Every finding on record at The Orchards at Roseville

Based on observation and interview, the facility failed to maintain the building mechanical ventilation in good working order, resulting in stagnant air and odors. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 06/02/2026 at 10:35 AM, the shower room located next to the therapy room on 1st floor South, was observed with Maintenance Supervisor I. The ambient air inside the room felt humid and heavy. The ceiling vent was checked by placing a piece of toilet tissue against the vent cover. There was no suction available to hold the piece of toilet tissue against the ventilation grate cover. Maintenance Supervisor I stated, It's not drawing air. I'll have to check the belts. On 06/02/2026 at 10:42 AM, the North and South Hall soiled utility room ceiling vents were checked and found to be non-functional On 06/02/2026 at 10:50 AM, the bathroom ceiling vents for rooms [ROOM NUMBERS] were also observed to be non-functional. On 06/03/2026 at 9:50 AM, Maintenance Supervisor I was queried regarding the non-functional vents, and stated it was due to broken belts, but provided no further explanation. a policy regarding the mechanical ventilation was requested on 06/03/2026 at 2:14 PM but was not provided by the end of the survey.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination, potentially affecting all residents. Findings Include: On 06/02/2026 at 11:28 AM, a ceiling tile located in the hallway right outside the basement boiler room, was observed with water damage across the entire 2'x4' ceiling tile. The ceiling tile was bulging downward and was stained with a large ring of a black, mold-like substance. On 06/03/2026 at 10:30 AM, Maintenance Supervisor I was queried about the water damaged ceiling tile. Maintenance Supervisor I confirmed the water damaged ceiling tile. Maintenance Supervisor I stated there was a leak somewhere above the ceiling tile. Maintenance Supervisor I stated an outside repair company had been out to look at the leak but was unable to repair it. Maintenance Supervisor I provided no further information regarding a plan going forward for repairing the leak. Maintenance Supervisor I removed the stained ceiling tile, which crumbled into several pieces while being removed. Upon observation of the piping above the ceiling tile, a leak was observed coming from piping high up into the ceiling, and a slow drip of water continued onto the floor.

Based on observation, interview, and record review, the facility failed to maintain the dumpster area in a clean manner. This deficient practice had the potential to affect all residents in the facility. Findings include: On 06/02/2026 at 11:30 AM, the facility's 2 exterior trash dumpsters were observed. There was a buildup on the ground behind the dumpsters, of various items such as disposable gloves, straws, cups, paper, pieces of cardboard, water bottles, plastic bags, leaves and sticks. On 06/03/2026 at 9:50 AM, Maintenance Supervisor I was queried about the maintenance of the exterior dumpster area and stated that Maintenance was responsible for keeping the area clean but provided no further explanation. On 06/03/2026 at 2:40 PM, review of the facility's undated policy Physical Plant Exterior Maintenance noted: 1. Clean the building's exterior and grounds of all trash, rubbish, debris, unused equipment/furniture, in addition to periodic cleaning of problem areas.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment for five residents (R13, R59, R93, R129, and R130) out of 25 reviewed for homelike environment, in the 1st floor dining and shower rooms and the 2nd floor shower room. Findings include: On 06/02/2026 at 10:35 AM, the 1st floor South shower room was observed with black mildew in the corners of the shower area. On 06/02/2026 at 10:40 AM, the 1st floor North shower room was observed with black mildew along the bottom wall tiles and in the grout in between the tiles. On 06/02/2026 at 10:50 AM, Resident 93 (R 93) was observed sitting in a chair in the hallway directly outside their room. When R 93 stood up, the chair was observed with 2 large tears in the vinyl of the seat cushion, and foam padding was exposed. The surface of the seat cushion was not smooth and easily cleanable. 06/02/2026 at 9:27 AM, Resident 13 (R 13) reported the shower rooms need to be replaced and that they are old. On 06/02/2026 at 12:09 PM, in the second-floor shower room, there was a thick layer of dust on the interior baffles of the ceiling vent. In addition, there was mildew on the tiles and there were numerous cracked and missing floor tiles. In the attached bathroom, there was a shower chair observed with a brown, dried on substance on the seat cushion. On 06/02/2026 at 12:15 PM, in the first-floor dining room, there were 5 resident dining tables observed with peeling and missing laminate. Also in the dining room, the sink countertop was observed with missing laminate topcoat, leaving exposed, rough particle board along the edges of the counter. Review of the facility policy Resident Rights on 06/03/2026 at 1:40 PM noted: Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . On 6/2/26 at 9:33 AM, an observation of the flooring around R59's bed revealed that multiple floor tiles appeared loose, broken, and chipped. On 6/2/26 at 10:05 AM, R59 was interviewed regarding the observed tiles but was unable to respond. On 6/3/26 at 11:40 AM, Director of Housekeeping (DH) G was interviewed in R59's room and shown the floor tiles. DH G indicated they would inform the Maintenance Director. A review of R59's electronic medical record (EMR) revealed that R59 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and Dementia. R59's most recent Minimum Data Set Assessment (MDS) dated [DATE] revealed that they had a severely impaired cognition and required staff assistance for all activities of daily living (ADLs). On 06/02/2026 at 10:18 AM, an observation of R129's room revealed a built up layer of dirt in the corners of the room and along the baseboards. Further observation of the room revealed an approximately two foot long section of crumbling drywall behind the baseboard on the wall opposite the entry door and an outlet cover partially detached from the wall. Observation of the bathroom revealed peeling paint around the baseboards, and a prominent ring of a dark brown substance around the upper rim of the toilet basin. R129 stated that their bathroom was filthy because the toilet and sink have not been cleaned for a week, and voiced concerns regarding the previously described crumbling section of drywall and soiled areas of the floor. A review of R129's electronic medical record (EMR) revealed they were admitted into the facility 5/19/2026 with diagnoses of lymphedema (swelling due to accumulated fluids), schizoaffective disorder, and tachycardia (fast heartbeat). Review of R129's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 06/03/2026 at 11:55 AM, an additional observation of R129's bathroom revealed dark discoloration several inches high along the bottom of the bathroom door, and heavily chipped paint along the entire bottom of the door and corners of the doorframe. Further observation of R129's room revealed a dark line on the wall approximately two feet off the floor across from R129's bed spanning most of the wall. The majority of the wallpaper along the top perimeter of the room was curling up at the bottom margin and peeling away from the wall. Several scratches in the paint on the radiator were observed, as well as two approximately one inch by four inch sections of chipped paint on the top ledge of the windowsill. R129 stated it was depressing to see all the scratches and dirt on the walls, and they felt their nose was getting stuffed up due to the dirt in their room. On 06/04/2026 at 10:04 AM, further observation of R129's room revealed a buildup of dirt near their bed in the corner between the radiator and the wall. On 06/04/2026 at 9:59 AM, an interview was conducted in R129's room with Housekeeper J. Housekeeper J stated the floors are cleaned almost every day unless a resident is getting care, and they will go back to that room if they have time. When Housekeeper J was shown the dirty areas and they said that some of it could be mopped or cleaned off. R130 On 6/2/2026 at 10:48 AM, R130 was observed sitting in their doorway. R130 stated they had to use the restroom but could not get to the toilet because there was a bedside commode (BSC) on the way. R130 stated they do not use the BSC and was unsure why it was in their bathroom. A review of the medical record revealed that R130 was admitted into the facility on 5/26/2026 with the following medical diagnoses, Repeated Falls and Muscle Weakness. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15, indicating an intact cognition. R130 also required staff assistance with bed mobility and transfers. On 06/03/2026 at 9:28 AM, the BSC was still stored in the bathroom and next to the toilet. On 06/03/2026 at 2:30 PM, the BSC was noted to be full of urine, feces, and toilet paper. R130 stated they did not use the BSC and did not know who came in to use the BSC. R130 stated they do share bathrooms; however, no one has been in the other room for the last three days. On 06/03/2026 at 3:15 PM, an interview was conducted with Certified Nursing Assistant (CNA) E. CNA E stated they took R130 to the bathroom that morning and the BSC was in the room. CNA E reported that R130 does not use the BSC and it's to high for R130 to get on. CNA E reported they were going to clean the BSC out but was unsure who used it because the room that shares the bathroom is empty. CNA E reported that R130 did complain to them about it, but they did not remove it because they were unsure why it was there. On 06/04/2026 at 9:09 AM, R130 reported the BSC was cleaned out, but still in their bathroom. R130 reported they were unsure why it hasn't been removed yet. On 06/04/2026 at 9:19 AM an interview was conducted with the Director of Nursing (DON). The DON reported R130 shares a bathroom and it may have belonged to the previous roommate in the other room. The DON then proceeded to remove the BSC out of R130's bathroom. An undated facility policy titled Social Service Standard Operating Procedures (SOP)- Resident Rights noted The resident has a right to a safe, clean, comfortable, and homelike environment.

Based on observation, interview, and record review, the facility failed to secure medications left unattended at the bedside for one (R37) of three residents reviewed for medication storage. Findings include:On 06/02/2026 at 9:53 AM, during an initial resident screening, R37's bedside table was observed to have a plastic medication cup with four pills inside sitting unattended. No residents or staff were in the room. At 10:45 AM, the medication cup with four pills remained unattended on R37's bedside table with no residents or staff present. At 12:40 PM, R37 had returned to their room and the plastic cup with four pills remained untouched on the bedside table. Review of the facility record for R37 revealed they were admitted to the facility on [DATE] with diagnoses including chronic kidney disease and Adult Failure to Thrive. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognition was intact. On 06/03/2026 at 12:15 PM, the facility Director of Nursing (DON) was interviewed and said medication should not be left with the resident. If they refused or not taken for any reason they should not be left in the room, and the nurse should secure the medication until they are administered or disposed of. On 06/03/2026 at 1:50 PM, Licensed Practical Nurse (LPN) D who was R37's nurse the morning of 06/02/26, was interviewed at the medication cart and reported they were not aware R37 had not taken their medication. Review of the facility policy Medication Storage in the Facility dated 2024 revealed the Procedure statement 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications are allowed unsupervised access to medications.

Based on observation, interview, and record review, the facility failed to maintain an accurate record of receipt and disposition of controlled drugs for one of three medication carts reviewed. Findings include:On 06/03/2026 at 3:53 PM, a reconciliation between the controlled substance logbook and the on-hand tablet count of three blister packs of controlled medications (Oxycodone 15mg, Pregabalin 50mg, and Lorazepam 0.5mg) from the second floor back cart revealed a discrepancy of one less tablet present in each of the three blister packs compared to the amount of tablets that should have been in the blister packs as indicated by the cart's controlled substance logbook.During this observation, an interview was conducted with Licensed Practical Nurse (LPN) F. LPN F stated they had been the one administering medication from the second floor back cart that day and they had given the doses of those three medications (to a resident) earlier but had not signed them out of the logbook. They further stated the expectations for signing controlled substances out of the logbook was, it needed to be done by the end of their shift. Review of the Medication Administration Record (MAR) for 6/3/26 revealed LPN 'F administered: -Oxycodone 15mg was administered at 9:00AM, -Pregabalin 50mg was administered at 9:00AM and-Lorazepam 0.5mg was administered at 10:00AM.At 3:50 PM, a review of the controlled substance logbook on the cart did not reveal a record of the medications from these three blister packs having been signed out.On 06/03/2026 at 4:10 PM, an interview was conducted with the Director of Nursing (DON) and they confirmed it is not acceptable to wait until the end of the shift to sign controlled substances out of the logbook, and that each controlled substance must be signed out at the time they are taken out of the blister pack to administer to a resident. A facility policy dated 2024 titled PCU019- Controlled Medications- Administration revealed When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration, amount administered, signature of the nurse administering the dose, completed after the medication is actually administered.

This citation pertains to Intake 3014173. Based on interview and record review, the facility failed to provide adequate and timely pain management for one (R126) of three residents reviewed for pain. Findings include:A review of an Intake called into the State Agency revealed the complainant reported they were admitted into the facility for rehabilitation following a hip fracture with surgical repair. The complainant indicated they were not provided with pain medication for up to 48 hours and when they inquired about their pain medication they were told it was on back order. A review of the medical records for R126 revealed they were admitted to the facility on [DATE] and discharged on 05/08/26 with diagnoses that included Displaced Intertrochanteric Fracture of Right Femur. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognition was intact. A review of R126's physician orders revealed an order for Oxycodone (narcotic pain medication) 5 milligrams (mg) four times daily as needed for pain with an order date and start date of 05/05/26. A review of the resident's care plan revealed a focus area addressing pain/discomfort dated 05/05/26 that included the interventions Administer my analgesic (pain medication) per orders and Anticipate my need for pain relief and respond as soon as possible to all/any complaints or signs of pain. On 06/03/2026 at 10:50 AM, R126 was interviewed via phone and reported they were given one oxycodone pill and that was on the night before they left the facility. The resident confirmed they had been at the facility for about 48 hours having excruciating pain after having pain medication in the hospital then abruptly having nothing when they came to the facility. The resident confirmed staff told them, It (Oxycodone) was back ordered and was not offered any alternative to the Oxycodone. A review of R126's May 2026 Medication Administration Record (MAR) revealed the dates 05/05/26 and 05/06/26 were blank for the administration of Oxycodone, no record of pain levels, or explanation of lack of administration. The MAR documented on 05/07/26, Oxycodone 5 mg was administered at 07:05 PM (the night prior to the resident's discharge) for a pain level of 6/10 (0-10 pain scale with 10 being maximum pain). Review of R126's progress notes revealed no documentation addressing pain, any difficulty in obtaining the Oxycodone, or staff offering an alternative pain medication. On 06/03/2026 at 12:11 PM, the facility Director of Nursing (DON) was interviewed and reviewed R126's record. The DON said their expectation was the nurse should have been able to pull the medication from the backup supply and if the medication was not available it should have been available by the next day as their pharmacy delivers to the facility twice daily. On 06/04/2026 at 12:35 PM, Licensed Practical Nurse (LPN) D who worked with R126 on 5/5/26 and 5/6/26 was interviewed via phone. It was noted that LPN D had entered the resident's initial admission progress note on 5/5/26 and entered the Oxycodone order on 05/05/26. LPN D was asked if there is a delay in obtaining the ordered medication and reported an alternative can be provided if the physician orders it. Review of the undated facility policy Pain Management revealed the policy statement The facility will assess and identify residents experiencing pain, determine the type and severity of the pain and develop a care plan for pain management. The care plan is implemented and continually evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions. Procedure: 11. The staff will implement the care plan, monitor the resident, and administer therapeutic interventions for pain, if ordered.

Based on observation, interview, and record review, the facility failed to apply a supportive right wrist brace for one resident (R130) out of one reviewed for supportive devices. Findings include:A review of the medical record revealed R130 was admitted into the facility on 5/26/2026 with the following medical diagnoses, Repeated Falls and Muscle Weakness. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15, indicating an intact cognition. R130 also required staff assistance with bed mobility and transfers. A review of the physician's order revealed the following, Ordered: 5/27/2026 .Right Wrist Brace .Active.On 06/02/2026 at 2:05 PM, R130 was observed in the hallway with no right wrist brace observed in use.On 06/03/2026 at 9:36 AM, R130 was up in their wheelchair and eating breakfast. No right wrist brace was observed in use.On 06/03/2026 at 12:00 PM, R130 was asked about the right wrist brace and stated they have not worn it in a while, but they were wearing it after their fall at home. R130 stated they are unable to apply it independently and needed assistance. On 06/04/2026 at 9:18 AM, an interview was conducted with the Director of Nursing (DON). The DON indicated the therapy department usually gives a restorative plan and the device, and they enter the order to be follow. On 06/04/2026 at 9:21 AM, Occupational Therapist (OT) B was observed putting the right wrist brace on R130. OT B reported the brace is more for comfort and support when they need it. OT B confirmed R130 does need assistance applying it. R130 reported the right wrist brace makes a big difference as far as support and if they don't wear it, then their right wrist is just floppy.A review of a facility policy titled, Braces and Splints noted the following .4. The therapist should establish a schedule for the splint and communicate to the restorative nurse. 5. A physician order should be written to include, Where the splint/brace is to be worn, When the splint/brace is to be worn, and why the splint/brace is to be worn .

Based on observation, interview, and record review, the facility failed to review and revise the fall care plan after a fall for one resident (R7) out of one reviewed for care plan revision.Review of a nursing progress note for R7 dated 5/24/2026 revealed R7 was observed lying on the floor to the right side of their bed. The note further documented R7's physician recommended placement of a floor mat.Review of a progress note for R7 dated 5/26/2026 revealed the interdisciplinary team (IDT) met to discuss this fall for R7, and through root cause analysis determined R7 had rolled out of bed. This progress note specified an intervention for utilization of a fall mat while R7 is occupying the bed. On 06/03/2026 at 10:10 AM and 2:32 PM, R7 was observed resting in bed with no fall mat in place.On 06/04/2026 at 9:14 AM, R7 was observed resting in bed with a folded-up fall mat sitting in the corner of their room away from their bed.Review of R7's electronic medical record (EMR) revealed they were admitted into the facility 11/23/2020 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and unspecified dementia. A review of R7's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating impaired cognition.Review of R7's care plan for falls did not reveal it had been revised to indicate use of a fall mat while they are in bed.On 06/03/2026 at 2:29 PM, an interview was conducted with Licensed Practical Nurse (LPN) H. LPN H stated they were not sure if fall mats were put into place after R7's most recent fall. They further stated that since R7 was recently put on hospice, equipment like a fall mat would be provided by their hospice team but it had not come in yet.On 06/03/2026 at 3:37 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed R7 does need a fall mat because of their recent fall out of bed. They further stated that R7's care plan should have been updated to include a fall mat so staff would know to implement that intervention.An undated facility policy titled MDS Standard Operating Procedures- Comprehensive Plan of Care revealed The comprehensive plan of care must be consistent with resident rights and.Include intervention to attempt to manage risk factors.Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur.

Based on interview and record review, the facility failed to develop a Post Traumatic Stress Disorder (PTSD) care plan for two residents (R3 and R115) out of three reviewed for mood/behavior. Findings include: R3 A review of the medical record revealed that R3 was admitted into the facility on [DATE] with the following medical diagnoses, PTSD and Schizoaffective Disorder, Bipolar Type. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. PTSD was also coded as an active diagnosis on the MDS. Further review of R3's care plans did not reveal a care plan with goals and interventions addressing their PTSD. On 06/03/2026 at 1:04 PM an interview was conducted with Social Worker (SW) A. SW A reported they are responsible for creating the care plans addressing PTSD and they must have missed developing R3 and R15. R115 A review of R115's was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include Post-Traumatic Stress Disorder (PTSD) chronic. A review of R115's Minimum Data Set (MDS) assessment dated [DATE] revealed R115 with an intact cognition and required assistance by staff to complete activities of daily living. A review of R115's medical record revealed, 5/28/2026 - Psychiatry Follow up . Reason: Depression/hallucinations. History of Present Illness . evaluated today for a follow-up visit . Mood remains at [R115's] baseline with intermittent episodes of depression. [R115] denies anxiety and suicidal ideations. [R115] reports continued intermittent visual hallucinations that [R115] is aware are not real and at times cause [R115] distress . A review of R115's care plan did not reveal interventions to address R115's PTSD diagnosis.

This citation pertains to intake 2638560. Based on interview and record review, the facility failed to ensure one resident (R700) did not receive discontinued medications out of two reviewed for unnecessary medications. Findings include: A review of the Electronic Medical Record (EMR) revealed R700 was originally admitted on [DATE]. Diagnoses included Fibromyalgia, and schizoaffective disorder. Further review revealed a Brief Interview for Mental Status score of 13/15 which indicated intact cognition. A review of the physician's orders revealed an order on 9/22/25 to discontinue Ultram (Tramadol-pain medication) once Norco (narcotic pain medication) arrives from pharmacy. The Norco arrived on 9/22/25 however the Tramadol was not discontinued. A review of the September 2025 medication administration record showed the Tramadol was administered on the following dates 9/24/25, 9/29/25, 10/1/25, 10/2/25, and 10/3/25, and the Norco was administered on: 9/23/25, 9/26/25, 10/1/25, 10/2/25, 10/4/25, and 10/5/25. R700 received both medications on 10/1/25 and 10/2/25. On 10/13/25 the order for the Tramadol was discontinued. On 11/20/25 the Nursing Home Administrator (NHA) was queried about the medication orders. The NHA said physician orders should be followed as written. A review of the undated Medication Policy noted the following: Medications are administered in accordance with written orders of the attending physician

This citation pertains to intake 2673919.Based on interview and record review, the facility failed to notify the guardian of a change in condition for one resident (#702) out of one resident reviewed for a change in condition. Findings include:It was reported to the State Agency that the facility failed to notify the guardian that R702 had been sent to the hospital. A review of the clinical record revealed R702 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R702's diagnoses included Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease and Chronic Respiratory Failure. R702 has a legal guardian who makes their decisions. Further review of the clinical record revealed on 10/29/25, R702 was sent to a vascular doctor's appointment outside the facility. At the doctor's appointment, R702 complained of chest pain and was sent 911 to the hospital. There was no documented communication in the clinical record regarding R702 being sent to the hospital. On 11/20/25 at 3:15 PM an interview with the Nursing Home Administrator (NHA) confirmed the facility did not notify R702's guardian of resident's change of condition and being sent to the hospital from their doctors' appointment. A request was made for a change in condition policy and notification of the guardian but was not received by survey exit.

