance between Nurse Aide #25 and Residents #103 & #105. Resident #103 "did not reach out" towards Resident #105. Nurse Aide #25 said Resident #105 "just swung. She is like 'If you are in my way I'm gonna make sure you get out of my way.' (Resident #103) didn't fall. It turned red-her upper arm. I didn't see any bruising in other places. I do know (Resident #104) had thrown (Resident #103) on the floor (earlier that same day). It seemed like not matter what we tried to do there was no stopping (Resident #105). She is very devious...(Resident #103) is very quiet. She's usually laid back. That's possibly why she is targeted. She just want to be by somebody." Resident #104 In an observation on 4/05/12 at 4:00 p.m. Resident #104 was walking in the corridor on the locked dementia unit. He opened his mouth upon request for a few seconds which revealed the front upper teeth were missing and the remaining teeth were in obvious poor condition. Per the Minimum (MDS) data set [DATE] Resident #104 had significant memory deficits (score of 3 out of a possible 15), exhibited inattention, disorganized thinking, psychomotor [MEDICAL CONDITION], altered levels of consciousness, was verbally and physically abusive, rejected care and wandered. Per the hospital Physician's Note dated 2/21/12 Resident #104's [DIAGNOSES REDACTED]. Per the Nurses' Notes dated 4/07/12 Resident #104 was discharged to a psychiatric facility. Resident #103 In an observation on 4/05/12 at 4:05 p.m. Resident #103 was seated in a chair in her room on the locked dementia unit. The back of her left hand from her knuckles to her wrist was swollen and bruised (purple), a large purple bruise extended from her left thumb to her wrist, her left elbow was discolored purple black and appeared fluid filled, a large purple bruise extended from below her left elbow down her left lower arm and a dime sized purple bruise was approximately 2 inches above her left elbow on the back of her arm. Resident #103 was unable to remember what happened to cause her injuries. Per the Minimum (MDS) data set [DATE] Resident #103 had significant memory loss (score of 2 out a possible 15). Per the Psychiatric Admission Evaluation dated 1/11/12 Resident #103's [DIAGNOSES REDACTED]. Resident #105 In an observation on 4/05/12 at 4:08 p.m. Resident #105 was asleep on her bed with Nurse Aide #21 seated outside her door. Nurse Aide #21 said she was providing 1:1 supervision for Resident #105 and "you stay where you can see her. When she moves you move." Per the Minimum (MDS) data set [DATE] Resident #105's [DIAGNOSES REDACTED]. In an interview on 4/09/12 at 11:00 a.m. the Director of Nursing said Resident #105 was admitted to a psychiatric facility on 4/08/12. ( )