This citation pertains to Intake 2623867.Based on observations, interview, and record review the facility failed to provide wound care as ordered for one sampled resident (R701) of three reviewed for wound care. Findings include: A review of the complaint summary noted, Today (9/18/24) [R701] was seen by [R701's] wound care providers (that [R701] sees every other week) and [R701's] dressings were dated 09/12/2025.On 9/28/25 at 10:24 AM, R701 was observed in their room lying in bed. R701 feet were observed wrapped and dated 9/28/25 and in heel protector boots. R701 was asked about their wound care and offered no complaints. A review of R701's medical record wound consultation noted, 9/18/2025 . Bandage not changed for six days-dated 9/12 !! Not appropriate! A review of R701's treatment record noted. Order: apply betadine and dry dressing to left medial heel. every day shift every 2 day(s) for protection maintain bil (bilateral) heel elevation while in bed. Blank without documentation were September12th, 14th, 16th, and 18th.On 9/28/25 at 1:01 PM, a review of R701's treatment record was completed with Unit Manager A which confirmed the treatments were not documented as provided on September 12th, 14th, 16th, and 18th.A review of R701's medical record revealed R701 was admitted to the facility on [DATE] with diagnosis of Moderate protein calorie malnutrition and Pressure ulcer right heel unstageable, pressure ulcer of sacral region.On 9/28/25 at 1:35 PM, the Director of Nursing was asked about the missed treatments for R701. The DON explained that they found out about the missed treatments after R701's wound care appointment. The DON explained the Nurses are expected to complete care as ordered daily, as needed, and document daily.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included interventions actions to correct the past noncompliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.Past Non-Compliance Issue: Wound DocumentationThe facility failed to ensure complete and timely documentation, comprehensive skin assessments, treatments and physician orders for residents with wounds. This failure has the potential to delay identifying changes in wound status, hinder appropriate treatment, and follow physician orders which could negatively impact healing outcome.Corrective Action PlanElement 1.All residents identified with wounds during the period 8/13/2025 had an immediate comprehensive skin assessment completed by licensed nursing staff. Skin assessment, wound documentation was updated in the medical record, and treatment orders were reviewed and confirmed by the attending physician. Any changes in wound status were addressed with revised treatment plans.Element 2.A facility-wide skin assessment was conducted for residents to ensure that no additional wounds or skin integrity issues went undocumented. Residents at high risk were identified immediately, physician notified, treatment orders, and appropriate care plans updated.Element 3.Nursing staff were re-educated on the facility policy and procedure for skin assessments, treatment, and wound documentation including frequency, completeness, and accuracy of entries. Element 4A weekly wound care review process was implemented, led by the wound care nurse/designee, to verify that all wounds are treated as ordered, documented, assessed and care plans updated.Shift supervisors are required to review documentation for completeness at the end of each shift.The Director of Nursing or designee will audit 100% of new wounds and 20% of existing wound documentation weekly for two months, then monthly for three months. Audit results will be reviewed in the facility's Quality Assurance Performances Improvement (QAIP) meetings. Any identified gaps will be addressed with immediate staff education or corrective actions. Compliance will be considered sustained with 6 consecutive months showing 100% adherence to documentation and assessment requirements.Compliance Date 9/26/2025.

This citation pertains to Intake: MI00153342. Based on observation, interview, and record review, the facility failed to ensure coordination of care between the facility and hospice services, implement a plan of care regarding hospice services, and ensure a signed agreement between all hospice entities and the facility was obtained for three (R's 303, 304 & 305) of three residents reviewed for quality of care. Findings include: R303 On 6/10/25 at 10:39 AM, R303 was observed laying back in a chair in the community room. An interview could not be conducted with the resident due to their cognitive impairment. A review of the medical record revealed R303 was admitted to the facility on [DATE], with a readmission date of 12/29/22 and diagnoses that included: Alzheimer's disease and vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition for R303. R303 was dependent on staff for all Activities of Daily Living (ADLs). A review of a hospice document revealed R303 was enrolled in hospice services on 5/15/25. A review of a hospice care plan implemented on 6/4/25 noted the following intervention, . Collaborate care with Hospice service, MD (medical doctor), IDT (interdisciplinary team) . The care plan did not contain interventions on the care of services provided by the hospice entity or the plan of care expected from the facility staff. Further review of the Electronic Medical Record (EMR) and hospice binder revealed no documentation of a collaborative plan of care implemented for R303. R304 On 6/10/25 at 10:48 AM, R304 was observed with their eyes closed lying on their back in bed. R304 was easily awakened by verbal prompts. An interview could not be conducted with the resident due to their cognitive impairment. A review of the medical record revealed R304 was admitted to the facility on [DATE], with diagnoses that included: multiple sclerosis and dementia. A MDS assessment dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition and was dependent on staff for all ADLs. A review of a hospice document revealed R304 was enrolled in hospice services on 7/24/24. A review of a hospice care plan implemented on 9/10/24, noted one intervention . Provide my medications as scheduled and report any changes to (hospice name) . Further review of the Electronic Medical Record (EMR) and hospice binder revealed no documentation of a collaborative plan of care implemented for R304. R305 On 6/10/25 at approximately 11:00 AM, R305 was observed sleeping in bed and did not awake to verbal stimuli. A review of the medical record revealed R305 was admitted to the facility on [DATE], with a diagnosis that included dementia. A MDS assessment dated [DATE], noted severely impaired cognition and was dependent on staff for all ADLs. A review of a hospice document revealed R305 was enrolled in hospice services on 5/23/24. A review of a hospice care plan implemented on 5/30/24, noted the following intervention . Consult with my physician and Social Services to have hospice care for me while I am staying with you . Further review of the Electronic Medical Record (EMR) and hospice binder revealed no documentation of a collaborative plan of care implemented for R305. A review of the hospice agreement for the hospice group assigned to R305, revealed an unsigned agreement from both parties- the hospice entity and the facility. On 6/10/25 at 11:57 AM, Licensed Practical Nurse (LPN) C (the nurse assigned to R's 303, 304 & 305) was interviewed and asked if they knew the hospice role and responsibilities of care for R's 303, 304 & 305. LPN C stated they weren't really sure but could ask someone in leadership. At 12:00 PM, Certified Nursing Assistant (CNA) D (assigned to R304) was interviewed and was asked if they knew what days hospice visited R304 and what care/services was provided for each visit. CNA D stated in part . I'm not sure of the days. Typically, I just catch them washing or feeding (the residents) . CNA D confirmed this is the only way they knew if they were responsible to bathe or provide feeding assistance to the residents or if hospice was responsible for the task, is by walking into the room and observing the hospice staff providing the service. At 12:07 PM, CNA E was interviewed and asked how they were made aware of hospice visits and what care hospice was expected to provide that day (bathing, feeding assistance etc.) CNA E stated, they really don't know until they see the hospice staff in the resident rooms. CNA E stated in part . in other facilities it's usually written down and we know . At 12:12 PM, CNA F (assigned to R's 303 & 305) was interviewed and asked if they knew the days hospice staff were expected to visit R's 303 & 305 and what care/services the hospice staff was expected to provide. CNA F stated they never know when hospice is coming. CNA F stated in part . I don't know unless I walk in the room and see them (hospice staff) . CNA F was unsure of the collaboration of care with hospice services. On 6/10/25 at 12:57 PM, the facility's Administrator and Director of Nursing (DON) was interviewed and asked about the lack of coordination of care with hospice services and the inadequate hospice care plans for R's 303, 304 & 305 and acknowledged the concerns. When asked about the hospice agreement for R305, the Administrator explained the hospice company had changed their name and the signed agreement they had on file was under the previous company name. When asked, the Administrator stated a new agreement had not been signed under the new company name. A review of a facility policy titled Hospice Services Facility Agreement revised November 2017, documented in part . If hospice care is furnished in the facility through an agreement, the facility will . Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC (long term care) facility before hospice care is furnished to any resident . The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .

This citation pertains to Intake number MI00151441. Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, comfortable environment for one of one resident (R32), six confidential group residents, with the potential to affect the remaining 107 residents residing at the facility. Findings include: R32 On 4/28/25 at 10:45 AM, R32 was interviewed and asked about their satisfaction with the care and services they were receiving at the facility. R32 indicated every time they received a shower in the 100 south unit shower room, the shower filled up with water and leaked out the door into the hallway. R32 further indicated that because of the large amount of water, the shower room floor could become very slippery. R32 stated, It's not safe. A review of R32's electronic medical record (EMR) revealed that R32 was admitted to the facility on [DATE] with diagnoses that included Seizures, Schizophrenia, and Dementia. R32's most recent minimum data set assessment (MDS) dated [DATE] revealed that R32 had a moderately impaired cognition and required staff supervision for showers. On 4/29/25 at 1:38 PM, the 100 south unit shower room door leading into the shower room was observed to have a blanket spread out by the bottom of the door and a yellow plastic sign by the door which stated, Caution Wet Floor. Observation of the floor by the door revealed water stains on the flooring. On 4/29/25 at 1:41 PM, confidential staff F was asked about the 100 south unit shower room and confirmed at times, water ran out from the shower room into the hallway. On 4/29/25 at 1:45 PM, certified nursing assistant (CNA) G was observed to enter 100 south unit shower room and proceeded to give a resident a shower. As the shower occurred, water was observed flowing under the door and into the hallway. A puddle of water was observed on the floor in the hallway outside of the shower room. On 4/29/25 at 2:02 PM, CNA D was interviewed about the condition of the 100 south unit shower room and indicated the drain in the shower plugs up, water accumulates in the shower and sometimes runs out into the hallway of the unit. CNA D stated, Sometimes I have to take my shoes and socks off when I give a resident a shower. On 4/30/25 at 10:46 AM, Maintenance Director (MD) A was interviewed regarding the condition of the 100 south unit shower room. MD A indicated they had plunged the drain in the shower room multiple times and it continued to plug up. On 4/30/25 at 1:07 PM, the Administrator (NHA) was interviewed regarding the shower room on the 100 south unit. The NHA indicated the shower floods when staff drops the hand held shower on the floor with it running and had been educating them about putting the hand held shower back in the holder when not in use. 47283 An observation of the 2nd floor was completed on 4/28/25 at approximately 12:00 PM. There were gnats observed in the hallway outside the dining room. The dining room walls had multiple scuffed areas that needed repair. A round dining table had large area (approximately 1/4th of table surface) of missing veneer. The countertop with the sink in the dining room and the large countertop on the North end of the dining room had missing banding's with sharp areas of the countertop exposed. The cove base/trim under the sink and countertop were missing including other areas of the dining room. A considerable amount of dirt and debris were observed around the missing cove base/trim under the countertops with areas of broken/missing floor tile/laminate. Throughout the survey multiple follow-up observations were completed on 4/29/25 and 4/30/25 to confirm the initial observation. At approximately 12:20 PM an observation of room [ROOM NUMBER] was completed. The room had a fly trap bag hanging from the ceiling tile that had a significant number of gnats. There were gnats observed outside in the hallway. An observation of the 1st floor dining room was completed later that day at approximately 5 PM. The counter with sink was missing banding on both sides with sharp areas exposed. The cove base/trim under the sink and countertop were missing including some other areas of the dining room. A considerable amount of dirt and debris were observed around the missing trim/cove base under the countertops with areas of broken/missing floor tile/laminate. At approximately 5:20 PM, gnats were observed in the North unit hallway. On 4/30/25, at approximately 7:40 AM, a piece of peeled laminate, approximately 5 to 7 inches in size was sticking out from the floor with areas of floor bucked around creating uneven walking surface down the North hallway. An interview with the Maintenance Director (MD) was completed on 4/30/25 at approximately 7:45 AM. They were queried about their routine maintenance rounds process. The surveyor walked with the maintenance director to the 1st and 2nd floor and shared the observations. They confirmed gnats were an ongoing issue and they were trying to address the concern with their pest control vendor. An interview with the facility Administrator was completed on 4/30/25 at approximately 9:30 AM. They were queried about their rounding process and they reported they rounded daily and were following up with maintenance of any concerns that were identified. They added that gnat concern was recently brought to their attention and their pest control vendor is addressing the concern. 49102 On 04/30/25 at 2:00 PM a meeting was held with a confidential group of residents. Five of the residents expressed concern about dirty shower rooms. On 4/30/25 at 3:00 PM, the Director of Nursing (DON) toured the shower room on 1 north with surveyor. The following concerns were observed: a bath chair that was soiled with black substance all over the seat, several brown spots on the floor, tile was cracked in several place around the tub and in the shower area, the bathroom toilet was littered with dirt, molding around tub peeling away; grout in bathroom incomplete. A facility policy titled Resident Rights with no date, stated the following, Procedure 9. Safe environment. The resident has a right to a safe, clean, comfortable .environment .

Based on observation and interview, the facility failed to ensure all corridor areas used by residents were provided with safe and secure handrails. This deficient practice has the potential to affect all 115 residents who are independently ambulatory with, or without an assistive device, and residents who were able to self-propel in their wheelchairs living in the facility. Findings include: An initial observation of the 2nd floor was completed on 4/28/25 at approximately 12:00 PM. During this observation residents with cognitive impairment were observed walking in the hallway using the handrails as well as residents were using the rails to move around in their wheelchairs. The end caps for the handrails were missing with sharp areas of the handrails exposed in multiple areas throughout the 2nd floor hallway. There were 2 end caps missing near the elevator, near the doorways of rooms 218, 221, outside the unit manager's office. Throughout the survey multiple follow-up observations were completed on 4/28/25, 4/29/25 and 4/30/25 to confirm the initial observation. An interview with the Maintenance Director (MD) was completed on 4/30/25 at approximately 7:45 AM. They were queried about their routine maintenance rounds process. When they were queried further on the observations, they confirmed the multiple missing handrail end caps. During an observaiton with the Maintenance Director MD on the second floor, they said they had fixed the end caps on the first floor and they had placed the order for more. An interview with the facility Administrator was completed on 4/30/25 at approximately 9:30 AM, they were notified of the observations of the missing end caps and they reported that the Maintenance Director MD had placed the order and waiting for shipment. A facility provided undated document titled Resident Rights read in part, The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules governing resident conduct and responsibilities during the stay in the facility Safe Environment: The resident has a right to a safe, clean, comfortable and home like environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observation, interview, and record review, facility failed to update a care plan timely on transfer (from one surface to anther) ability based on the comprehensive assessment for one (R10) of one resident reviewed for care plans. Findings include: R10 R10 was originally admitted to the facility on [DATE]. R10 had a recent admission to hospital and they were recently readmitted back to the facility on [DATE]. R10's admitting diagnoses included heart failure, end stage renal failure, conversion disorder with seizures, and protein calorie malnutrition. Based on the Minimum Data Set (MDS) assessment dated [DATE] R10 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicative of intact cognition. Review of R10's care plan revealed that R10 needed a mechanical/total body lift with 2-person for their transfers. During an observation completed on 4/29/24 at approximately 3 PM, Certified Nursing Assistant (CNA) H was observed transporting R10 in a shower chair from room to the shower room. Approximately 15 minutes later CNA H was observed transporting R10 back to the room and closed the door. CNA H was asked how they were going to assist R10 with their transfer and if they had a mechanical lift in the room. CNA H reported R10 did not need a mechanical lift and could stand up and transfer with their assistance. Review of R10's Kardex (care plan for CNAs) read under transfer status (name of mechanical) lift - always 2-person assist and total dependent. Further review of R10's care plan revealed the following interventions for R10 to transfer safely, Call for assistance with leg rest and self-transferring initiated on 1/28/25 and mechanical lift - always 2-person assist and total dependent initiated on 7/2/24. Further review of R10's Electronic Medical Record (EMR) revealed a comprehensive MDS (Minimum Data Set) assessment dated [DATE], completed after R10 returned from the hospital. The assessment revealed R10 needed substantial staff assistance (more than 50% assistance) for transfers, not a mechanical lift with 2-person assistance as noted in the care plan and Kardex. An interview with the covering Unit Manager (UM) I was completed on 4/29/25 at approximately 4:20 PM. They were queried how the CNAs obtained the information to care for their resents. UM I reported that they received the information form the Kardex and if they also received reports from the previous shift CNA. They were asked what their process was if there was a discrepancy in the care plan, they reported that CNA would report the nurse and nurses were expected to check the care plan and follow up with therapy if resident needed a further assessment. An interview with the Director of Nursing (DON) was completed on 4/29/25 at approximately 3:15 PM. They were asked to explain their process and expectations on how CNAs received the care information and how they were updated. DON reported that CNAs received their information Kardex and they were expected to follow Kardex. If a resident had a change in their condition and or during routine periodic assessment any change in resident's plan of care/interventions were updated accordingly in care plan and Kardex. An interview with MDS Coordinator K was completed on 4/20/25 at approximately 12:50 PM. They were queried about the care plan update process and they reported they had completed R10's comprehensive assessment after they returned from the hospital and did not update the care plan for transfers. An undated facility provided document titled Comprehensive Plan of Care read in part, Each resident we'll have a comprehensive care plan developed within seven days after the completion of a comprehensive or quarterly assessment. The comprehensive care plan is prepared by the interdisciplinary team and to the extent practicable the participation of the resident or the resident's representative. The quarterly care plans are reviewed and updated by the interdisciplinary team and to the extent practicable the participation of the resident or residence representative . The comprehensive plan of care must be consistent with resident's rights and address the residents' individual needs, strengths, and preferences in an I format, reflects current standard of professional practice, include goals with measurable objectives, reflect intervention to meet both short- and long-term resident goals, include interventions to prevent avoidable decline in function or functional level.

Based on observation and interview, the facility failed to offer a mirror of appropriate height visible from a wheelchair level to perform their shaving/grooming for one of one resident (R83) reviewed for accommodation of needs. Findings include: R83 R83 was recently admitted to the facility after hospitalization on [DATE]. R83's admitting diagnoses included recent left above knee amputation, Chronic Obstructive Pulmonary Disease (COPD), and peripheral vascular disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], R83 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. An initial observation was completed on 4/29/25 at approximately 7:55 AM. R83 was in their bed. R83 had a wheelchair, parked next to their bed. An interview was completed during this observation. R83 was asked about their care and if they had any concerns. R83 reported that they were unable to stand up because of their recent amputation and they used their wheelchair. They added they were not able to see themselves in the mirror. When asked to explain further, they reported the mirror in the bathroom was too high and they were not able to see themselves to be able to shave or groom. R83 had facial hair and they stated they would like to shave. When they were queried if they had notified the staff, R83 reported that they had spoken to nursing staff members about the mirror and needing a shave. R83 stated I don't know they can't get this fixed. The was observed the mirror in bathroom was approximately 2 feet higher from the sink level and there was a soap dispenser installed in between the mirror and sink. Follow-up observations were completed on 4/30/25 at approximately 9:10 AM, 12:35 PM and 2:30 PM. R83 was in their room and had facial hair. When asked if any facility staff member had assisted in providing a mirror to assist with their shaving. R83 reported they did not get any assistance and they were still waiting. During these observations R83 stated that I don't need any help to shave and reiterated they just needed a mirror of right height so they could shave and groom on their own. During the observation at 12:35 PM, R83 reported a man came over and asked them if they needed a shave and added, just talk to maintenance. They added I can't even see how I look. Review of R83's Electronic Medical Records (EMR) revealed an Occupational Therapy evaluation dated 3/5/25 documenting R83 needed supervision/set up assistance with grooming. R83's Activities of Daily Living (ADL) care plan revealed R83 needed set up assistance for grooming and personal hygiene. An interview with Unit Manager (UM) I was completed on 4/30/25 at 12:45 PM. They were asked how they would accommodate the needs of a resident who needed a mirror to shave/groom when they were unable to use one in the bathroom. UM I reported they (facility staff) would offer assistance to shave and made sure that they were safe. When queried further on R83's preferences and the current set up they reported they would speak with their Director of Nursing (DON) and management to get a mirror or fix the set up. An interview with Certified Nursing Assistant (CNA) L was completed on 4/30/25 at approximately 2:35 PM. CNA L was assigned to care for R83 during that shift. They were queried about the concerns R83 had and if they were aware. They added that they had not heard anything about the mirror. On 4/30/25, at approximately 9:35 AM, the facility Administrator was notified of the concern. They reported they were unaware of this issue and they would follow up with the Maintenance Director. A facility provided undated document titled Resident Rights read in part, The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules governing resident conduct and responsibilities during the stay in the facility Respect and Dignity: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health and safety of the resident or other residents .

Based on observation, interview, and record review, the facility failed to provide the medications acyclovir (treatment for viral infections) and mupirocin ointment (treatment for skin lesions) as ordered, for one resident (R26) of five reviewed related to medication administration. Findings include: On 04/28/25 at 2:10 PM, R26 reported they had not been consistently treated for their urinary tract infections and impetigo (reddish itchy sores, often around the nose and mouth which may rupture, ooze, and then crust). R26 reported they had not refused any treatments for these conditions. R26 was observed to have two raised areas about the size of a pencil eraser on the forehead. Both were pink in color and one had a scabbed ring around the base. R26 reported the areas itched and had needed to scratch them. On 04/28/25 at 3:04 PM, Licensed Practical Nurse (LPN) C was asked about potential causes of missed medications and reported some history of difficulty with getting medications from the pharmacy and resident insurance. On 04/30/25 at 12:39 PM, R26 appeared with a similar pink/red raised area on the right side of their chin. A review of the record for R26 revealed R26 was admitted into the facility on [DATE]. Diagnoses included Pulmonary Disease, Heart Disease and Chronic Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score, and was dependent on staff assistance for showers/bathing, upper and lower body dressing, personal and toileting hygiene and transfer. A review of the physician orders and the April 2025 Medication Administration Record (MAR) revealed Acyclovir had been ordered on 04/02/25 for the face and then discontinued on 04/04/25 with no administrations documented. The mupirocin ointment 2% had been ordered for three times a day on 04/04/25 and discontinued on 04/19/25 as completed. 30 administrations had been documented as not given. 12 administrations had been documented as provided, even though the medication had not been sent from the pharmacy. Further review of the MAR notes did not indicate the physician was contacted related to the unminstered doses. On 04/30/25 at 10:30 AM, concerns were reviewed with the Director of Nursing (DON). The DON reported the Acyclovir was ordered 04/02/25 then discontinued 04/04/25 and the Mupirocin was ordered on 04/04/25 and discontinued as completed on 04/19. Upon review of the progress notes, there was no documented contact with the pharmacy about the missing medications. At 11:06 PM, the DON called the pharmacy and asked if the medications had been delivered and the pharmacy reported they had not been sent. A review of the facility policy titled, Medication Administration and General Guidelines dated 03/2025 revealed, medications are administered as prescribed, in accordance with state regulations and good nursing principles . Medications are administered in accordance with written orders of the attending physician . The physician must be notified when a dose of the medication has not been given .

Based on interview and record review, the facility failed to ensure resident showers were provided as scheduled for two residents (R18, R59) of six reviewed for care completions and documentation. Findings include: R18 On 04/28/25 at 1:49 PM, R18 reported they had not received their shower one day last week, Tuesday 04/22/25. A review of the record for R18 revealed R18 was admitted into the facility on [DATE]. Diagnoses included Stroke, Mood Disorder and Chronic Pain. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 13/15 Brief Interview for Mental Status score, and R18 required substantial/maximal assistance of staff for showers/bathing, upper and lower body dressing, and R18 was dependent for personal and toileting hygiene and transfer. A review of the April 2025 shower/bathing task in the Electronic Medical Record (EMR) documented bathing was Monday and Thursday between 7:00 PM and 7:00 AM. The documentation which did not correspond with the designated shower days indicated total dependence and the amount of staff needed for assistance but did not indicate if the shower/bath had been completed. On five of the eight days the task was indicated as activity did not occur. A review of the paper shower sheets for April 2025 recorded bathing of R18 on 04/18/25, 4/25/25, and 4/29/25. Documentation of additional showers was requested from the facility, but not received prior to survey exit. R59 On 04/28/25 at 2:01 PM, R59 reported the previous week on Tuesday 04/22/25 staff said the mechanical lift battery was not charged and they could not get them out of bed for their shower and nobody came to give them a shower on Friday 04/25/25. R59 reported their shower was usually in the afternoon. A review of the record for R59 revealed R59 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 13/15 Brief Interview for Mental Status score, impaired range of motion of the upper and lower extremities and R59 was dependent on staff for showers/bathing, upper and lower body dressing, personal and toileting hygiene and transfer. A review of the April 2025 shower/bathing task in the Electronic Medical Record (EMR) documented bathing was Tuesday and Friday between 7:00 AM and 7:00 PM. The documentation which corresponded with the designated shower days indicated total dependence and the amount of staff needed for assistance but did not indicate if the shower/bath had been completed. On 04/18/25 the task was indicated as did not occur. A review of the April 2025 paper shower sheets recorded bathing of R59 on 04/18/25. Documentation of additional showers was requested from the facility, but not received prior to survey exit. On 04/30/25 at 10:30 AM, concerns were reviewed with the Director of Nursing (DON). The DON reported it was the nurse's and aide's responsibility to complete the shower and skin assessment for the resident. The nurse must go in and complete a skin assessment at the time of the shower. The resident does have the right to refuse, and it must be documented. The location of the documentation for showers was reviewed and the task area was confirmed that it did not allow a shower to be documented as completed. On 04/30/25 at 12:55 PM, the facility reported they did not have a policy specific to documentation of showers.

This citation pertains to Intake: MI00135614 Based on observation, interview and record review, the facility failed to provide adequate supervision and implement interventions to prevent an elopement from the facility for a severely cognitively impaired resident (R906), who was a known wanderer and at risk of elopement. On 3/26/23, the R906 exited the facility building through an alarmed door, and then through a second unalarmed door at approximately 12:00am.The resident was located at a local gas station which was .8 miles away, and a 15-minute walk in a high traffic, busy vehicular area. The resident was transported back to the facility by the local police, after responding to a call by the gas station security, approximately 30-40 minutes after the resident was identified as missing. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 3/26/23 and the immediacy was removed 3/26/23 per review of the facility's responding interventions as verified on 4/18/2023. The IJ was identified on 4/18/23 during an abbreviated survey. The facility's Nursing Home Administrator (NHA) was notified of the IJ on 4/18/23 at 1:24 PM and was asked for an abatement plan. The IJ was removed on 3/26/23, based on the facility's implementation of the abatement plan as verified onsite on 4/18/23. Findings include: A review of Intake MI00135614 revealed the following, Incident Summary dated 3/26/23: Administrator received a phone call at approximately 12:15 a.m. that [R906] was not in the facility. [R906] was observed in [their] room at approximately 11:00 p.m. At approximately 11:40 the alarm sounded, and the staff went to check where the alarm was sounding. When they went to the door where the alarm was sounding, they did not see anyone at the door nor outside. The staff immediately did a head count and could not account for [R906]. The staff contacted the [local police department] at 12:08 (am) and discovered that [R906] had walked over to the police department. [R906] was returned to the facility at 12:25 (am) by [local police]. The [local police department] is located right next door to the facility .[R906] did have a wander guard on at the time [they] left the facility but upon return it was gone . On 4/18/23 at 9:23 AM, R906 was observed sitting in their room eating breakfast. Attempts to interview R906 were made to no avail, as they were pleasantly confused and speaking in a non-sensical manner. A review of R906's medical record was reviewed and revealed that they were admitted into the facility on [DATE] with diagnoses that included Vascular Dementia, Other Ulcerative Colitis without complication, Sick Sinus Syndrome, and Bipolar Disorder. Further review of R906's medical record revealed a Minimum Data Set (MDS) assessment dated [DATE] revealing a Brief Interview for Mental Status (BIMS) score of 3/15 indicating a severely impaired cognition, and required supervision with Activities of Daily Living. Further review of R906's medical record revealed an Elopement assessment dated [DATE] revealing that the resident was at risk of wandering. A review of R906's Care Plan revealed the following, Focus: ELOPEMENT: I am at risk for elopement r/t (related to) Dx (diagnosis) Vascular dementia, cognitive impairment, hx (history of) of eloping from previous group home, and making statements about wanting to leave the facility, I also decline to wear a wander guard and if one is put on me, I will take it off. I chose to take my wander guard off at times. Date Initiated: 03/10/2022. Revision on: 10/03/2022 .Interventions: At times you may have to monitor my location every 15/30/60 (minutes) If this occurs, document my wandering behavior and attempted diversional interventions in behavior log. Date Initiated: 07/26/2022. Revision on: 07/26/2022 . On 4/18/23 at 10:49 AM, an interview was completed with the Director of Nursing (DON) regarding R906 and the timeline of events of their elopement. The DON explained that the length of time R906 was missing was less than 30 minutes as the alarm sounded at midnight, in which a head count was completed, and the police was notified that R906 was missing. She further explained that the police department contacted the facility at 12:18am indicating that they located R906, and the police brought R906 back to the facility at 12:25am. The DON explained that R906 went out of the door located on the 100-unit, North hallway, and was located inside a local gas station. A review of the local police department's police report revealed the following, On 3/26/2023 at approximately 0008 (12:08 am) hours, I was dispatched to the listed address [facility] for an elderly [resident] that staff was unable to locate. Staff believed [R906] left the building. As I arrived on scene, dispatch updated that a call came in from [local gas station security]. An elderly [resident] matching the description of [R906] had walked into the gas station. I made contact with [R906] inside the gas station. [R906] appeared to be in good health and was speaking with security. [R906] stated [they] did not need medical treatment. [R906] advised [they do not] stay at [nursing facility], and stays at [their] home every night. [R906] could not say where [their] home was, stated [they do not] have any family, and could not remember [their spouse's] name .[R906] agreed to come with officers, which I had [them] sit in the backseat of patrol [vehicle number] .I transported [R906] to [facility] . On 4/18/23 at 11:30 AM, an interview was completed with Licensed Practical Nurse A (LPN A), assigned nurse for R906 the night of their elopement. She explained that R906 had to be redirected back to their room that night by their assigned certified nursing assistant (CNA B), took the resident to their room. LPN A explained that 5-7 minutes later, the door alarm went off and when they checked for R906, they were gone. LPN A explained that she executed the elopement policy and explained that R906 was gone from the facility between 30-40 minutes. LPN A was asked if R906 had on a Wander Guard that evening, and she indicated that she confirmed that it was in place at the start of her shift, and that it was located on their ankle. On 4/18/23 at 12:20 PM, CNA B was interviewed via phone and explained that she observed R906 in bed asleep at 10:00 pm. She explained that at shift change (11:00 pm) they heard the alarm, completed a room count, and realized that R906 was missing. CNA B explained that she drove around in her car looking for R906, and did not see them, and that R906 was missing for approximately 20-30 minutes. On 4/18/23 at 12:43 PM, CNA C was interviewed via phone regarding R906's elopement from the facility. She explained that she was assigned to R906 for the afternoon shift and that anytime she is assigned to R906, the resident lies in bed and stays in their room. CNA C explained that she last saw R906 in their room at 10:15 pm, and that she eventually left at the end of her shift at 11:00 pm. She reports that upon leaving, she did not hear any alarms. On 4/18/23 at 1:25 PM, the current Nursing Home Administrator (NHA) admitted that the resident did elope from the facility, however, he explained that the staff handled the elopement protocol appropriately by responding to the alarm and completing room checks. A review of R906's medical record revealed the following progress notes: 8/18/2022 10:56 (10:56 am) Nurses Note: Writer spoke with physician regarding wander guard placement for resident. Based on elopement assessment, resident is triggering high. However currently, resident is not actively seeking exit. Physician gave orders that wander guard placement is not warranted at the time and resident will be reapproached for wander guard daily and as needed. 8/18/2022 12:08 (12:08 pm) Physician Progress Notes: Discussed earlier today with the nursing and other staff regarding elopement risk for [R906]. [R906] has dementia and has not shown any behavior of elopement and currently is refusing to wear the wander guard. Will keep the wander guard off and regularly reassess [their] behaviors and make necessary changes. Further review of the R906's medical record revealed the following physician's order dated for 8/18/22: Offer and place wander guard if resident is agreeable every shift. A review of R906's progress notes and Medication Administration Records (MAR) did not reveal if or when a wander guard had been placed on the resident between the order date, and the date of their elopement on 3/26/23. In addition, on 3/26/23, the MAR was observed as blank on the shift that R906 eloped. A review of the facility's Missing Resident Hazard revealed the following, Policy: It is the policy of this facility to reasonably protect the residents form harm through the prevention of elopements. A missing resident is one that cannot be located within the facility and has not been signed out. Facility Abatement Plan: Element 1 R689 currently lives in the facility. R689 was reassessed for elopement immediately upon return on March 26, 2023m with a score of 13 indicating high risk for elopement. A complete head to toe assessment and pain assessment was completed, and no issues were identified. A UA lab work was ordered and completed with no issues identified. A new Wander Guard was also placed on resident immediately upon return on March 26, 2023. MD and guardian were made aware immediately. Ordered were revised to check for placement and functionality daily. The provider saw R689 and there were no immediate issues identified. Plan of care was reviewed and revised as needed. R689 was seen by Social Services and there was no decrease or effects on their psychosocial wellbeing and quality of life. R 689 was immediately placed on 15-minutes checks on March 26, 2023. Exit doors remained activated with no concerns. Element 2 Residents residing in the facility can be affected in an equivalent manner. Remaining residents are accounted for at 100%. 11 (eleven) residents were identified. Doors and alarms were checked immediately by staff, to ensure the safety of other residents. The 11 (eleven) residents at high risk for elopement care plans were reviewed by the DON (Director of Nursing) on March 26, 2023, and revised as needed. Elopement Books located at each nurse's station were reviewed/revised as needed by the Director of Nursing on March 26, 2023. The Maintenance Director did a check on the door alarms , the battery was changed, and the door was sounds appropriate and not automatically disable without the use of a key. The Maintenance Director implemented daily battery checks on all the door alarms. Element 3 The Elopement Policy was reviewed and deemed appropriate. Staff were re-education on the elopement policy immediately. The Maintenance Dept. has been reeducated on continued battery checks of alarmed doors. The Maintenance Director implemented daily battery checks on all the door alarms. The remained staff will be reeducated upon return to work. Element 4 The Maintenance Director implement a daily battery check on all the door alarms for one week then three tome a week for 1 month, then monthly thereafter. The Maintenance Director will report any findings to the QA committee monthly for 3 months and then as directed by the committee. Facility will conduct elopement drills 1x monthly to ensure facility complaint. All results of audits will be brought to QAPI. The Nursing Home Administrator will be responsible for sustaining overall compliance with this plan. Date of Compliance: 3/26/23

This citation pertains to Intake MI00133133. Based on interview and record review, the facility failed to protect the resident's (R904) right to be free from physical abuse by another resident (R903), resulting in R904 being repeatedly punched in the head, transfer to the hospital for diagnostic evaluation of injury, hematoma (bruise) and redness, and continued fear. Findings include: A facility reported incident (FRI) was submitted to the State Agency alleging a resident to resident physical abuse incident involving R903 (perpetrator) and R904 (victim) that occurred on 11/16/2022. On 1/23/23 at 3:47 PM, R904 was interviewed at the facility. R904 was observed to be short in stature and petite in size. R904 used a wheelchair but was observed to be able to stand up without assistance. R904 was asked to recall the incident involving herself and R903 that occurred in November 2022. R904 stated, I was sitting at the table, she (R903) just came in and started pounding on me. She's not going to come back here is she? She told me she wasn't done with me, that I'd be getting more. R904 explained that days prior to the physical altercation, there had been a birthday party at the facility. R904 indicated that there was one piece of cake left that R903 tried to take, but it was intended for a different resident. R904 admitted that she loudly told R903 that the piece of cake wasn't hers but that R903 ignored her at the time. R904 added that she ended up with a bump on the head, from being hit by R903 and needed to get a scan. R904 stated, I would be very scared if she came back .She wasn't a friend or anything but we would talk occasionally .I feel safer without her here. When queried if R903 hitting her was accidental or intentional, R904 replied, I think [R903] knew what she was doing .She told me I deserved more. A review of R904's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Bipolar Disorder, Asthma, Failure to Thrive, Hypertension, and History of Falling. Further review revealed that the resident is cognitively intact and requires supervision to extensive assistance from staff for activities of daily living (ADLs). A review of R904's progress notes revealed: -11/16/2022 20:07 (8:07 PM) Nurses Note Note Text: Writer was made aware by staff that the residents had an altercation with another resident. Writer approached the resident and ensured she was safe. Assessment was completed, resident did not have any c/o (complaints of) pain, writer observed a hematoma apx (approximately) the size quarter on the left side of resident's forehead with some redness noted [Physician] .ordered for the resident to be transported to the emergency room for a cat (CT-computerized tomography test) scan . -11/16/2022 21:39 (9:39 PM) .[Ambulance] arrived to transport resident to hospital via stretcher .no c/o pain. Swelling noted to right eye, hematoma noted to right temple no new changes . -11/17/2022 12:44 (PM) .Writer followed up with resident after her return from the hospital. Writer asked if she feels safe in the facility resident stated as long as I don't have to see her (R903) I will be fine. Resident stated she is not in pain and safety is maintained. Writer assessed resident psycho-social needs and resident appears to be fine talking and laughing with others in dinning (sic) room at this time. -(Psych Services Note) 11/22/2022 15:56 (3:56 PM) .Patient (pt-R903) .noted to have been involved in altercation with peer .pt with noted ongoing irritability, symptoms of anxiety mild to moderate, sporadically occurring, exacerbated by ongoing placement and difficulty coping at times. Appetite/sleep are fair. Cognition at baseline . On 1/23/23 at 4:09 PM, the Nursing Home Administrator (NHA) was queried regarding R903. The NHA indicated that R903 was sent to the hospital for a psychiatric evaluation after the incident that occurred with R904. When queried if R903 had been involved in other incidents with staff or residents in the past, the NHA stated that R903 had been involved in past facility-reported incidents. The NHA was asked to provide the facility's behavior plan that was in place for R903 that was a result of past incidents. A review of R903's MDS dated [DATE] and medical record revealed that the resident was initially admitted into the facility on [DATE] and discharged on [DATE]. R903's medical diagnoses included Hip and Nasal Fractures, Falls, Seizures, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, Traumatic Brain Injury, Major Depressive Disorder, and Dementia. Further review revealed that the resident was moderately cognitively impaired and was mostly independent/required some supervision from staff for ADLs. A review of R903's progress notes revealed the following: -5/28/2022 07:18 (AM) Admission Note Note Text: Resident arrived to facility .Resident very aggressive and has impaired hearing .Resident was kicked out of group home for aggressive behavior. Resident alert with slight confusion . -(Psych Services Note) 6/21/2022 16:51 (4:51 PM) .Pt noted to have long-standing hx (history) of mental illness/schizoaffective disorder; managed on multiple psychotropic medications, pt noted to have hx of progressive cognitive impairment and long-standing mood fluctuations and symptoms of psychosis. Noted to have symptoms of paranoia since admission on 6/2/22. Pt with symptoms moderate in intensity and at times severe, associated with accusing others of talking about her, stealing her belongings, as a result pt with difficulty adjusting and sleep disrupted . -9/26/2022 18:28 (6:28 PM) Incident Note Note Text: Resident stated she is stealing my clothes the lady with the grocery basket! Writer went to look to see if any of her clothing was with her and noted no clothing in room. As writer was coming out of room, writer observed both residents hitting each other. No observable injuries noted . -(Psych Services Note) 10/6/2022 14:43 (2:43 PM) .Today, facility staff requested [R903] be seen due to a recent physical encounter with a fell ow female resident. On 9/26 she was observed in an altercation with a female resident where they were both hitting each other .Today on exam resident was again calm but severely cognitively impaired and hard of hearing .Apparently, she has remained fixated for months with various staff here on the idea that people here are stealing her clothes .[R903] has severe cognitive impairment and delusional beliefs. Today she was unable to provide any meaningful account of the incident. Her behavior was likely triggered by something that occurred in her environment at the time, as (to my knowledge) she does not have a pattern of being spontaneously aggressive here. Recommend staff provide her with increased monitoring when she is nearby other residents who are prone to be confused/aggressive . -(Psych Services Note) 10/18/2022 23:39 (11:39 PM) .Pt with noted ongoing symptoms of mood swings, associated with severe, sporadic epsiodes (sic) of impulsivity, resistance to care, ambulating unsafely; at times agitated; continues on noted Rx (prescriptions) with no side effects, appetite/sleep vary; pt with noted cognitive decline and impairment, interval BIMS 6/15 (moderate/severe impairment) . -11/16/2022 18:18 (6:18 PM) Nurses Note Note Text: Resident in a physical altercation with another resident in the dining room. Resident was arguing with another resident. Resident redirected to room. A review of R903's care plan included the following: -Focus: I have a behavior problem, at times I may choose to lower myself to the floor and remove my soft cast .Sometimes I falsely accuse other residents, and staff for stealing my clothes or my belongings I never possessed .I may confabulate, and perseverate and make up stories/statements that never happened and change them over time. Date Initiated: 10/03/2022, Revision on: 11/01/2022. -Interventions: Approach me and speak in a calm manner. Divert my attention and remove me from a situation as needed. Date Initiated: 10/03/2022. -Praise any indication of my progress/improvement in behavior. Date Initiated: 10/03/2022. Information regarding R903's previous resident to resident incident and noted aggressive behavior was not found upon review of their care plan. On 1/24/23 at 8:09 AM, Witness A (former employee of the facility) was interviewed via phone regarding the incident involving R903 and R904. Witness A explained that he was talking with R904 at a table in the dining room, when R903, came from nowhere and just started throwing hands on this old lady [R904]. Witness A claimed that R903 hit R904, at least four times .and swung about six times. Witness A stated that nearby staff separated the residents. On 1/24/23 at 8:22 AM, Witness B (former employee of the facility) was interviewed via phone regarding the incident involving R903 and R904. Witness B stated that R904 was sitting at a front table in the dining room with Witness D. Witness B stated, [R903] came storming in there, she walked past me but I didn't know what she was going to do .no one had told me the two residents had had a conflict days prior .She walked past the table and started hitting [R904]. Witness B stated that R903 did not say anything to indicate she was about to start hitting R904. When queried regarding any past aggressive behavior exhibited by R903, Witness B stated she was unsure of any because she had been new to the facility when the incident occurred. On 1/24/23 at 8:30 AM, the Social Work Director (SWD) was interviewed and queried regarding if R903 had exhibited any behaviors at the facility prior to the incident with R904. The SWD indicated that R903 had shown behaviors of insistence that her clothing was being stolen and fixation on alleged missing clothing. The SWD stated that R903 had lashed out at other people at her prior living arrangement (group home setting) and would go into other residents' rooms here at the facility and state others' clothes were hers. The SWD explained that she had attempted to find alternate/more suitable placement for R903. Upon reviewing R903's record, no information was found regarding referrals sent to alternate settings after June 2022. When queried regarding her assessment of how R904 felt after the incident happened, the SWD stated that R904 had indicated she felt safe in the facility but didn't understand why the incident had occurred. The SWD indicated she thought R903 may have felt like she was being teased by other residents, causing her to lash out. On 1/24/23 at 8:52 AM, Witness D (current resident) was interviewed regarding the incident involving R903 and R904. Witness D described a birthday party for another resident that occurred days prior to the physical altercation. Witness D explained that R904 hollered at [R903], about taking a piece of cake that was not intended for her, but added that R904's voice is very loud. Witness D also admitted that they, R904, and others may have made comments about some of R903's behaviors in the past. Witness D stated that on the day the altercation occurred, [R903] came frantically over here with no warning and started pounding on [R904]. They broke it up and took [R903] away and she said, 'I'm going to get her again, she deserves more.' I couldn't believe what I was seeing. It was scary when [R903] said she wasn't done with [R904] when she was being taken out of the facility. When queried regarding R903's past behaviors in the facility, Witness D stated that R903 seemed, very agitated all the time .Yelled things out that didn't make sense . and added, I do think [R903] knew what she was doing when she hit [R904] .[R903] was aggressive in nature. Witness D stated that R904 ended up with a lump on her head. A review of the facility's policy/procedure titled, Abuse and Neglect Prohibition Policy, reviewed/revised 2/17/20, revealed, Policy: Each resident has the right to be free from abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Physical abuse includes hitting, slapping, punching, and kicking .Procedure: .When known, the facility will accommodate the needs of residents and staff who have been involved in incidents (recent or past) of abuse to minimize risk .

This citation pertains to intake #'s: MI 042 and MI 210. Based on observation, interview and record review, the facility failed to secure a door prior to exiting the building, and failed to adequately supervise Resident (#711) of three residents reviewed for exit seeking behavior, resulting in an Immediate Jeopardy (IJ) when Resident #711 exited the building unbeknownst to staff after 09:00 PM on 07/25/2022, wandering approximately 1.8 miles (per map [NAME] directions) away from the facility lost, and the likelihood of serious injury, harm, impairment or death. Findings include: A review of the complaint in regard to Resident #711 revealed the following: .a concerned citizen found [Resident #711] leaned over .walker and out of breath on the road. The concerned citizen asked [Resident #711] if .needed help and .stated that . needed to get home and that .lived up the road. The citizen soon realized [Resident #711] was confused and had no idea where .lived so [law enforcement] was contacted. LE (law enforcement) made contact with [Resident #711] and .(Resident #711) had no idea where .was at. [Resident #711] stated .was out for a walk and was on .way home. [Resident #711] was talking to .son who was not there .had no medical bracelets or any sort of identification. [Resident #711] had a piece of paper from a bed ticket from ordering food earlier and LE realized that .resided at [Skilled Nursing Facility/SNF]. Dispatch contacted the home (SNF) but no one answered. LE then went to the home but it took a while before anyone answered the door. LE asked if [Resident #711] lived there and staff stated yeah but panicked when they could not locate [Resident #711]. Staff was unaware that [Resident #711] was gone. Staff reported that there is only 1 nurse for every 30 patients. The nurse (Nurse A) from [Resident #711]'s floor had to leave because there was no food in the facility and she had to go to the grocery store. She asked a different nurse to watch her floor but that did not happen and [Resident #711] escaped the facility. [Resident #711] is supposed to have a GPS bracelet . On 08/17/2022 at 09:41 AM, Resident #711 was observed dressed, in the activity area. Resident #711 was not interacting with anyone and appeared disheveled. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #711 was admitted to the facility on [DATE] with the diagnosis of Metabolic [CONDITION(S)] (a brain disorder). Resident #711 needed supervision with walking and had a Brief Interview of Mental Status (BIMS) score of 03, indicating a severely impaired cognition. A record review of the hospital documentation prior to Resident #711's admission to the facility revealed the Resident was restrained while in the hospital for safety reasons and impulsiveness and had hygiene problems and had a questionable living situation because the Resident lived alone. The Resident refused a neurology work up for Dementia. A record review of the Elopement assessment dated [DATE] revealed that Resident #711 scored 17, indicating a high risk to wander. A record review of the Progress Notes for Resident #711 revealed the following: 6/27/2022 21:46 (09:46 PM) Nurses Note .Resident's son visiting and attempted to take resident home. This writer intervened and informed son, resident has a legal guardian. Called legal guardian on file and no one answered the phone. Resident is A&0 (alert and oriented) x1-2 (baseline). Encouraged resident back to bed. Informed son visiting hours are from 8 a.m. to 8 p.m. 6/27/2022 21:49 (09:49 PM) Nurses Note .Telephoned on-call mgr (manager) and was not able to leave a voice mail. Resident exit seeking with son. Intervened - resident has a legal guardian. Attempted to call legal guardian and no one picked up the phone. 7/5/2022 06:39 (AM) Nurses Note .At hour of sleep resident began to wander in the hallways. Resident's assigned CNA (Certified Nurse Assistant) saw resident walk towards the door and .pushed it open. CNA assisted resident back to .room. 7/7/2022 13:33 (01:33 PM) .Complaint: evaluate capacity for medical decision-making and capacity to handle personal/financial affairs .admitted [DATE] from [Local Hospital], where .was hospitalized due to metabolic [CONDITION(S)] .had severe [CONDITION(S)] at the hospital and was being administered [MEDICATION(S)] (an antipsychotic) for [CONDITION(S)]. At current facility likely for long-term care, as there were concerns about resident's ability to care for .self at home/in the community. Hospital notes indicated concerns from resident's outpatient PCP (Primary Care Physician), and that the concerns have been present for at least several months now. Resident was demonstrating increasing impairment in .ability to care for .self at home and was not engaging in appropriate self hygiene. (Resident #711) had been referred to a neurological institute for dementia evaluation but did not go. Resident had a preexisting diagnosis of unspecified dementia at the time of this evaluation. Referred by attending physician/SW (Social Worker) to evaluate capacity. Resident was cooperative with encounter, but severely slowed and confused. Affect was completely flat and speech was extremely delayed. Resident had absolutely no idea what was going on and could not recall events that have occurred here within the past few hours. (Resident #711) kept asking to go home, though was calm with .requests .Demeanor: +Apathetic; 'dazed' appearance .Motor Movements .profoundly slowed, difficulty executing fine or gross motor movements .Speech: +Restricted; profoundly delayed initiation. Mood & Affect: flat, dazed appearance with eyes wide open and minimal blinking. Thought Process: +Confused/Disorganized; +Slowed .Orientation: +Place-Impaired; +Time-Impaired; unable to state name but looks up to name being called. Memory: +Recent-Impaired; +Remote-Impaired; Attention: +Attention-Impaired; +Concentration-Impaired; Language: +Impaired Language Skills; Fund of knowledge: +Poor; Judgement & Insight: +Judgment poor; +Insight poor .Plan: continue medical management of underlying causes contributing to [CONDITION(S)]. Unspecified dementia with behavioral disturbance .Resident is severely cognitively impaired, unable to state (their) name, and currently LACKS capacity for medical decision-making and lacks capacity to handle personal/financial affairs . 7/13/2022 18:15 (06:15 PM) Nurses Note .Received resident sitting up in bed at start of shift. Extreme confusion noted, A&O x1. Has been putting all of (their) belongings into bags and telling staff (is) going home. Reassured .is safe here and redirected .to .room. Also encouraged .to participate in activities .Wanderguard (a bracelet that will set off alarms when exiting thru specific doors) checked and functional. All needs met at this time, call bell in reach, bed low position. Continue to monitor. 7/26/2022 12:00 (AM) Nurses Note .In to see resident to speak to .regarding incident from the night before, resident was resting quietly in bed. No signs of attempting to leave the facility. Resident states .didn't recall leaving the facility the night before. Staff will continue to monitor the resident. 7/26/2022 07:58 (AM) Nurses Note .Resident received at beginning of shift in stable condition .is alert x 2 with episodes of confusion. Around 9:30 pm, resident wandered out of the building .states that .was attempting to go home. Writer did rounds on resident at 9:00 pm and then began to pass meds. At that time, resident exited the building. Resident was retrieved by the .police dept safe and unharmed .denies pain, no new skin injuries obtained, and vitals within normal range. Guardian, Admin (Administrator), and physician notified of clinical situation. Resident is currently in .room asleep. Safety measures in place, will continue to monitor. (Authored by Nurse A). 7/27/2022 17:33 (05:33 PM) Nurses Note .Resident slept all day except for meals. At 4 pm and 5:20 pm attempt to walk towards elevator with all belongings pushing rolling walker, easily redirectable to go back to room. Staff re-educated to provide frequent monitoring and where-abouts of resident. All staff verbally expressed knowledge of understanding. 7/29/2022 15:04 (03:04 PM) .Social Worker met with [Resident #711] in the dining room .expressed going home and was just waiting. Social Worker advised to wait for staff at all times . A record review of the care plan (initiated 07/05/2022) revealed the following for Resident #711: Focus-I am an elopement risk I am exhibiting exit seeking behavior, I have periods of high confusion with 'exit seeking' behavior, I have verbally expressed the need to leave. Goal- My safety will be maintained. I will not leave the facility unattended. Interventions-Consult with Psych services if needed. Encourage me to attend activities of choice to promote happiness. I have a Wanderguard on my person with placement and function checked daily. Keep my picture in the Elopement book so all are aware. Observe me for my whereabouts frequently. Personalize my room to be a 'homelike'. Since I am an elopement risk - Observe my mood and listen for me saying such things as ;I want to go home' or 'I want to leave.' Focus- .I am a wanderer so this should be monitored by activities. My three favorite things to do are watch TV, go outside and keep up with the news. Interventions-Life enrichment can assist me with directing me to the dining room during leisure activities. A record review of the Physician Orders revealed the following for Resident #711: May place wander guard and Check wander guard placement, functionality. Ordered 07/26/2022. On 08/17/2022 at 11:10 AM, Resident #711 was observed laying in bed. Resident #711 was attempted to be interviewed but was very hard to understand and unable to answer questions appropriately. On 08/17/2022 at 11:25 AM, the Nursing Home Administrator (NHA) was interviewed in regard to Resident #711 exiting the building the night of 07/25/2022. The NHA explained that the facility called her at home around 10:00 PM to let her know that Resident #711 had exited the building and the police department brought the Resident back to the facility. The NHA further explained that the nurse in charge of the Resident had last seen Resident #711 around 09:00 PM while passing meds and continued on doing her med pass. Sometime after that, the Resident went downstairs with their walker and walked thru the front doors of the building following two staff members that were going out on break. The NHA stated that two staff members had went out on a break and had not seen that Resident #711 was behind them and no one noticed the resident was missing until the police brought the Resident back around 10:00 PM. The NHA was asked about the wanderguard that had been ordered for Resident #711 and stated that Resident #711 had removed the wanderguard bracelet. On 08/18/2022 at 09:01 AM, Resident #711 was observed up in bed sitting at the bedside eating breakfast. Resident #711 was asked if they remembered going outside of the building and stated, I don't think so. On 08/19/2022 at 10:12 AM, an interview with Nurse A was completed via telephone. Nurse A explained that originally, she was assigned a different unit downstairs but was reassigned to the upstairs unit where Resident #711 was at (on 07/25/2022). Nurse A explained that she passed medications around nine at night and then left the building with the CNA. Nurse A stated that the Residents were upset that there were no snacks within the building and were crying and upset. Nurse A stated, We have diabetics, they needed their snacks, they were hungry. So I left with the aide to [local grocery store chain] and bought bread and peanut butter and jelly and stuff. The dietary department was short that day. I don't know what was going on but they left without leaving the door open (to the kitchen to get snacks). I don't know how long I was gone for, it wasn't excessive, I think around 40 minutes. When I got back, the police had literally just brought (Resident #711) back. Nurse A further explained that the Resident had taken off their wanderguard and had told them that. Nurse A stated, I am the one who called the Administrator and filled out the accident report. It was scary! I am so glad that (Resident #711) was found! What would have happened if no one had found them? (Resident #711) was completely confused! The Director of Nursing was not available to interview during the survey process. A review of the facility policy titled Missing Person Hazard (undated) revealed the following: It is the policy of this facility to reasonably protect the residents from harm through the prevention of elopements. A missing resident is one that cannot be located within the facility and has not been signed out .Doors ensuring that are closed after you exit. When exiting through a door stop and wait to make sure that the door shuts completely behind you. Make sure that a resident does NOT exit the door behind you. The Administrator was notified of Immediate Jeopardy on 08/17/2022 at 01:13 PM and a plan of correction was requested to remove the immediacy that began on 07/25/2022. The facility provided the following removal plan. Immediate Jeopardy was removed on 7/26/2022 as validated by the team on 08/18/2022. Removal Plan: Background [Resident #711] has been living at our facility since 06/27/2022 .Diagnosis is Metabolic [CONDITION(S)], Hypertension, [CONDITION(S)], Muscle Weakness and [CONDITION(S)]. Her BIMS score is a 3, she is ambulatory and does have a guardian. Resident was assessed for elopement on 7/4 (2022) and found to be high risk. The elopement book was updated, and a wader (sic) guard was placed on the resident. The interdisciplinary team deduced that at some point that night [Resident #711] had taken off her wander guard and at approximately 9:15 pm followed 2 staff members out the front door when they left for their break. At approximately 9:43 pm on 7/25/22 the .police responded to a phone call from a good Samaritan regarding [Resident #711] walking on [local street approximately 1.8 miles away from facility]street lost. The good Samaritan waited until [local police department] arrived and brought [Resident #711] back to our facility. The Administrator and DON (Director of Nursing) were contacted at 10:30 (PM) and informed that the [local police department] had found (Resident #711) and brought .back to the facility. Resident was dressed appropriately for the weather. A full skin assessment was completed, guardian and physician were contacted. Resident was unharmed and stated .was just trying to go home. [Resident #711] placed on 15 minutes checks, new elopement assessment completed, new wander guard placed back on [Resident #711] to ensure resident's safety. Social work following for wellness check's times 3 days and referral to a lock down dementia unit sent out .has been accepted to a lock down dementia unit. We are waiting for the okay to transfer from the receiving facility. ELEMENT 1 [Resident #711] exited the front door behind 2 staff members after they left for their break. (Resident #711) was found and brought back to our facility by [local police department] on July 25th, 2022, at approximately 10:10 pm upon return skin assessment was completed no issues noted, social worker followed up and no psychosocial effect noted. ELEMENT 2 Residents that reside in the facility and that are at risk for elopement may have the potential to be affected. A root cause analysis identified that the resident followed 2 staff members out the front door when they were going on break. Remaining residents were accounted for. 123 residents were reviewed by the DON or designee on 07/26/2022. 7 residents out of 123 were identified as risk for elopement. Care plans for all 7 residents have been reviewed/revised as needed by the DON or designee on 07/26/2022. The maintenance director shortened the length of time the doors remain open after entering in the code. Elopement books located at the front reception and every nursing station were checked for accuracy on 07/26/2022. An elopement drill was completed on 07/26/2022. ELEMENT 3 The Elopement policy was reviewed by the DON and Administrator and deemed appropriate on 07/26/2022. Staff will be re-educated upon return to work on the elopement policy and making sure that every exit door shuts behind them prior to exiting the building. ELEMENT 4 An adhoc QAPI (Quality Assurance Process Improvement) meeting was held on July 26th, 2022, to complete a root cause analysis and a performance improvement plan to ensure sustained compliance, the DON or designee will audit the placement of wander guards 3 times a week for a month and weekly for 2 months, wander guard checks Q (every) shift per nursing and complete random audits 3 times a week for a month and weekly for 2 months to ensure staff are waiting for the door to close prior to exiting the building. If residents are actively seeking the exit, they will be monitored by the staff more frequently as needed and residents will be immediately evaluated to be moved to the 2nd floor if appropriate. Although the immediate jeopardy was removed on 7/26/2022, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, as sustained compliance could not be verified by the State Agency.

This citation pertains to Intakes: MI 752, MI 624 and MI 981 Based on observation, interview and record review, the facility 1) failed to prevent repeated and aggressive physical resident to resident abuse exerted by Residents (R604 and R608), 2) implement abuse policies and procedures and 3) failed to ensure an environment free of physical abuse for four Residents (R605, R606, R 607 and 602) out of nine residents reviewed for abuse, resulting physical abuse towards residents and staff, fear, pain, and mental anguish of residents utilizing the reasonable person concept. Findings include: A review of the Facility investigation report dated 2/18/22 noted the following: nurse observe (R604) in the hallway pulling and grabbing on (R 607's) hair at 9:10 pm, nurse separated residents. R605 and R604 A review of the Facility investigation report dated 2/18/22 noted the following: (R604) reportedly gained the attention of resident R604 and then struck and grabbed at (R605) as (they) leaned in. Staff immediately intervened to separate the residents and (R605) then became aggressive towards staff and proceeded through the halls knocking things off of shelves and counters and pulling the AED (automated external defibrillator) machine off a wall . A review of the Facility investigation report dated 3/16/22 noted the following: Resident (R604) pulled resident (R606) hair. Staff immediately intervened and separated the two residents. Both residents were assessed and staff is petitioning (R604) for a psychiatric evaluation .: On 3/16/22 at 1:08 PM, R604 was observed in a private room sitting on their bed. An interview was attempted, however, R604 did not respond to questions and did not make eye contact. A review of R604's medical record noted an initial admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R604's medical record dated 3/8/2022, noted the following: 3/8/2022 15:07 (5:07 PM) Nurses Note Text: (R604) was being combative toward staff and residents . A review of R604's medical record dated 2/21/2022, noted the following progress note: 15:06 (3:06 PM) .(R604) noted refusing meds and has hx (history) of being physically combative and hit nurse causing injury and other staff members also pulling down objects on the walls . A review of R604's medical record dated 2/18/2022, noted the following progress note: 12:46 (12:46 PM) Nurse Practitioner Note Text: Pt (patient) is noted to have aggressive behavior at this time towards staff and residents. (R604) is not responsive to verbal redirection and is destructive to anything (R604) can get (R604) hands on in the hallway and in his room .At this time (R604) is a danger to staff and residents. A review of R604's medical record dated 1/1/2022, noted the following progress note: Nurses Note Text: Nurse observe resident in the hallway pulling and grabbing on another resident hair at 9:10 pm, nurse separated residents. DON notified at 9:15 pm, Administrator notified at 9:22 pm, physician notified at 10:00 pm no new orders received, guardian (brother) notified at 10:15 pm. Resident is is being monitor every 15 minutes by nursing staff, no c/o (complaints of) pain, no new skin concern, call light within reach will continue with plan of care. A review of R604's medical record dated 12/20/21, noted the following progress note: 05:11 (5:11 AM) Nurses Note Text: Nurse observe resident being abusive towards another resident, constantly grabbing and pulling resident by night grown and knock resident out of wheelchair onto the floor in the hallway. As nursing staff was trying to separate resident's and redirect resident in bedroom, patient was combative, uncooperative and aggressive towards nursing staff. Physician notified order to send resident to hospital . A review of R604's medical record dated 12/19/21, noted the following progress note: 11:55 (11:55 AM) Nurses Note Text: Nurse observe resident being abusive towards another resident, constantly grabbing and pulling resident by night grown and knock resident out of wheelchair onto the floor in the hallway. As nursing staff was trying to separate resident's and redirect resident in bedroom, patient was combative, uncooperative and aggressive towards nursing staff. Physician notified order to send resident to hospital . A review of R605's medical record noted an initial admission on 4/30/15 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R605 had a Brief Mental Status (BIMS) of 4 out of 15 (Severe cognitive impairment). R605 required assistance with activities of daily living (ADL). On 3/16/22 at 12:55 PM, a staff member who did not want to be identified was interview and asked if R604 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .some staff are scared of (R604) because (R604) attacks when you least expect .I try to be careful around (R604). On 3/16/22 at 1:05 PM, another staff member who did not want to be identified stated the following, This is not the right place for (R604) .(R604) is very abusive to the residents .(R604) is young with a lot of strength .hurt many people . R 607 and R604 On 3/16/22 at 1:10 PM, R 607 was observed on the second-floor memory unit, sitting in the dining room talking to staff and other residents. R 607 was pleasantly confused and unable to interview. A review of R 607's medical record noted an initial admission on 1/28/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 607 had a Brief Mental Status (BIMS) of three out of 15 (Severe cognitive impairment). R 607 required extensive assistance with activities of daily living (ADL). According the facility reported incident dated 1/1/22 at 9:10 PM, R604 was observed in the hallway by nursing staff pulling and grabbing on R 607's hair. The facility's summary of investigation reflected, Nurse observed resident in the hallway sitting in wheelchair screaming r/t (related to) another resident (R604) grabbing and pulling (R604) hair . According the facility reported incident dated 12/19/22 at 10:15 PM, .(R604) was observed aggressively grabbing and pulling on (R 607) clothing while (R 607) was sitting in (R 607) wheelchair. Then, (R604) pulled (R 607) to the floor by (R 607) clothes . On 3/16/22 at 1:15 PM, R605 was observed on the second-floor memory unit, sitting in the dining room talking to staff and other residents. R605 was pleasantly confused and unable to interview. On 3/16/22 at 1:28 PM, the unsampled Resident Council President stopped this surveyor and stated, I've been talking to other residents and staff, and they are saying they are scared of (R604). I hear that (R604) is dangerous. I hope (they) don't come down here because I'm scared. R606 and R604 During the survey, it was discovered that R604 attacked R606. A review of R604's medical record dated 3/16/22 at 1:49 PM, noted the following: Nurses Note Resident (R604) grabbed resident's (R606) by hair and pulled a plug of hair from the roots. Resident were separated resident (R604) was taken to room and medicated as ordered . A review of the Facility investigation report dated 3/16/22 noted the following: Resident (R604) pulled resident (R606) hair. Staff immediately intervened and separated the two residents. Both residents were assessed and staff is petitioning (R604) for a psychiatric evaluation .: On 3/16/22 at 3:38 PM, R606 was observed on the memory unit, in their room sitting in a wheelchair crying. R606 was interviewed (with the Director of Nursing, DON) at their side, and asked about being hurt by R604. R606 started uncontrollably crying. R606 stated, (R606) was man to me .R606 pulled my hair .I'm scared, I'm scared .Will I need psychological help? At the time, the DON hugged and consoled R606. R606 continued weeping and wailing. R606 allowed the DON to look at their scalp, whereby R606's scalp was slightly reddened with an area of obviously shorter hair than other hairs. A review of R606's medical record noted an initial admission on 9/16/16 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R606 had a Brief Mental Status (BIMS) score of 6 out of 15 (Severe cognitive impairment). R606 required assistance with activities of daily living (ADL). On 3/16/22 at 3:50 PM, the Nursing Home Administrators (NHA) was interviewed and queried about the R604 attacking R605, R606, and R 607. The NHA revealed, We've tried to send R604 to the hospital because of (R604's) behavior but they keep sending (R604) back .We've been working on finding another placement but it is hard because of (R604's) behavior .When I place staff with (R604) for 1:1, they are attacked by (R604) . The NHA was informed that the Resident Council President reported that the residents fear (R604). The NHA stated, How does the Resident Council President know .I saw (them) talking to you .Well, these residents are always scared .they are scared when we have a tornado drill .they have dementia. The NHA was asked about the most recent incident involving R604 and R606. The NHA stated, R606 is a very emotional person anyway .(R606) cries when they cannot find their doll. A review of the facility's Abuse and Neglect Prohibition Policy dated 2/17/20 noted the following: Each resident has the right to be free from abuse .the facility will accommodate the needs of residents and staff who have been involved in incidents (recent or past) of abuse to minimize risk . R602 and R608 A review of the Facility investigation report dated 2/12/22 noted the following: A resident pre-Superbowl party activity was being held in the facility's first floor North dining room. Two Activity staff were present and providing residents with drinks and snacks. (R602) and (R608) were seated across the room from one another. Without warning or any discernable antecedent or provocation, (R608) walked across the room and pushed (R602) in (their) chair, causing it to fall over. The residents were immediately separated and (R602) was assessed by nurses .It appears (R602) may have struck (their) head when the chair fell , and therefore (R602) is being sent to the hospital for evaluation . A review of R602's medical record noted the following progress note: 2/13/2022 21:48 (9:48 PM) Nurses Note Text: resident was assaulted by another in the 1st floor dinning room during super bowl celebrations. resident was grab by other resident around and neck. resident fell to the floor backwards hitting her head on the floor backwards hitting her head on the floor . A review of R608's medical record noted the following progress note: 2/13/2022 03:24 (3:24 PM) Nurses Note Text: Nurse was made aware by other staff members that patient (R608) was physically aggressive toward other residents. (R608) was removed from north dining room where incident happened. It was reported to nurse that patient walked over to the other resident and pushed (R602) to the floor backwards out of the dining room chair, (R608) had night gown over (R602's) head and patient hit (their) had on floor . A review of R602's medical record noted an initial admission on 1/25/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R602 had a Brief Mental Status (BIMS) of 12 out of 15 (Moderate cognitive impairment). R602 required assistance with activities of daily living (ADL). A review of R608's medical record noted an initial admission on 10/21/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R602 had a Brief Mental Status (BIMS) of 00 out of 15 (unable to complete). R602 required limited assistance with activities of daily living (ADL). The facility's investigation noted, due to dangerous and unpredictable aggression, R608 was petitioned discharged from the facility to a hospital on 2/13/22. On 3/16/22 at 10:30 AM, R602 was observed on the memory unit in the hallway. An attempt was made to interview R602, however, R602 did not remember the incident. On 3/16/22 at 2:40 PM, the Nursing Home Administrators (NHA) interviewed and queried about the R608 attacking R602. The NHA said, (R602) was not hurt .We found out that R608 had been removed from a lot of facilities because of (their) behaviors. A review of the facility's Abuse and Neglect Prohibition Policy dated 2/17/20 noted the following: Each resident has the right to be free from abuse .

This citation pertains to intake MI 390. Based on interview, and record review the facility failed to provide appropriate supervision, monitoring, and to secure an alarmed door on the COVID unit for one sampled resident (R500) of five reviewed for elopement, allowing the resident to exit the building unbeknownst to staff on 12/11/21 between the hours of 12:31 AM to 2:30 AM, resulting in the likelihood of serious injury or death from being outside in the cold and near a heavily traffic congested road for an extended period. The police picked up the resident and transported them to the hospital on 12/11/21 at approximately 4:52 AM. Findings include: The Immediate Jeopardy (IJ) started on 12/11/21 and was identified on 1/5/22. The Administrator (NHA) was notified of the IJ on 1/5/22 at 2:21 PM and was asked for a plan to remove the immediacy. The IJ was removed on 12/13/21, based on the facility's implementation of the removal plan as verified onsite on 1/5/22. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. On 1/5/21 at 9:20 AM, an Incident/Summary report was reviewed which stated the following, Date/Time incident discovered: 12/11/2021 02:30 AM. Date/Time incident occurred: 12/11/2021 02:30 AM. Incident summary: On 12/11/21 charge nurse discovered that [R500] left facility undetected. Investigation summary .The resident exited the facility through the COVID unit .The door alarm system on the COVID had been deactivated . On 1/5/22 at 9:55 AM, R500's electronic medical record (emr) was reviewed and revealed the following, 12/11/21 07:54 AM, .rounds at 12:30 (AM) writer observed resident in bed sleeping at 2:30am writer proceeded with rounds and did not see resident in bed. writer notified staff, staff performed head counts of building resident was not found, staff searched neighboring business and parking lots for resident, staffing nurses notified don (Director of Nursing) via text and call to personal cell writer called police, police dispatched to facility at 4:00am police searched all units in facility as well as inside and outside of building. writer notified by officers that resident is being transported to hospital r/t head injury resident stated that he caught a ride to the destination. emergency contact notified, MD notified, no new orders received at this time. 1/5/22 10:00 AM, R500's EMR was further and indicated the following, 12/16/21 07:22 AM: Writer received resident in bed, alert and oriented x2-3 with confusion noted. Resident readmitted to facility 12/15/21. Writer completed admission skin assessment-Lft hand 5th metacarpal bone fx, Lft hand 5th outer finger open area with blackened inner area. Lft eyebrow laceration w/sutures in place. Bruising to Lft eye w/ swelling to eye. Vitals stable. Fluids encouraged. No s/s of covid during shift. No c/o pain voiced. No s/s of distress observed. Medication administered as scheduled. Comfort and safety maintained. Call light in reach. Bed in lowest position. Resident is on 15 min checks. Will continue with plan of care. On 1/5/22 at 10:15 AM a police report dated 12/11/21 4:52 AM regarding R500's elopement incident was reviewed and revealed the following, I began searching businesses in the area that were open. I observed an older w/m (white/male) at the bus stop at [name of street corner]. As I approached I noticed the male had a large laceration above his left eye and was soaking wet. I asked him if he was [R500] and he said he was .I called for an ambulance to my location and advised dispatch [R500] had been located. [R500] advised that he had fallen near 10 mile and then got a ride from a stranger. He advised he had been sitting in the bus stop for an hour or two. [R500] also had a laceration to his left palm. [R500] was transported to [Hospital] . On 1/5/22 at 10:27 AM, per the national weather service website, the approximate temperature on 12/11/21 was 39 Degrees Fahrenheit. On 1/5/22 at 10:45 AM, R500 was met in their room and interviewed regarding the elopement incident on 12/11/21. R500 indicated that they exited the facility and went to the bus stop. R500 indicated that when they exited the facility they were wearing clothes, shoes, and a jacket. R500 indicated that it was raining on 12/11/21. R500 revealed that they had a fall while outside on 12/11/21 and cut themselves above their eye. R500 indicated that they were picked up by the police and taken to the hospital. On 1/5/22 at 11:00 AM Maintenance staff (MS) A was interviewed regarding the elopement incident involving R500 on 12/11/21. MS A indicated that the door alarm on the COVID unit had been deactivated and that the resident exited the facility out of that door. MS A indicated that they now are in possession of the key to the alarm for the door on the COVID unit and monitor the door on a daily basis to ensure that the alarm remains activated. On 1/5/22 at 1:18 PM, Nurse C was contacted by phone and interviewed regarding the elopement incident involving R500. Nurse C indicated that they were the only staff working on the COVID unit on the night of R500's elopement. Nurse C indicated that R500 was in their room at 12:30 AM, and that when rounding was done again at 2:30 AM, R500 was not in their room. Nurse C indicated that they checked the entire building and outside the building and were unable to locate R500. Nurse C stated, I contacted the Administrator (NHA), Director of Nursing (DON), and the police. On 1/5/22 at 3:35 PM, the NHA was interviewed regarding their expectations for ensuring facility residents do not elope from the building. The NHA stated, At admission an elopement risk assessment should be completed and if a resident is at high risk for elopement or we notice exit seeking behavior, then interventions should be put in place. On 1/5/22 at 3:45 PM, a review of R500's EMR revealed that R500 had diagnoses that included, Subluxation (partial misalignment) of unspecified cervical vertebrae, COVID 19 (12/9/21), [CONDITION(S)], Muscle weakness, and History of falling. R500's most recent minimum data set assessment indicated that R500 had a moderately impaired cognition and required supervision for the majority of activities of daily living (ADLs). On 1/5/21 at 4:38 PM, a facility policy titled Missing Resident Hazard with no date on it, stated the following, Policy: It is the policy of this facility to reasonably protect the residents from harm through the prevention of elopements. A missing resident is one that cannot be located within the facility and has not been signed out. The removal plan included: Resident was reassessed for elopement on upon return on December 15, 2021, with a score of 17 indicating high risk for elopement. Wander guard placed on Resident #500 on 12/15/21 upon return. Remaining residents were accounted for, at 100% immediately, on 12/11/21. 125 out of 125 resident's elopement assessments were reviewed by the Director of Nursing or designee on December 13, 2021. 15 out of 125 residents were identified at risk for elopement on December 13, 2021. Maintenance Director checked and reactivated all doors with alarms were found to be in compliance by 12/12/21. Elopement Books located at each nurse's station were reviewed/revised as indicated by the Director of Nursing or designee on December 13, 2021. 75 out of 113 of staff have been re-educated on the Elopement Policy and continued activation of alarmed doors on December 13, 2021. The remaining staff will be educated prior to their next scheduled shift by the Inservices Director or Designee. Based on the above corrections immediacy was removed on 12/13/21

This citation pertains to intake: MI 949. Based on interview and record review, the facility failed to honor the rights of one Resident (R706), by providing life sustaining treatment to a resident against their wishes, and attempting to revive them after being found unresponsive, resulting in not following the wishes of the resident. Findings include: A review of the complainant's intake revealed an allegation of the facility failing to provide care and services according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R706 was admitted to the facility on [DATE] and readmitted on [DATE] on Hospice with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R706's Guardianship documentation noted, Facsimile Cover Sheet Date: Thursday, [DATE]. To: [Nursing Home Facility]. From: [Probate Court] . RE (regarding): [R706] . Please find attached a copy of Petition and Order signed by [local Judge] (Name of County) Probate Court, on [DATE]. PETITION AND ORDER. In the matter of [R706]. 1. I am interested in this matter and make this petition as Guardian . 3. I state: (state facts). R706 was admitted to [local hospital] on [DATE] due to acute [CONDITION(S)] respiratory distress. [R706] was put on a ventilator at that time. Since then [R706] has become completely unresponsive to stimuli and no longer requires sedation for the event. [R706's] medical team believes the best course of action at this time is to change [R706] Code status to Do Not Resuscitate (DNR) and start comfort care. 4. I REQUEST that: the court allow the office of public guardian to change [R706's] call status to Do Not Resuscitate and comfort care be started to allow for a peaceful and pain free end of life transition . Date [DATE]. Signed Petitioner . ORDER: IT IS ORDERED that the above petition is granted (checked). Date: [DATE]. Hospice documentation noted, [Local] Hospice, Fax, dated [DATE] . Hospice Certification and Plan of Care. Start date [DATE] . Advance Directives: DO NOT RESUSCITATE . A review of R706's medical record revealed, [DATE] 15:46 (3:46 PM) Nurses Note Text: writer received resident in bed sleeping this morning, no medication had been administered due to patient sleeping and not waking up for writer o (sic) medication to [R706], writer attempted several times to give medication but resident would just hold medication in [R706's] mouth without swallowing it. Writer spoke with residents sister about half an hour before seeing resident again to deliver a message from sister at that time the resident had very shallow breathing and was sweating profusely. Writer attempted to call NP (nurse practitioner) to inform of issue and to see if resident could be sent out to hospital, writer returned to residents room to assess and get new set of VS (vital signs) and the resident was not responding nor was there a rise and fall of the chest, code blue and 911 was called, CPR (Cardiopulmonary resuscitation) was started. R706's previous progress notes revealed the incorrect code status after readmission on [DATE] and being placed on Hospice. [DATE] 14:35 (2:35 PM) Administrator Note Text: resident arrived at facility by [local] ambulance alert via stretcher @ (at) 1300 (1:00 PM) accompanied by two EMT (Emergency Medical Technician) techs, . resident is Hospice . resident has NKA (no known allergies). resident is incontinent of B/B (bowel and bladder). resident in bed resting, no c/o (complaint of) pain or discomfort at this time, bed in lowest position, call light and personal items within reach. [DATE] 16:47 (4:47 PM) MDS Note Text: resident returned to facility with Hospice services initiated. significant change assessment initiated and IDT notified. [DATE] 13:38 (1:38 PM) Social Service Note Text: SW conducted quarterly review with resident. Resident had significant cognitive changes. Resident is now on Hospice. SW reviewed advance directive, resident remained a full code until further notice. Resident will remain in facility for LTC (long term care). SW will continue to observe for change and will follow up as needed. [DATE] 20:18 (8:18 PM) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Code Status: full code . On [DATE] at 1:17 PM, the Director of Nursing (DON) was asked about R706 code status being a DNR and receiving CPR. The DON explained that they were not aware and that they would look into it. No other explanation was received by the end of this survey. A review of the facility's policy titled Advance Directives Policy dated Nov. 1991, noted, Policy the facility will honor valid advance directives or treatment preferences made by the resident or the healthcare legal decision maker for the resident and shall provide information needed by resident/legal representative to assist them in making informed decisions . Resident Code status the completed and signed resident code status that is completed pursuant to this policy that summarizes the resuscitation desires of the resident as expressed by the resident or expressed by the healthcare legal decision maker. The resident code status is not an advance directive itself but is this facility procedure for quickly and uniformly identifying the residents code status .

This citation pertains to intake #'s: MI 502, MI 497, MI 459, and MI 261. Based on observation, interview and record review, the facility failed to prevent physical abuse to four residents (Resident #705, #711, #719 and #727) of 13 residents reviewed for abuse, resulting in pain and mental anguish utilizing the reasonable person concept. Findings include: Resident #705 (R705) On 12/13/2021 at 10:11 AM, Resident #705 was observed resting in bed. An interview was attempted, however, Resident #705 did not respond to verbal communication and appeared confused. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #705 was readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #705 had a Brief Interview for Mental Status (BIMS) score of 00, indicating a severely impaired cognition. On 12/13/2021 at 12:44 PM, the Unsampled Resident whom was the roommate of Resident #705 during the staff to resident incident reported on 12/14/2020 was interviewed. (The Unsampled Resident had a BIMS score of 15, indicating an intact cognition as of the last MDS assessment on 10/15/2021). Resident #705 was asked if they recalled an incident that they had witnessed with Resident #705. I remember it! It was sometime in November of last year (2020). A few weeks prior to that, I could hear her (CNA A) slapping (Resident #705), but I couldn't see because the curtains were drawn. This time (the reported incident), I could hear that sound again (smacking on skin), my curtains were open and I could see directly to (their) bed. I looked up and I could see her smacking him (demonstrating with an open hand) on top of the head. She did not know I could see it. She just literally kept doing it over and over. The Unsampled Resident was asked what Resident #705 was doing at that time and stated, (Resident #705) wasn't doing nothing. She stopped, then I seen her take the bed control and was hitting him on the head with it, over and over, like this (the Unsampled Resident demonstrated with their bed remote control, which was wired, how CNA A was hitting Resident #705). The Unsampled Resident was asked about reporting the CNA and stated, I wish I would have reported it sooner, but I didn't know what I know now. I didn't know if, one, if there would be retribution (by staff for reporting abuse) and two, if they were unionized here. I didn't report it for three to four weeks. I was hoping her set would change and (Resident #705) would no longer be hit by her. But, that didn't happen. A police officer came and talked to me about it. Her name is [CNA A]. They fired her. I have not seen her in a long time. A review of the Progress Notes for Resident #705 revealed the following: 11/03/2020-14:45 (02:45 PM) .Cena (Certified Educated Nurse Assistant/CNA) reported resident has a yellow bruise noted on the right cheek and .rt. (right) forehead. resident states I bumped my head but .does not remember when it happened. No c/o (complaints of) pain or discomfort. Unit manager and NP (Nurse Practitioner) notified. 12/09/2020-15:23 (03:23 PM) Unusual Occurrence Note .Alleged abuse against this resident from a staff member, witnessed by (Unsampled Resident whom was roommate to Resident #705 during incident) who is AOX3 (alert and oriented to person, place and time). (Unsampled Resident) was able to identify the staff member by name. Writer was informed by the resident's roommate that (they) witnessed a staff member (CNA A) hitting the resident on top of (the) head with the bed control remote. Per the resident the alleged abuse took place 3 weeks ago (November 2020) on a Friday during the afternoon shift. Resident (#705) is alert to self with confusion. Resident was unable to recall information related to the alleged abuse. Skin assessment completed, resident has no impairment in skin integrity. Pain assessment completed, resident has not c/o or s/s (signs and symptoms) of pain. Incident reported to administrator. Resident's daughter .called at number on face sheet, no answer, message left on voicemail to return call to facility. Dr (Doctor) .notified, no new orders given at this time. Resident is in bed resting, no distress noted, safety maintained, will continue to monitor. A record review of the facility investigation file revealed the following: Disciplinary Action Record CNA A -Employee suspended pending investigation for allegation of abuse. Signed 12/20/2020 by CNA A. Statements CNA A's Statement dated 12/10/2020-I did not hit [Resident #705]. [Resident #705] does yell when you turn (them) over on .(L) side (their) weak side towards the window. I don't have the remote control in my hand when I take care of (Resident #705). I work permanently afternoon shift. I can't recall any reason why [Unsampled Resident] would think that I would hit [Resident #705]. Also when (they) get changed (they) also yell and say stop turning me on that side which is the left side. Former Employee #1's statement, dated 12/14/2020-I heard her (CNA A) told a resident shut up-can't recall when. CNA D's statement dated 12/14/2020-I have not witnessed (CNA A) be rough with residents or verbally inappropriate, I believe the residents if the resident states it occurred I believe the resident. If [Unsampled Resident] says (they) witnessed something then I would believe the resident. Unsampled Resident interview dated 12/09/2020-Resident stated that .witnessed a staff member hit another Resident .stated that she (CNA A) hit (Resident #705) with the bed controller on .head and chest. He also stated he witnessed staff hit with hands .stated that the incident occurred 3 weeks ago on the afternoon shift .stated that the aide name is [CNA A]. Resident #705's statement-didn't recall. The facility concluded that the abuse was unsubstantiated due to Resident #705 not confirming the allegation. On 12/14/2021 at 09:35 AM, SW C was interviewed in regard to Unsampled Resident's allegation of abuse from staff to Resident #705. SW C explained they were unaware of the situation but stated, If [Unsampled Resident] said it happened, it happened, (they are) alert and oriented with a BIMS of 15, (Unsampled Resident) does not make up stories. On 12/14/2021 at 09:47 AM, the Director of Nursing (DON) was interviewed in regard to the allegation of abuse being unsubstantiated for Resident #705 when there was a credible eye witness who saw the incident. The DON explained that he was unaware of the situation and only been an employee at the facility since September of 2021. On 12/14/2021 at 01:00 PM, the Nursing Home Administrator (NHA) was interviewed with the DON. They were asked what the procedure was for alleged abuse. The NHA stated, We would separate the residents and make sure they were safe, first. Nursing would do skin assessments and follow up with the resident. We would get statements and start a file. We report it and find a conclusion. We should report to the State Agency in two hours if suspected harm, within 24 hours if no harm suspected. The DON explained that the facility ensures safety of the resident first and that staff have to report it to the abuse coordinator (NHA). The DON stated, We try to see if there could be different interventions in place. We notify the guardian, doctor and police if needed. The NHA was asked why if it was witnessed, the allegation was unsubstantiated in regard to Resident #705. The NHA was unable to provide an explanation by the end of the survey. During this time, the NHA was asked to provide the termination reason/document for CNA A. The document was not provided by the end of the survey. On 12/13/2021 at 12:50 PM, an attempt was made to contact CNA A via phone for an interview, a voice mail message was left with this Surveyor's contact information. The CNA did not call this Surveyor back by the end of the survey process. On 12/13/2021 at 02:21 PM, a request for the incident report for the bruises on the cheek and forehead of Resident #705 on 11/03/2021 was requested but not received by the end of the survey. Resident #711 (R711) A record review of the Progress Notes for Resident #711 revealed the following: 04/06/2021-18:11 (06:11 AM) Incident Note .Observed residents yelling at each other as writer began to run to intervene, resident (#711) hit 220-B with open hand in the mouth. Residents moved away from each other for safety. 06/22/2021-09:02 (AM) Behavior Note .writer observed resident hit another resident on .side leg area. the other resident was walking down the hallway and was accompanied by her one on one when resident came out the room and hit the other resident on the side. resident stated that (they) hit her because she needed a whooping. administrator .and doctor was notified. 06/22/2021-11:40 (AM) Social Services Note .Resident in the process of (being) petitioned out due to alleged incident. 08/17/2021-20:28 (08:28 PM) Behavior Note .Writer observed patient hit another patient on leg in hallway writer asked patient to .go (to) room to separate each other. patient became verbally aggress (aggressive) .called DR .new order to send patient out for a psych evaluation . A record review of the MDS dated [DATE], revealed that Resident #711 was readmitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/2021 at 10:44 AM, SW C was interviewed in regard to Resident #711's aggressive behavior toward other residents. SW C stated, (Resident #711) used to walk up to people and just tap their behinds, it was not malicious. (Resident #711) was sent out (petitioned to an acute care hospital) twice for it. A record review of the Care Plan for Resident #711 revealed the following: Focus: I have the potential to be physically aggressive. History of harm to others. Date Initiated: 04/07/2021 Goals: I will verbalize understanding of the need to control my physically aggressive behavior through the review date. Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates my behavior and document. Assess and address me for contributing sensory deficits Assess and anticipate my needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide me with physical and verbal cues to alleviate my anxiety; give me positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. I need my personal space. All interventions were dated for 04/07/2021. A review of the Facility Reported Incident (FRI) file dated for 04/06/2021 revealed the following: Investigation .[Nurse E] .noted the raised voices between the two resident and was walking towards them to separate them. Before Nurse .could reach them, [Resident #711] raised (their) open hand and (their) hand made contact with [Other Resident]'s cheek. Nurse E immediately separated the two residents . Nurse E's hand written statement dated 04/06/2021 revealed the following-I observed [Resident #711] standing over [Other Resident]. I heard them yelling at each other and I started running down the hall to intervene and seen [Resident #711] raise (their) hand in a hitting position and before I made it to them, [Resident #711] smacked [Other Resident] in the mouth. I immediately separated them for safety . A review of the facility investigation file dated for 06/22/2021 revealed the following: .Out of nowhere, [Resident #711] with an open hand came in contact with [Other Resident] leg/hip. Both residents were immediately separated .[Resident #711] was interviewed by the Director of Nursing .and when asked why .touched [Other Resident], [Resident #711] stated that (they were) tired of [Other Resident] . Resident #719 (R719) A record review of the MDS assessment dated [DATE] revealed that Resident #719 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Progress Notes for Resident #719 revealed the following: 07/19/2021-08:51 (AM) .Writer called to resident room staff informed writer resident struck roommate with walking cane mid between chest and ABD (abdomen). Residents immediately separated resident educated behavior (is) unacceptable and at no time should .strike anyone for any reason. Resident admits to striking roommate .Administrator DON and MD (Medical Doctor) made aware . 07/19/2021-09:16 (AM) .Writer called to resident room staff informed writer resident struck roommate with walking cane mid between chest and ABD. Residents immediately separated resident educated behavior (is) unacceptable .Resident states ' .I just got mad I should have not hit him I didn't hit him hard' . 08/11/2021-23:50 (11:50 PM) .Approximately 2140 (09:40 PM), resident was sitting in chair in hallway in front of nursing station when writer arrived to facility and began to receive report from fell ow nurse. Resident stated to writer that (they) had hit (their) neighbor (roommate) .in the chest. Resident stated that .neighbor was 'talking loud' . 08/12/2021-12:18 (PM) .SW alerted to resident aggressive behavior towards peer. SW spoke with resident about behavior. Resident stated .was very sorry and will not do it again. SW asked why .was aggressive, 'I don't know' . A record review of the Care Plan for Resident #719 revealed the following: Focus-I have the potential to be physically aggressive. Anger, Poor impulse control. Date Initiated: 07/19/2021 Goal-I will have fewer than 3 episodes per shift of behavior through the review date. Interventions-My triggers for physical aggression are (when my peers are disrespectful ro (sic) staff. My behavior is de-escalated by (feeling agitated).Assist me to develop more appropriate methods of coping and interacting. Encourage me to express feelings appropriately. Educate myself/caregivers on my successful coping and interaction strategies. I need encouragement and active support when I use these strategies. Explain procedures to me before starting and allow me to adjust to changes. If reasonable, discuss my behavior with me and why it is inappropriate and/or unacceptable. Minimize the potential for my disruptive behavior. Offer tasks which divert my attention Observe my behavioral episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. On 12/14/2021 at 09:35 AM, SW C was interviewed in regard to Resident #719's aggressive behaviors. SW C stated, I was not aware of aggressive behavior. On 12/14/2021 at 09:47 AM, the DON was interviewed in regard to Resident #719's aggressive behavior towards other residents. The DON explained that he was not working in the facility during the time of the incidents. Resident #727 (R727) A review of R727's medical record revealed, R727 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R727's medical record noted, Brief Interview Mental Status was unable to be assessed due to cognition and inability to perform assessment. On 12/13/21 at 10:32 AM, an attempt was made to visit R727, but their door was closed. Later R727 was observed in their room, an interview was unable to be conducted due to R727's cognitive impairment. A review of R727's progress note revealed, 11/16/21 13:29 (1:29 PM). Nurses Note Text: Resident started sitting in the middle of floor in the hall walking on knees and just sitting. As writer was walking past resident grabbed hold and refused to let go of staff pants. Resident also became violent with resident family member and continued to go after staff and hit a resident with an open hand in the face. Resident continued to go after staff and trying to rip room tag phone and computer off wall. Staff was unable to redirect resident. Resident was petitioned out to [local hospital] for behavior and [local area escorted by local police]. All responsible parties and form of behavior and transfer. A review of the facility's provided documentation noted, On 11/6/21 at approximately 11:00 AM [R727] was observed walking down the hall and [R727] was witnessed by CNA J striking [a resident] across the face with [their] hand . Staff immediately intervene to ensure both residents safety although [R727's] behavior was not able to be managed and 911 was alerted by staff charge nurse notified the physician and ordered to petition [R727] out for psychiatric evaluation was made . On 12/14/21 at 11:42 AM, CNA I was interviewed and asked about R727's behavior and stated, [R727] can be combative at times, staff does not want to go in alone because of [R727's] behaviors, [R727] doesn't like to be changed or anything. On 12/14/21 at 11:53 AM, Nurse Supervisor H was interviewed and asked if R727 has had any other incidents since the last hospitalization and stated, No [R727] hasn't had any incidents or anything reported. Nurse H was asked if they were here for the incident that occurred on 11/6/21 and stated, No. A review of CNA J's witness report revealed, On 11/06/21 around 11:00 AM [R727] was in the hall sitting with [their] feet folded when [Nurse K] walked past and [R727] grabbed her leg. I then told [R727] to let her go. Then [R727] got up and started to walk down the hall [R727] then walked past [other resident] and slapped the left side of [other resident] face. I ran down to make sure [other resident] was OK. [other resident] stated [other resident] was fine, it didn't hurt. Then when [a visitor for another resident] nephew came out of [their] room, [R727] than grabbed his neck, I proceeded with the nurse helping to have R727 let his neck go. I then followed [R727] to [R727's] room until [R727] went in and closed the door but before [R727] got to [R727's] room [R727] knocked over stuff at the nurses station [R727] tried to tear the kiosk down. Then went to R727 room and closed the door. A review of the facility policy titled Abuse and Neglect Prohibition Policy dated 02/17/2020 revealed the following: Policy-Each resident has the right to be from abuse, mistreatment .and mental abuse .Definitions-Physical abuse includes hitting, slapping, pinching, and kicking .C. Prevention-1. Residents, families, and staff will be able to report concerns, incidents and grievances without fear of retribution .The facility will monitor residents for changes in behavior, bruises/injuries of unknown origin or of a suspicious nature or other types of patterns .The facility Supervisory staff will integrate into the supervisor process monitoring the behavior of staff members and residents .

This citation refers to intake # 0. Based on observation, interview, and record review the facility failed to utilize proper infection control precaution notification, proper personal protection equipment (PPE), keep doors closed, and have an adequate supply of PPE on the door mounted supply holders on the COVID 19 transition unit affecting three residents (R911, R912, R913) of 14 residents reviewed for infection control resulting in the potential for the preventable spread of infection and/or COVID 19. Findings include: The Immediate Jeopardy (IJ) started on 10/13/20 and was identified on 10/22/20. The Administrator was notified on 10/23/20 at 8:53 AM of the IJ and was asked for a plan to remove the immediacy. The IJ was removed on 10/23/20, based on the facility's implementation of the removal plan as verified onsite on 10/23/20. Although the immediacy was removed, the facility's deficient practice remained isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. On 10/13/20 at 8:10 AM, a tour of the COVID 19 transition unit was completed. The following observations were made during a tour of this unit, no infection control precaution signs were on the doors for R911, R912, and R913. The doors were open for R911, R912, and R913. No gowns were present in the supply holder on R911's door. On 10/13/20 at 8:15 AM, Certified Nursing Assistant (CNA) G offered to verify that R911 was in their room on the transition unit and was observed entering R911's room with only a face mask on. CNA G was queried on if they should be wearing full PPE when entering a resident's room on the transition unit. CNA G stated, No, only if I am providing care to the resident. CNA G was queried on the lack of an infection precaution sign being on R911's door, to indicate the resident was under observation for COVID 19. CNA G stated, There should be a sign on the door. It must have fallen off. CNA G was further queried about whether R911's door should be shut. CNA G stated, I don't think so. On 10/13/20 at 8:30 AM, Nurse H who was working on the transition unit, was queried on infection control precautions signs being on the residents doors. Nurse H stated, Yes there should be a sign on the door. Nurse H was further queried about residents on the transition unit needing to have their doors closed. Nurse H stated, No the door can be open. On 10/13/20 at 11:45 AM, the infection control preventionist (ICP) J was met for an interview. ICP J was queried on if isolation precaution signs should be on the doors of residents on the transition unit and if transition unit doors should be closed. ICP J stated, Yes to both questions. ICP J was queried on the appropriate PPE to be donning when entering a room on the transition unit. ICP J stated, They should be wearing a gown, gloves, and a mask. ICP J was queried about their expectations for facility staff working on the transition unit. ICP J stated, Make sure PPE is fully stocked in the door caddy, staff should be wearing appropriate PPE when entering rooms, PPE should be discarded in the room, and hand washing should occur. On 10/13/20 at 12:15 PM, the Director of Nursing (DON) was met for an interview. The DON was queried on their expectations for facility staff involving infection control practices and caring for residents on the transition unit. The DON stated, Staff should be following all precautions listed in our policy. The DON was queried on expectations for the appropriate PPE to be worn by staff when entering transition unit residents' rooms. The DON stated, Staff should be wearing a mask, gloves, gown, and goggles. The DON was queried about if infection control precaution signs should be on doors of residents on the transition unit. The DON stated, Yes, signs should be on the doors. On 10/13/20 at 12:30 PM, a review of R911's electronic health record (EHR) revealed that R911 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. R911's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated that R911 had an intact cognition. On 10/13/20 at 12:40 PM, a review of R912's electronic health record (EHR) revealed that R912 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R912's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated that R911 had an intact cognition. The resident was on the transition unit due to leaving the facility for a medical appointment. On 10/13/20 at 12:45 PM, a review of R913's electronic health record (EHR) revealed that R913 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R913's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated that R913 had no evaluation of their cognitive status. On 10/13/20 at 1:00 PM, a review of a facility policy titled COVID 19 Interim Guidelines Updated [DATE] revealed the following, All new residents , residents who leave the facility for any reason must be placed on the transition unit for 14 days and be monitored for symptoms of COVID 19. Full PPE is required .for residents in surveillance. Residents must remain in their room and door should be closed . On 10/23/20 at 10:30 AM, Activity Aide (AA) H was asked about their role in infection control. AA H reported they would wear a mask and wash their hands. AA H was asked about hand hygiene for the residents as they share the different items such as puzzles and blocks and foam and paper play pieces that could not be wiped down. AA H paused and indicated that they had not considered the need for hand hygiene. AA H did not have wipes or hand sanitizer on the cart. An unopened box of gloves was observed on the cart. On 10/23/20 at 1:15 PM, a review of audit sheets completed by ICP J revealed the following, 10/14/20 and 10/16/20, Staff observed wearing the following properly in the isolation and transition unit, Gowns, Goggles, No; Doors closed, No; Staff washing hands before and after donning and doffing, No; PPE removed and hands washed before leaving isolation unit or leaving each room on the transition unit, No; 10/17/20, Staff observed handwashing between residents; activities, meal serving, No; Staff washing hands between donning/doffing, No; 10/19/20, PPE removed and hands washed before leaving isolation unit or leaving each room on the transition unit, No. IJ Abatement Plan-F880 12 out of 12 residents on the transition unit were assessed (vital signs taken) by the Director of Nursing or designee on October 23, 2020 and residents remain at baseline. 12 out of 12 residents door were closed on the transition unit and residents were educated on keeping their doors closed and staying in their rooms on October 23 ,2020 by the Social worker Each resident room on the transition unit that was occupied by a resident has an isolation box on the door containing Gowns, Gloves, Face shields or goggles. The Central Supply person or designee inspected each box on October 23, 2020 to ensure compliance. A Sign has been placed on the Transition Unit Door to identify the transition unit on or October 23, 2020 by the Central Supply Person Each Resident room has a sign on the door identifying the PPE that is required to be worn when entering the room - Gown, Gloves, N 95 Mask and Goggles/Face Shield on October 23, 2020 by the Central Supply Person 50 out 141 were re-educated on the infection control policy by the Staff Development Nurse or designee on October 23, 2020. Other staff will be educated prior to the commencement of their shift A) PPE to be worn when working on the transition unit when going into resident rooms - Gown, Gloves, N95 mask and Goggles or face shield B) Donning and Doffing PPE on the transition unit C) Each resident room door is to be kept closed and resident to stay in their room D) Signage to be placed on each resident room door identifying the PPE that is to be worn into the Resident Room

This citation refers to MI 502. Based on observation, interview and record review the facility failed to ensure physical abuse did not occur for one sampled resident (R906) and verbal abuse did not occur for one sampled resident (R914), of three reviewed for abuse resulting in R906 with a bloody nose and R914 yelled and cussed at. Findings include: A review of the MIACTS (Required Incident Report to the State) report revealed: Resident (R906) walked into Resident (R905'S) room on August 30, 2020 at 8:15 PM. Resident (R905) threw a plate at (R906) and hit (R906) in (the) nose resulting in a bleeding nose. Residents were immediately separated. A pain and a skin assessment was completed for both residents noting a small cut on (R906's) nose. (R906) was moved to a different room as (their) room has an adjoining bathroom to (R905's) room. On August 30, 2020 Nurse (A) overheard a loud noise and went to investigate and found (R906) walking out of (R905's) room and (their) nose was bleeding. Upon further investigation a broken plate was found on the floor. Upon interviewing (R905) as to what happened, (R905) stated, (R906) came into my room and I threw the plate at (R906) as I didn't want (R906) in my room. (R906) had a small cut inside his nose resulting from the plate hitting his nose. An x-ray was ordered to rule out a fracture and there was no evidence of a fracture. Was Harmed: (R906). A review of the record for R906 revealed R906 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment with a Brief Interview for Mental Status Score (BIMS) of six out of 15 and the need for supervision with most activities of dailiy living. A review of the record for R905 revealed R905 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severe cognitive impairment with a Brief Interview for Mental Status Score (BIMS) of four out of 15 and the need for extensive assistance of one person for dressing, hygiene aand toilet needs. On 10/13/20 at 10:20 AM, a mesh stop sign was observed stretched across door frame of R905's room. The door was open. On 10/13/20 at 1:18 PM, R905 was interviewed in their room. R905 was asked about the incident between the residents and reported that the resident had scared them when they entered the room so they threw the plate to scare them away. R905 further commented they felt staff were afraid of them and did not come in sometimes for hours. R905 was observed to have limited use of their left arm and leg. R905 was observed to have foam and plastic dishware and utensils. R914 On 10/13/20 at 10:07 AM, during an interview with R60, R914 walked in and out of R60's room three times. R60 remarked that it had happened before and did not like R914 wandering in and out of their room. R914 was eating food as they were walking. On 10/13/20 at 10:25 AM, R78 was being interviewed about the care at the facility and R914 walked in and out of the opposite sex room twice. R78 reported it would bother them if they were dressing. R914 wandered all the way in to the widow and back out. A donut was observed on the bed of one of the residents who was sleeping. Staff indicated R914 may have put it there. On 10/13/20 at 10:43 AM, R914 was observed in the doorway of room [ROOM NUMBER]. On 10/13/20 at 11:40 AM, during an interview with R98, R914 wandered into the room and R98 yelled at R914 to get the (expletive) out. On 10/13/20 at 12:01 PM, R914 entered and exited the doorway of room [ROOM NUMBER]. On 10/13/20 at 12:53 PM, during an interview with R22, R914 entered the room walked in twice and was kindly redirected by R22 and walked out. R22 commented that R914 was the resident thief. On 10/13/20 at 1:34 PM, R914 was observed to remove the stop sign from across the doorway, velcro it to the opposite side and walk through the doorway then back out of R98's room. Housekeeping staff redirected the resident from the doorway. A review of the record for R914 revealed; R914 was admitted into the faciity on 10/24/19. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition and the need for limited or extensive assistance of two persons for toilet needs, hygiene and dressing On 10/13/20 at 2:10 PM, Nurse D, was asked about R905. Nurse D reported they had heard the resident throws food, yells out and can be combative, but seems to know what they are doing and was cooperative when their blood sugar was checked. Nurse D continued and reported they had never seen R905 fighting with staff other than tearing up the mattress. Nurse D noted R906 was new to the facility at the time and may have just exited the bathroom on the wrong side by mistake. When asked about R914 Nurse D reported they are prone to wandering all day and requires redirection, but that R914 is easily redirected. On 10/13/20 at 2:18 PM, the Director of Nursing (DON) was asked about the incident between R905 and R906 and reported they were the one who investigated it at the time as they were new to the facility. The DON commented R914 really didn't bother anyone and stop signs had been put up to help limit the rooms R914 entered. The DON was also asked about call light placement for R87 and reported each resident should have a call light in reach. The DON was asked about the table top in the heat register and reported some one should have removed it. On 10/13/20 at 2:27 PM, CNA C was asked about R905 and reported R905 does have mood swings (may may kick and cuss) so staff will try to go in as pair to provide care. On 10/13/20 at 5:13 PM, the Social Worker (SW) was asked about R905, R906 and R914. The SW confirmed R914 wanders and needs redirection. R905 can be verbally aggressive and make threats but was not normally physically aggressive. The SW reported R906 had accidentally walked into the room of R905 and was moved away from R905 and was not aware if R905 had any prior incidents with residents nor had R905 had any since. The SW reported neither resident specifically talked about the incident when asked. On 10/13/20 at 5:57 PM, A review of concerns was conducted with the Administrator and DON. The administrator was asked about the incident between R905 and R906 and reported: R906 who lived next to R905, had gone into the conjoining bathroom and come out the door into R90's room. The nurse heard a loud noise and went to the room to investigate and saw R906 coming out of R905's room with a bloody nose. The nurse saw the broken plate on the floor and asked R905 about it. R905 reported they had thrown the plate at R906. R906 had a small cut from where the plate hit their nose. It was not witnessed, but it is what we think happened. Incidents ports were completed and the police were called. When asked what type of incident this was investigated as, the Administrator reported this as an abuse incident. A review of the facility Abuse and Neglect Prohibition Policy revised 02/17/20 revealed, Policy: Each Resident has the right to be free from abuse .Definitions: Abuse: Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish .Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability.

This Citation Pertains to Intake Number MI 770. Based on observation, interview and record review, the facility failed to provide necessary supervision and monitoring to prevent a second elopement from the emergency exit door on the second floor of the facility at approximately 8:00 PM on 8/1/20 for one (#702) of five Residents reviewed for elopement. An Immediate Jeopardy (IJ) was identified when Resident #702, a severely cognitively impaired Resident who was assessed as being a high elopement risk and had a previous elopement attempt on 7/28/20, exited the building without staff knowledge for an undetermined amount of time. The Resident crossed Kelly Road and Church Street before being located by staff near a bank by the intersection of Kelly Road and Church Street resulting in the likelihood for serious harm, injury, and/or death. The Administrator was notified of the Immediate Jeopardy on 8/5/20. A plan to remove the immediacy was requested. The IJ was removed on 8/5/20 based on the facility's implementation of the plan removal as verified onsite on 8/6/20. Although the IJ was removed, the facility's deficient practice remained at isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of intake documentation revealed a Facility Reported Incident, dated 8/2/20 revealed Resident #702 exited the facility without staff knowledge on 8/1/20 at 8:00 PM. The intake form detailed, Door alarm sounding, and staff went to investigate and found (Resident #702) outside the facility. (Resident #702) was returned to the facility within 3 minutes with no harm . Resident placed on 15-minutes checks . Record review revealed Resident #702 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to limited assistance to perform Activities of Daily Living (ADLs). During a tour of the second floor of the facility on 8/5/20 at 11:10 AM, a smeared, odorous brown colored substance was observed on the floor in Resident #702's room. The Resident was not visible in their room and did not respond to knocking on the room door. On 8/5/20 at 11:20 AM, Resident #702 was observed ambulating in the hallway of the facility. A brown colored substance was observed on the Resident's clothing and hands and the Resident was carrying a greeting card with visible chunks of the brown substance on it. When spoke to, the Resident did not provide meaningful responses. Licensed Practical Nurse (LPN) A was present in the hallway at this time and stated, Don't touch (Resident #702), (the Resident) has poop on them. When asked if the brown substance on the Resident's hands and clothes were stool, LPN A revealed it was. A Nursing Assistant was then observed assisting the Resident back to their room. Observation of the Resident's room at this time revealed additional brown colored, odorous Bowel Movement (BM) on the floor of the room near the bed as well as on the floor and walls in the bathroom. An interview was conducted with LPN A on 8/5/20 at 11:35 AM. When queried regarding BM being on the floors, walls, and Resident #702's clothing and person, LPN A replied, (Resident #702) does that when attempting to clean themselves after having a BM. LPN A was then asked if they were working the day Resident #702 exited the facility and replied, Which time? With further inquiry, LPN A revealed they were working one day when Resident #702 attempted to elope from the facility. When asked what occurred, LPN A stated, (Resident #702) pushed the back door and went out. I followed (the Resident) because they were very upset. When asked what Resident #702 was upset about, LPN A stated, (Resident #702) wanted to go see their (significant other). LPN A revealed they were able to calm the Resident down and get them to come back into the facility because they told them they would set up an appointment (for a visit). When queried regarding how the Resident exited the building as their room is located on the second floor, LPN A revealed the Resident went down the emergency stairway exit and then outside and onto the road. When asked, LPN A stated they never lost sight of the Resident. LPN A was then queried regarding the date the incident occurred. LPN A revealed they were unable to recall but indicated they documented a note in Resident #702's medical record. LPN A then reviewed Resident #702's medical record and stated, 7/28. When asked about the date Resident #702 exited the facility again without staff knowledge, LPN A reviewed the medical record and stated, 8/1, (Resident #702's) nurse that day was (LPN B). During the interview, two forms labeled 15 Min (minute) checks) with Resident #702's name were observed sitting on the desk of the nurses' station. The forms were dated 8/1/20 and 8/2/20. When asked about the 15-minute check forms, LPN A confirmed they were for Resident #702. Upon request, LPN A provided a copy of the forms at this time. When queried if facility staff were still completing 15-minute checks on Resident #702, LPN A replied, No. When queried if there were any additional forms, LPN A indicated they were unaware of any other forms and stated, Administration probably picked them up if there were. When queried how staff were aware of Residents who were elopement risks in the facility, LPN A provided the unit Elopement Book. Review of the book revealed a list of 15 Residents dated 6/15/20. When queried regarding the Resident's on the list, LPN A reviewed the list and stated, Some of those people aren't even here anymore. When asked how many Residents on the list were no longer in the facility, LPN A reviewed the Electronic Medical Record (EMR) and stated, Two that I know of. One was discharged on [DATE] and one was discharged on [DATE]. When queried regarding interventions in place to prevent elopement for Resident #702, LPN A indicated the Resident had a wanderguard (device placed on a Resident that alarms when they come in proximity with an exit door). LPN A was then asked if Resident #702's wanderguard worked and replied, That's a good question. When queried regarding facility policy/procedure pertaining to monitoring wanderguards to ensure functioning, LPN A revealed maintenance checks the doors and stated, It is on the MAR (Medication Administration Record) and they (wanderguards) have an expiration date. When queried if the batteries in the wanderguard can go bad, LPN A revealed that nursing are supposed to check the wanderguards for placement and functionality each shift. When asked how the wanderguards are checked, LPN A stated, There is a little box you put up to it that is green if it is okay. When asked to see the wanderguard monitoring device, LPN A revealed it was in the other medication cart and they did not have a key to access it. LPN A then stated, You also know if it works because it will go off if they walk past a door. When asked if all the doors on the second floor had the wanderguard alarm system in place, LPN A indicated they did not. When asked if the door that Resident #702 exited the facility through had a wanderguard alarm system in place, LPN A replied, No. Detailed review of Resident #702's 15-Minute Check form documentation revealed the form dated 8/2/20 was not completed from 4:45 AM to 6:45 AM. An interview was completed with Nursing Assistant C on 8/5/20 at 11:55 AM. When queried if they were assigned to care for Resident #702, Nursing Assistant C revealed they were. When asked if they were working when the Resident eloped from the facility and if the Resident frequently wanders, Nursing Assistant C replied, I usually work downstairs and indicated they were not familiar with the Resident. The facility investigation was requested from the Administrator on 8/5/20 at 12:05 PM. Upon request, the Administrator stated, Our five-day investigation isn't due yet. When queried what had occurred, the Administrator indicated the Resident had exited the facility and was brought right back by facility staff. Review of provided investigation for Resident #702's elopement revealed a Incident and Accident Report dated 8/1/20, a Weekly Head to Toe (skin) Assessment and a Pain assessment. Review of the Incident and Accident Report revealed the following: -8/1/20 at 8:00 PM . Condition Prior to Incident: Confused/Disorientated . Brief Description: Upon alarm sounding off, writer and staff immediately checked/search east door and Resident room. Finding Resident had left 2nd floor by back hallway emergency exit door. Staff immediately located Resident safe with steady gait . New Action Taken to Prevent Reoccurrence . Resident Education . 15 min checks . Review of Incident and Accident Report dated, 7/28/20 at 12:00 PM, for Resident #702 revealed, Condition Prior to Incident: Alert . Confused/Disorientated . Incident Type: Elopement . Brief Description: Resident exited out of back stairwell from the second floor onto Kelly Rd. Nurse behind (Resident) the whole time attempting to redirect them. Nurse eventually able to talk with (Resident) and bring back into facility safely . New Action Taken to Prevent Reoccurrence . (None indicated) . The actual staff schedule, including staff worked, was requested from the Administrator on 8/5/20 at 12:24 PM. Review of the staff schedule revealed LPN A and Nursing Assistant D were assigned to care for Resident #702 on 8/1/20 at the time of the elopement. Review of Resident #702's medical record revealed Elopement Assessments dated 10/29/19, 11/12/19, 11/19/19 1/28/20, 5/4/20, 7/28/20, and 7/29/20 all indicated the Resident was a High Risk to Wander. Review of Resident #702's progress note documentation in the EMR revealed the following: -7/24/20 at 5:16 PM: Nurses Note . Increased agitation and aggression with staff, resident in other resident's room refused to leave out, unable to redirect resident, resident walking up on staff in their face refusing to move raising voice, unable to redirect behavior NP (Nurse Practitioner) phoned new order to give [MEDICATION NAME] (antipsychotic medication) IM (intramuscular injection) now and new order for [MEDICATION NAME] (anti-anxiety medication) prn (as needed) . -7/28/20 at 12:22 PM: physician progress notes [REDACTED]. Assessments/Plans: Wandering in diseases classified elsewhere - high elopement risk. we will relocate resident to a different room, closer to the nursing station. continue with wanderguard. review with staff . -7/28/20 at 12:26 PM: Behavior Note . Resident was noted at the back stairwell door on the second floor pushing the door to exit, writer attempted redirecting when (Resident #702) then pushed the door exiting down the stairs and out the side door of the facility onto Kelly road. Writer behind (Resident) the whole time finally able to talk to (Resident) and redirect back into the facility safely. -7/29/20 at 12:09 PM: Nurses Note . Resident redirected back to room several times. Wander guard in place will continue to monitor. -8/1/20 at 8:00 PM: Unusual Occurrence Note . Upon alarm sounding off writer, and staff immediately checked/search each door, and residents' room. Finding resident had left 2nd floor by back hallway emergency exit door. Staff immediately located resident with steady gait. Alert with confusion, disorientation. Resident stated/responded to writer they were going home. NO apparent injury, no c/o (complaint of) pain nor facial discomfort. Supervisor notified, POA (Power of Attorney)/Family notified, MD notified. New order 15 min rounds check for location and behavior. Agitation noted PRN (as needed) anti-anxiety given. Reassessed Resident appears more calm, comfort and safety, maintained. -8/3/20 at 10:17 AM: Social Services . Quarterly Note: BIMS (Brief Interview for Mental Status) is a 3 (severely cognitively impaired) . (Resident #702) is an elopement risk with wandering behaviors (Resident) may attempt to go through exit doors. (Resident) is a every 15-minute check. (Resident #702) conversations fluctuate may not remember nor realize what say . Additional record review revealed a Nurse Practitioner Note, dated 12/20/19, which revealed, Resident exhibiting increased confusion, wandering behaviors and attempts to elope . At 12:10 PM on 8/5/20, a phone interview was attempted to be completed with LPN B. A voice mail with return phone number was left. Review of Resident #702's Medication Administration Record [REDACTED]. Documentation indicated the wanderguard had been checked. Additional review of Resident #702's medical record revealed a care plan entitled, I am an elopement risk I have periods of high confusion with wandering behaviors and may attempt to go through exit door. Actual attempted to elope 8/1/20 @ 8:00 PM (Initiated: 11/8/19; Revised: 8/2/20). The care plan included the interventions: -Distract me from exit seeking by offering me (SPECIFY) (Initiated: 8/2/20). No interventions were specified on the care plan. -Every 15 minutes safety checks (Initiated: 8/2/20) -I have a Wanderguard on my person with placement and function checked daily . Expire 7/2020 (Initiated: 11/8/19; Revised: 6/15/19) -Keep my picture in the Elopement book so all are aware (Initiated: 11/8/19) -Move my room closer to the nursing (station), for frequent observation (Initiated: 7/30/20) -Since I am an elopement risk - Observe my mood and listen for me saying such things as 'I want to go home' or 'I want to leave' (Initiated: 8/2/20) An interview was conducted with the Director of Nursing (DON) on 8/5/20 at 1:00 PM. When queried regarding Resident #702's elopement risk and attempts including actual elopement from the facility on 7/28/20 and 8/1/20, the DON indicated they were aware of the Resident's attempted elopement on 7/28/20. When asked what interventions were implemented after the elopement attempt, the DON stated, We moved (Resident #702) closer to the nurses' station. The DON was then asked about Resident #702's wandering behavior after being moved to a different room and stated, (Resident #702) calmed down and then started to wander again. When asked if the Resident had potentially calmed down due to administration of [MEDICATION NAME], the DON did not provide an explanation. The DON was then queried regarding the doors Resident #702 exited the building through on 7/28/20 and 8/1/20 and replied, The door (Resident #702) went out is the same door as before (on 7/28/20). When queried regarding the effectiveness of the intervention of moving the Resident's room, the DON revealed the intervention was not effective due to the Residents ability to self-ambulate and wandering. The DON was then asked if Resident #702's wanderguard was functioning at the time of the elopement and stated, It (door the Resident exited on 7/28/20 and 8/1/20) does not have the wanderguard sensor on it. With further inquiry, the DON revealed the door was a fire door exit which lead to the stairs. The DON further revealed the door would open after the handle was pressed for 15 seconds and that an alarm would sound at that time. When asked, the DON indicated Resident #702 attempts to leave the facility when they want to see their significant other. At this time, the DON provided 15-Minute Check Forms for Resident #702 dated, 8/1/20, 8/2/20, 8/3/20, 8/4/20, and 8/5/20 (beginning at 7:00 AM). When queried where they had obtained the check forms from, the DON indicated the forms were at the nurses' station. When queried regarding the 15-Minute Check Forms dated 8/1/20 and '8/2/20 sitting on the nurses' station desk, the DON indicated the forms for 8/3/20 and 8/4/20 were in a drawer at the nurses' station. Review of the 15-Minute Check Form dated 8/5/20 revealed documentation indicating Resident #702 was in their room from 7:00 AM until 12:00 PM. When asked about the form dated 8/5/20 and LPN A's statement that facility staff were no longer completing 15-minute checks for Resident #702, the DON was unable to provide an explanation. At 1:20 PM on 8/5/20, an interview was conducted with LPN A and the DON. LPN A was queried regarding the 15-Minute Check Form dated 8/5/20 for Resident #702 after they had stated 15-minute checks were not being completed and stated, After I talked to you, I started one. When asked for clarification, LPN A confirmed the form was completed retroactively after interview was conducted with State Surveyor. LPN A exited the interview at this time. When asked about LPN A's response related to 15-minute checks for Resident #702, the DON stated, I just found out about that too. When queried regarding facility policy/procedure regarding documentation of 15-minute checks retroactively, the DON revealed that is not what should occur but did not provide further explanation. When queried regarding the wanderguard expiration date listed in Resident #702's care plan, the DON indicated they would check the device. An interview was completed with Nursing Assistant D on 8/5/20 at 1:30 PM. When queried if they had been assigned to care for Resident #702 on 8/1/20, Nursing Assistant D replied, I don't know right now. When asked if they recalled Resident #702 or any other Resident eloping while they were working, Nursing Assistant D replied, I don't remember looking for anybody. When queried regarding facility policy/procedure pertaining to a Resident elopement in the facility, Nursing Assistant D did not provide a response. On 8/5/20 at 1:44 PM, an interview was conducted with Nursing Assistant E. When asked, Nursing Assistant E revealed they were working on the second floor of the facility when Resident #702 eloped. Nursing Assistant E stated, (Resident #702) wasn't my patient and revealed (Nursing Assistant D) was assigned to Resident #702. When asked what occurred when Resident #702 eloped, Nursing Assistant E stated, The alarm went off and we went and checked the (Resident) rooms. The alarm goes off if somebody gets out. Nursing Assistant E was asked what they were doing when they heard the alarms and replied, I was in a patient room providing care. With further inquiry about what had occurred, Nursing Assistant E revealed the staff split into teams of two people and each team went one way down the hall. Nursing Assistant E then revealed they were not aware of where Resident #702 had been located because they did not locate the Resident. At this time, Nursing Assistant E stated, I ended up being upstairs (second floor) all by myself due to other staff searching for Resident #702. When asked how long the Resident was outside of the facility, Nursing Assistant E was unable to provide a length of time. When asked if Resident #702 normally had wondering behaviors and if the Resident had attempted to elope from the facility previously, Nursing Assistant E replied, Lately (Resident #702) has been anxious and trying more. An interview was conducted with LPN B on 8/5/20 at 2:53 PM. When asked, LPN B revealed they were working on 8/1/20 and assigned to care for Resident #702. When queried regarding Resident #702's elopement, LPN B stated, I was talking to (another nurse) and I don't know what happened. I heard an alarm sound. We all took off looking at exit doors and rooms. When asked if staff were able to identify which Resident was missing from the facility, LPN B revealed they had looked out of the window and stated, I could see someone reacting outside. I ran down the stairs and caught (Resident #702). (The Resident) had crossed the street and made it right to the bank (across Kelly Road and Church Street). When asked if Resident #702 had crossed the road intersection, LPN B confirmed they had. LPN B then stated, I gave (Resident #702) [MEDICATION NAME] when they came back. LPN B was then asked if Resident #702 was an elopement risk and stated, Not to my knowledge. When queried the length of time the Resident was outside of the building, LPN B was unable to provide a time frame. When asked why they had not included that the Resident had crossed the road and where they were located in the Incident and Accident Report they had completed, LPN B did not provide an explanation. At 3:00 PM on 8/5/20, an interview was conducted with the DON. When asked if they were aware Resident #702 crossed the road and was located by staff near the bank, the DON replied, I was. When queried how long the Resident was gone from the building without staff knowledge, the DON revealed they did not know a length of time. When asked if the facility has cameras in place that would have recorded the elopement occurrence and if the footage was reviewed, the DON indicated the facility does have cameras and stated they did not review them. When asked why the footage was not reviewed as part of the facility investigation, the DON stated, I was told they delete automatically and only maintenance can view the cameras. An interview was completed with Maintenance Director G on 8/5/20 at 3:05 PM. When queried regarding cameras within the facility and recording, Maintenance Director G replied, Cameras record for two weeks. With further inquiry related to what areas of the facility the cameras record, Maintenance Director G revealed the cameras record the doors including the emergency exit doors but do not cover outside of the building. Maintenance Director G was then asked if they had reviewed the camera footage for 8/1/20 around 8:00 PM pertaining to Resident #702's elopement and revealed they had not and had not been asked to. Maintenance Director G was asked at this time to review the footage to determine the time Resident #702 exited and returned to the facility on [DATE]. Maintenance Director G indicated they would review the footage and provide the times. Maintenance Director G did not provide the time of Resident #702's elopement exit and return to the facility by the conclusion of the survey on 8/6/20. Review of facility provided policy/procedure entitled, Elopement, Potential Resident (No Date) revealed, It is the policy of this facility to provide residents with a safe and secure environment and identify residents who may be at risk for unobserved exit from the facility . 4. If a resident id identified as being at risk for elopement . the following interventions will be put into place. a Care plan developed that identified the specific risk factors displaced by the resident . d. Elopement risk will be identified on the Resident Status Sheet. e/ A wander alarm devise will be placed on the resident . 5. If the resident attempts to leave the facility without authorization and there is a witness . e. Determine what additional interventions are needed to minimize another attempt . f. Update the resident's care plan with additional preventive measures for elopement . 6. If the resident exits the facility without authorization and there is no witness and if located . f. Assess/investigate why and how the elopement attempt was made. Identify necessary steps to prevent further attempts and document steps taken in the Unusual Occurrence Investigation. g. Implement strategies to minimize recurrence of elopement attempt . k. Update the resident's care plan with preventative measures for elopement . Facility Abatement Plan: Element 1 Resident #702 was reassessed by the Director of Nursing or Designee for elopement on August 5 2020 and resident remains as an elopement risk. A Schedule has been established to monitor the involved Resident #702 every 15 minutes. Resident #702 Wandergard was checked on August 5 and was in place and functioning. Resident #702 Wandergard is checked Q shift Resident #702 had his elopement careplan reviewed and revised as indicated by the Director of Nursing or designee on August 5, 2020. Resident had a skin assessment at the time of the event on August 5, 2020 and there were no changes in skin integrity. Social Work evaluated Resident on August 5, 2020 and noted no changes to his psychological status. Medication Review has been completed by the Nurse Practitioner on August 5, 2020. Physician and Psyche Services evaluation completed. Element 2 All Residents that reside in the facility are at high risk for elopement can be affected. 91 out of 91 resident's elopement assessments were reviewed by the Director of Nursing or designee on August 5, 2020. 15 out of 91 residents were identified as at risk for elopement had their careplans were reviewed and revised by the Director of Nursing or designee on August 5, 2020. 11 out of 15 residents had their wandergard bracelets checked for function and placement by the Director of Nursing or designee on August 5, 2020. 4 out of 15 residents who are not wearing wandergard bracelets were placed on 15 minute documented checks indefinitely by the Director of Nursing or designee on August 5, 2020. 7 x Wandergard Bracelets have been ordered from Secure Care and 4 will be delivered by Friday August 7, 2020 and the remaining 3 will be delivered by Tuesday August 11, 2020. Door alarms were checked by the Maintenance Director or designee on August 5, 2020 and were found to be in compliance. Elopement Drill was completed on August 5, 2020 by the Maintenance Director. Element 3 The Elopement Policy was reviewed by the QAPI Team and was deemed appropriate on August 5, 2020. Elopement Books located at each Nurses Station were reviewed and revised as indicated by the Director of Social Work or designee on August 5, 2020. 67 out of 120 staff have been re-educated on the Elopement Policy by August 5, 2020. The remaining staff will be educated prior to their next scheduled shift. Door alarms are being checked daily by the Maintenance Director of designee to ensure compliance. Any areas of non compliance will be addressed at the time of observation. An AdHoc QAPI Meeting was held on August 5, 2020 to analyze the incident to ensure that processes are being implemented. Element 4 The DON or designee will audit resident at risk for elopement daily x 7 days to ensure careplans are updated, weekly for 4 weeks and then monthly for 3 months to ensure the proper plan of care is in place. Corrective action will be implemented immediately as necessary. Findings will be reported in the monthly QAPI meeting

This Citation Pertains to Intake MI 2- COVID- 19 Based on observation, interview, and record review, the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control (CDC) guidance and failed to provide care and assessment per professional standards of practice for care of Residents with confirmed and suspected Covid-19 (a highly contagious severe respiratory infection) for 23 Residents (including Resident #'s 11,20, 21, 28, 34, 65, 67, 91, 703, 704, 705, 706, 707, 708, and nonsampled Resident #'s 1, 2, 3 and 4) housed on the designed isolation unit of the facility. This deficient practice resulted in lack of appropriate application, utilization, and disposal of Personal Protection Equipment (PPE), lack of assessment per nursing professional standards of practice, lack of facility provided and dedicated medical equipment for Residents on isolation precautions, lack of adequate disinfection and cleaning procedures, cross contamination between the isolation unit and non-isolation areas of the facility, ongoing Resident infections including two Residents (#701 and 702) being transferred to the Isolation Unit on 3/29/20, nine Resident deaths with confirmed/suspected Covid-19 infection and the likelihood of infection and/or death for all 95 Residents residing in the facility. The Immediate Jeopardy (IJ) started on 3/12/20 and was identified on 3/29/20. The Administrator was notified of the Immediate Jeopardy on 3/29/20 and was asked for a plan to remove the immediacy. The IJ was removed on 3/29/20, based on the facility's implementation of the removal plan as verified onsite on 3/29/20. Although the immediacy was removed the facility's deficient practice was not corrected and remained widespread with actual harm that is not immediate jeopardy. Findings include: Record revealed, since 3/12/20, the infection rate within the facility increased exponentially with 19 Residents being sent to the hospital as Persons Under Investigation (PUI- person who has both consistent signs or symptoms and risk factors of infection without available testing for infection confirmation) with Covid-19 symptoms, two confirmed deaths related to Covid-19 and seven additional Resident deaths for Residents considered PUI. Review further reviewed twenty-three PUI Residents with symptoms of Covid-19, including one confirmed Resident with Covid-19, remained in the facility on the isolation unit. Upon entering the facility at 6:15 AM on 3/29/20, Licensed Practical Nurse (LPN) A was observed exiting the Resident care area of the facility, through a closed door, and entering the lobby of the facility wearing a blue colored, long sleeve PPE gown. LPN A did not remove the gown and/or perform hand hygiene prior to exiting the Resident care area of the facility. An interview was completed with LPN A at this time. When queried regarding Covid-19 infection within the facility, LPN A revealed the One South Unit was being utilized as an isolation unit for Residents with positive or suspected Covid-19 infection. LPN A completed the facility Covid-19 screening and recorded a temporal (forehead) temperature (for this surveyor) of 80.3 degrees Fahrenheit (F- Normal body temperature range is 97.0 F to 99.0 F). The temperature recording was not immediately retested to ensure accuracy of the thermometer. LPN A was then observed reentering the Resident care area of the facility in the same blue colored PPE gown without doffing (removing) or donning (applying) new PPE. Cloth, hospital style gowns (short sleeved with snap arms) were available in the lobby area of the facility and provided as PPE to individuals entering the facility. However, the lobby/screening area was not consistently staffed and staff were observed entering the main facility door utlizing their employee badge. On 3/29/20 at 6:20 AM, an observation occurred of the One-South unit of the facility. The unit entrance doors were closed with a sign in place which indicated PPE including gown, head protection, eye protection, gloves, and mask were required for entry. However, no PPE and/or method to perform hand hygiene were present near the entry doors to the unit and there were no staff present in the area outside of the isolation unit doors. Upon entering the unit, PPE and/or a method to perform hand hygiene was not present near the entrance of the unit. A tour of the unit at this time revealed the doors to all Resident rooms were open. Several rooms had two Residents in the room. The Residents were noted to be less than six feet apart from each other in bed and the curtains between the Residents were open. Resident #65 and Resident #91 did not have a curtain in their room. A pole and pump for intravenous (IV) medication administration was observed in the hall of the facility directly outside of an occupied Resident room. The IV pump had IV medication hung on the pole with the medication administration tubing connected and fed through the IV pump. The medication was labeled for administration to an unknown Resident. Two staff were present on the unit, LPN A and Nursing Assistant G. LPN A was wearing a blue colored, long sleeve PPE gown and mask. Nursing Assistant G had a cloth hospital style gown over their scrubs and a mask. Both Nursing Assistant G and LPN A's masks were not positioned properly on their heads/faces and neither staff member were wearing eye protection. An interview was conducted with LPN A on 3/29/20 at 6:30 AM. When queried if they were wearing the same PPE gown they wore when they entered the facility lobby, LPN A replied, Yes. When queried why they did not remove their gown prior to exiting the isolation unit and Resident care area of the facility, LPN A stated, We were told we can leave it on our whole shift and change gloves. When asked how many Residents were on the isolation unit, LPN A replied, Have 23 now. LPN A further revealed additional Residents were transferred to the isolation unit from other areas of the facility during the night. When asked which Residents were transferred to the unit during the night, LPN A revealed Resident #701 and Resident #702. When asked how many staff were present on the unit, LPN A replied, Only me and a CNA (Nursing Assistant) down here all night. With further inquiry, LPN A stated, I can't even take a break, these patients are critical. When asked how many of the Residents had been diagnosed with [REDACTED].#1) and stated, They told me these people (Residents) are all pneumonia but it is not like I have time to look up medical information. LPN A further revealed the facility was unable to obtain tests for [MEDICAL CONDITION] and stated, There are no tests. When asked, LPN A indicated the unit was considered the Covid Unit and Residents with Covid-19 symptoms were placed in the unit. LPN A was queried if they were always assigned to work in the isolation unit of the facility and replied, No. This is my second time working down here. When asked what symptoms the Residents on the unit were displaying, LPN A replied, Loss of smell/taste, diarrhea, shortness of breath, [MEDICAL CONDITION] (decreased blood oxygen level), fever. When queried regarding Resident assessments and if any Residents had fevers, LPN A stated, Pretty much everyone. LPN A was then observed touching their face and then preparing medications for administration to a Resident. When asked if any Residents were having trouble breathing, LPN A indicated there was and revealed they had a portable finger pulse oximeter to assess Resident oxygen levels. Two portable pulse oximeters were observed on the medication cart. One pulse oximeter was pink in color and the other was yellow. The yellow colored pulse oximeter did not have a plastic piece covering the batteries of the pulse oximeter and the batteries were noted to be exposed and secured in the device with tape. A wrist style blood pressure monitoring device was also noted on the medication cart. When queried regarding the pulse oximeters and wrist blood pressure cuff, LPN A revealed they were their personal devices. When asked if the facility had automatic vital sign monitoring machines, LPN A replied, No. With further inquiry regarding the use of personal monitoring items for Resident care and facility provision of equipment necessary for Resident care, LPN A stated, Sometimes you gotta spend your own money to make your day go okay. When queried regarding the location of PPE for staff working on the isolation unit and where they had obtained the blue gown they were wearing, LPN A stated, It was here when I got here but there were only two (gowns available). When queried regarding eye protection, including a face shield or goggles, LPN A stated, We don't really have face shields. There are a couple pair of goggles, but they slide right off my face. When asked if any Residents on the isolation unit were receiving breathing treatments, LPN A replied, Yes. When queried if they were aware their mask was not positioned properly and was not fitted across the bridge of their nose, LPN A replied, No. LPN A then stated, I have one (Resident) who is actively dying right now. When asked about the Resident, LPN A replied, They are a DNR (Do Not Resuscitate) but not hospice. On 3/29/20 at 6:45 AM, an interview was completed with Nursing Assistant G. When queried regarding their assignment, Nursing Assistant G revealed they were the only Nursing Assistant working on the isolation unit of the facility and had 23 Residents. Nursing Assistant G further revealed there was no housekeeping or other staff present on the unit to assist on midnight shift. When queried how many Residents on the unit required assistance and/or were incontinent, Nursing Assistant G replied, 98%. Nursing Assistant G was asked how they are able to provide care to each Resident every two hours and stated, I can't. Nursing Assistant G further revealed they do their best but must prioritize which Resident needs to be changed the most. When queried regarding the IV pole and medication outside of a Resident room, Nursing Assistant G looked at the name of the Resident on the IV medication bag in the hall and stated, Oh, that Resident was transferred to the hospital. Nursing Assistant G was asked when the Resident was transferred, and replied, I think a week or so ago. When asked why they were wearing a hospital gown over their scrubs, Nursing Assistant G revealed that was what they had been provided as PPE by the facility. With further inquiry regarding PPE and if they were provided a blue gown, like LPN A was wearing, Nursing Assistant G stated, Only gave a hospital gown. When asked if they were provided and/or had eye protection available for PPE, Nursing Assistant G replied, No. When queried if they received education regarding how to properly don, wear, and doff their mask, Nursing Assistant G stated, Not recently. When queried if they are in close proximately to Residents when they are coughing and if the Residents breathe on them during care, Nursing Assistant G replied, Absolutely. At 6:50 AM on 3/29/20, Resident #701 was observed in their room with the door of the room open to the hall. The Resident was wearing only a disposable brief and was visible from the hall of the facility. The Resident's legs were off the bed, with their bare feet on the floor. They were not speaking but appeared to be reaching for something on the floor. Nothing was visible on the floor. Nursing Assistant G was observed entering the room at this time. Nursing Assistant G touched the Resident and multiple items in the room without gloves before applying gloves. An interview was conducted with Housekeeping Staff X on 3/29/20 at 7:00 AM. When queried, Housekeeping Staff X revealed they were assigned to clean the isolation unit of the facility. When asked what products they were using to clean, Housekeeping Staff X revealed they were cleaning with Peroxide with multi surface cleaner and disinfectant spray. When queried what items are cleaned in Resident rooms, Housekeeping Staff X replied, Wipe down the toilet, sink, doorknobs, bed side table, call light, side rail. When queried what the floors are cleaned with, Housekeeping Staff X replied, The regular floor cleaner. Housekeeping Staff X was queried if the process for cleaning rooms when a Resident is discharged from the facility is different and stated, Spray the whole room with the cleaner and let it sit for five minutes. On 3/29/20 at 7:13 AM, Housekeeper K was asked about training related to cleaning for the [MEDICAL CONDITION] and reported a gown and mask were to be worn while in the facility. The gown worn by Staff K was noted to be untied in the back and hung loosely at their sides. Housekeeper K further revealed their mask was to be worn for thirty days and they placed it into a Ziplock bag when leaving work for the day. On 03/29/20 at 7:20 AM and at 11:45 AM, the two south shower room toilet area was observed to have a bed sheet, a toilet brush laying on its side, two crumpled paper towels, and a crumpled disposable glove scattered around the floor. Two large black combs rested on the sink counter and a piece of clothing hung off the back of a shower chair. An interview and observation of the isolation unit of the facility was conducted with the Assistant Director of Nursing (ADON) who also functions as the facility infection control nurse on 3/29/20 at 7:20 AM. When queried regarding facility policy/procedure and expectations regarding PPE for staff upon exiting the unit, the ADON indicated PPE should be removed and hand hygiene should be performed. When queried where staff are to place removed PPE and perform hand hygiene, the ADON stated, There should be a container there (at unit exit). When asked why there was not a PPE disposal container, the ADON indicated they were not sure where the disposal containers had gone. When asked about hand hygiene, the ADON indicated staff would be able to wash their hands in a Resident room or the soiled utility room. When queried if those areas were upon exiting the unit, the ADON stated, No. A tour of the unit was conducted with the ADON at this time. All the hall doors to occupied and unoccupied Resident rooms remained opened. When queried if the doors are supposed to be closed per facility policy/procedure, the ADON replied, Yes. When queried regarding staff utilization of personal wrist blood pressure monitors, thermometers, and pulse oximeters for Resident care, the ADON indicated they were not aware staff were using personal monitoring devices for Resident care. When queried regarding reports that an automated vital sign monitoring device was not available in the facility, the ADON stated, We don't have one. The ADON further revealed obtaining automated vital sign monitoring devices was something they had been working on. When queried regarding facility staffing in the isolation unit, the ADON stated, I worked all night in the other unit due to staffing concerns. No further explanation was provided. When asked about dedicated monitoring equipment in Resident rooms who are on isolation, the ADON revealed a blood pressure cuff and equipment should be present in each Resident room in the isolation unit. On 3/29/20 at 7:37 AM, an interview was completed with Licensed Practical Nurse (LPN) B. When queried, LPN B revealed they were assigned to work on the unit for day shift and that this weekend was the first time they worked on the isolation unit. When queried who and how many Nursing Assistants were assigned to work on the unit for day shift, LPN B replied, I don't know, probably one. When queried how Resident vital signs are obtained and if there are blood pressure cuffs in each Resident room, LPN B stated, No, I have my own. LPN B was then observed removing a wrist style blood pressure monitoring device, a thermometer, and a portable finger pulse oximeter from a cloth bag on top of the medication cart. When asked if the facility provided equipment for monitoring and assessing Resident condition, LPN B revealed the facility did not have vital sign monitoring equipment and they purchased their own. When asked if they used the items for multiple Residents, LPN B indicated they did. When queried how they cleaned the items between use on different Residents, LPN B revealed they use alcohol from home and produced an unmarked, colored spray bottle from a different bag at the nurses' station containing a liquid. With further inquiry, LPN B stated they, Filled it (spray bottle) with a bottle from home. When queried regarding facility policy/procedure pertaining to cleaning medical equipment utilized in Resident care, LPN B did not provide an explanation. On 03/29/20 at 7:45 AM, Nursing Assistant P, Nursing Assistant M and Nursing Assistant N were asked about residents who had recently transferred to the isolation unit and reported Resident #67 had A couple of days ago. Resident #67 was transferred into isolation on 3/27/20 with a fever and cough. Resident #711 was in the room next door and was transferred into isolation on 3/31/20. A review of the record for Resident #711 revealed: Resident #711 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. COVID 19 assessments for Resident #711 from 3/17/20 to 3/31/20 documented no fever, cough or congestion. A review of the Nurse Practitioner (NP) note dated 3/31/20 revealed: Reason for Visit: PNA (pneumonia); high rate of COVID 19 exposure in facility. Pt (Patient) was noted to have increased cough with copious secretions (congestion) and hypoxemia (low oxygen/shortness of breath) over the weekend, left eye opaque, yellow crusts to lid margins, will start [MEDICATION NAME] (antibiotic) and transfer to isolation unit. High rate of exposure of COVID 19 in facility. A nurse progress note dated 3/29/2020, 2:22 PM, resident observed choking on secretions. vitals are as follows: BP (blood pressure) 157/118 . Spo2 87% (oxygen saturation) assessment findings: audible crackles in both lungs. These notes contradict the COVID assessment findings. On 3/29/20 at 7:50 AM, Nursing Assistant H was observed standing in the hall of the isolation unit, wearing a hospital gown over their scrubs, near a food tray delivery cart. Nursing Assistant H was not wearing eye protection. An interview was conducted at this time. When asked if they were the assigned Nursing Assistant for the isolation unit on day shift, Nursing Assistant H stated, No. There is no CNA down here. Nursing Assistant H was asked if they had ever worked on the isolation unit and replied, No. I'm just down here to pass trays. Nursing Assistant H was then observed removing a food tray from the cart and entering Resident #95's room. Nursing Assistant H did not have gloves on and touched the Resident's bedding and overbed table. Nursing Assistant H then exited the room without performing hand hygiene and returned to the food tray cart in the hall. Nursing Assistant H obtained another tray from the cart and entered Resident #28's room. Nursing Assistant H moved the Resident's personal items on the overbed table, placed the tray on the table, touched the Resident's bed controller, adjusted the Resident in bed, and opened items on the Resident's food tray without wearing gloves. Nursing Assistant H then exited the room without performing hand hygiene, walked down the hall to the food tray cart, and obtained another food tray. Nursing Assistant H then entered and exited Resident #5 and Resident #11's room with the tray, did not provide the tray to either Resident, and placed the tray back in the food tray cart. Nursing Assistant H proceeded to obtain another food tray and entered Resident #34's room. Nursing Assistant H was observed touching multiple items in the Resident's room including the light switch, the overbed table, the bed, and the bed controller. Nursing Assistant H opened items on the Resident's tray and exited the room without performing hand hygiene. As Nursing Assistant H was walking back to the food tray cart, they were observed touching their face. On 3/29/20 at 8:06 AM, Housekeeper Y was observed not wearing the required gown while on the second floor. At 8:10 AM on 3/29/20, an observation of vital sign measurement occurred with LPN B for Resident #21. LPN B took their personal wrist blood pressure monitor and pulse oximeter into the Residents room. When asked how they were feeling, Resident #21 stated, I don't feel good. I'm coughing and I feel like I'm going to throw up. LPN B obtained the Resident's blood pressure at this time. They placed the cuff over the Resident's wrist but did not raise the Resident's arm and wrist to the level of their heart. LPN B did not obtain the Resident's temperature while in the room. LPN B then removed the wrist blood pressure monitor and placed it directly on the Resident's overbed table. When asked if the Resident had a dedicated, disposable blood pressure cuff and thermometer in their room, LPN B revealed they were not aware of any Residents having dedicated, disposable equipment. LPN B then looked in the Resident's room and stated, No, nowhere. LPN B then exited the room carrying the wrist blood pressure monitor and pulse oximeter. LPN B placed the equipment directly on the medication cart, where medications are prepared, prior to cleaning the equipment by spraying it with the unknown substance in the unlabeled spray bottle they previously revealed they had brought from home. An interview was conducted with LPN A and LPN B on 3/29/20 at 8:15 AM. When queried if the room divider curtains were supposed to be pulled between Residents sharing a room, LPN A stated, Yes. When queried regarding Resident #65 and Resident #91 not having a curtain in their room, LPN A indicated they were not sure why there was not a curtain in the room. When queried if the hall doors to the Resident rooms were supposed to be shut on the isolation unit, LPN B stated, Not made aware if supposed to. We can't see the Residents if we are supposed to. A cloth bag was observed sitting on the nurses' station counter. When queried regarding the bag, LPN A revealed it was their bag. When asked if they were supposed to bring personal items on the isolation unit, per facility policy/procedure, LPN A stated, They (facility management/ administration) haven't said anything. At this time, LPN A and LPN B were queried regarding the IV pole and medication outside a Resident's room. LPN A revealed the Resident who the medication was for had been transferred to the hospital. On 3/29/20 at 8:20 AM, After passing trays to multiple other rooms, without wearing gloves or performing hand hygiene, Nursing Assistant H was observed exiting the isolation unit, without performing hand hygiene and without removing the hospital gown they wore within the isolation unit as PPE. An interview was conducted with Nursing Assistant Z and Nursing Assistant AA on 3/29/20 at 8:22 AM. Both staff were observed in the hall of the isolation unit wearing hospital gowns over their scrubs and without eye protection. When queried regarding PPE and the cloth hospital gown they were wearing over their scrubs, Nursing Assistant Z stated, That's all they gave me and Nursing Assistant AA nodded their head in agreement. When queried regarding eye protection, Nursing Assistant Z revealed there were goggles available somewhere on the unit and Nursing Assistant AA stated they didn't know about eye protection. When queried where PPE is supposed to be placed upon exiting the unit, Nursing Assistant Z walked to the isolation unit exit doors and indicated there was nowhere to place PPE after removal. When asked where they removed PPE when exiting the unit, Nursing Assistant Z did not provide a response. When queried where they obtained the hospital gown being used as PPE, Nursing Assistant Z indicated they got the gown in the lobby when they first arrived at the facility for work. On 3/29/20 at 11:13 AM, CNA S was asked about the care of Resident #702 and reported the Resident had been transferred to the COVID isolation unit due to a rough, dry cough. CNA S did not recall what PPE was in use at the time of transfer. On 3/29/20 at 11:15 AM, a tour of the one north unit was completed. Resident #701's name was present outside of the door of the room and the Resident's bed was observed with no sheets and/or bedding in place on the mattress. The room was shared with Resident #701 and Resident #20. Resident #20 was observed in their room in bed with only undergarments on. An interview was conducted at this time. When asked how they were feeling, Resident #20 stated, I'm so hot. When queried regarding if they were feeling sick, Resident #20 indicated they just felt so hot. When asked if their roommate had been ill, Resident #20 revealed they had. An interview was conducted with LPN BB on 3/29/20 at 11:20 AM. When queried regarding Resident #20 stating they felt hot and their roommate recently being transferred to the isolation unit as a PUI for Covid-19, LPN BB indicated Resident #20 is frequently hot. When queried regarding the Resident's temperature, LPN BB obtained a thermometer from a bag on top of the medication cart. When asked if the thermometer was provided by the facility, LPN BB stated, No, I always use my own. When asked if the facility provided equipment to obtain Resident vital sign measurements, LPN BB indicated they needed to use their own due to the lack of availability of equipment and working equipment at the facility. On 3/29/20 at 11:30 AM, Housekeeper O was asked when they had received their training on cleaning for COVID and stated, Two days ago. Housekeeper O noted they had been working during the outbreak, but not on the isolation unit. Housekeeper O reported the use of a Peroxide Multi Surface Cleaner and Disinfectant for all cleaning activity. Housekeeper O did not know how long the dwell time (time to disinfect) for the disinfectant was as they reported the cleaner was sprayed on and wiped off (immediately). The product details for the cleaner indicated a three to five minute dwell time for the Flu and other germs and as fast as 45 seconds for Norovirus. An interview was conducted with the ADON on 3/29/20 at 12:15 PM. When queried how facility nursing staff know which Residents should be placed in the isolation unit of the facility, the ADON replied, We have a protocol from the Doctor. When queried regarding staff use of personal vital sign monitoring equipment including reliability of equipment and results, the ADON indicated staff are supposed to use facility equipment and stated, I would like something standard. The ADON was then queried regarding observation of staff personal items/bags on the counter of the nurses' station in the isolation unit and stated, (Staff) stuff should be in their lockers, gonna be getting themselves sick. When queried regarding facility policy/procedure related to cleaning equipment after use, the ADON indicated cleaning solutions were available for staff to use. When asked about LPN B bringing a bottle of unknown and unlabeled solution from home to clean their personal devices used to obtain Resident vital signs, the ADON stated, No. It will be gone. When queried regarding infection control tracking and mapping of infections, the ADON stated, With everything that has been going on, I honestly haven't had a chance to really get to it. When asked if they had identified any trends in the areas of Covid-19 infection within the building including commonalities and/or illnesses among staff, the ADON indicated they had not noted the infection to be in any specific area of the building. All completed infection control data including line listing and mapping information were requested at this time. On 3/29/20 at 1:58 PM, the IV pole and pump with medication labeled for a discharged Resident remained in the same place in the hall of the facility and all Resident room doors remained open. At 2:00 PM on 3/29/20, coughing could be heard in the hall from Resident #702's room. The door to the room from the hallway was open. Upon knocking and entering the room, the Resident was observed in bed. The Resident was receiving oxygen via nasal cannula by means of a portable oxygen tank. An interview was conducted with the Resident at this time. When asked how they were feeling, Resident #702 stated, I need cough medicine and something for pain. Resident #702 was asked when they were moved into their current room on the isolation unit and indicated the prior night. When asked how long they had been coughing, Resident #702 revealed they were unsure of the date. When asked if they had been coughing as much as they are now when in their other room in the facility, Resident #702 stated, Yeah, I was. Review of Resident #702's medical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). Review of facility provided documentation revealed the Resident was transferred to the isolation unit of the facility on 3/29/20. Review of Resident #702's progress note documentation in the medical record revealed the following: -3/18/20: Nurse Practitioner (NP) Note . Reason for Visit: worsening cough x 1 day . RR (Respiratory Rate) regular & unlabored, mild expiratory wheezing . NP (Non-Productive) cough .reports worsening cough today . hypoxemia (abnormally low concentration of oxygen in the blood) reported, no SOB (Shortness of Breath) . monitor VS (Vital Signs) daily. Order placed . Check CXR (Chest X-Ray) if no improvement . -3/25/20: Nurses Note . Resident . lying in bed at a high fowler position (sitting upright) resident C/O (Complain Of) persistent dry cough . -3/26/20: Respiratory Therapy Note .admits to cough, lung sounds with course air entry . -3/26/20: Nurse Practioner Note . Reason for Visit: persistent cough x 1 week . lung sounds diminished . Cough . Check CXR, (laboratory testing) . Monitor T (Temperature), HR (Heart Rate), SPO2 (blood oxygen level) closely. Discussed with nurse . Review of Resident #702's Chest X-Ray results, dated 3/26/20, revealed, Impressions: Minimal left lower lung zone linear atelectasis (lung collapse or closure with no air exchange) noted . Resident #702's vital sign documentation revealed the Residents blood oxygen level (SPO2) was 89% (normal range greater than 92% on room air) with oxygen via nasal cannula on 3/29/20 at 7:12 PM. Review further revealed the Resident had never received oxygen therapy while at the facility and their SPO2 level previously ranged from 93 to 98% on room air. On 3/29/20 at 2:10 PM, Resident #701 was observed in their room in the facility with their eyes closed. The Resident's room door was open, the Resident was uncovered in bed, and wearing only a disposable brief. Review of Resident #701's medical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). Review further revealed the Resident was transferred to the facility isolation unit on 3/28/20 from the one north unit of the facility due to symptoms of Covid-19. Further review of Resident #701's medical r (TRUNCATED)

This Citation Pertains to Intake MI 2 - COVID-19. Based on interview and record review, the facility failed to document and implement interventions per Health Care Provider (HCP) order and failed to respond to a change in condition in a timely manner for one (#704) of one Residents reviewed for change in condition resulting in lack of documentation, and Resident #704 experiencing a change in in condition, severe decline in health condition, and delayed transfer to the hospital related to Covid-19. Findings include: On 3/29/20 at 2:30 PM, an interview was conducted with Resident #704's roommate. When queried regarding care including isolation and infection within the facility, the roommate revealed they became ill after (Resident #704) had been ill. With further inquiry, the roommate stated, My roommate (Resident #704) was real sick. They got moved (to the isolation unit) on Saturday. An interview was conducted with Licensed Practical Nurse (LPN) B on 3/29/20 at 2:35 PM. When queried regarding Resident #704, LPN B revealed the Resident was in the hospital but was unsure of the Resident's current condition. Review of Resident #704's medical record revealed the Resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to perform Activities of Daily Living (ADLs). Record review further revealed Resident #704 was transferred to the hospital on [DATE] and had not returned to the facility. Review of Vital Sign Documentation for Resident #704 revealed the following: -3/22/20 at 8:03 AM: SPO2 89 % on Oxygen via Nasal Cannula -3/22/20 at 11:35 AM: SPO2 83 % on High Flow Oxygen Resident #704's medical record also included the following orders: -3/20/20 at 3:13 PM: Sodium Chloride Solution 0.9% . Inject 50 milliliter (mL)/hour subcutaneously X 24 hours for hypovolemia (decreased fluid/dehydration), anorexia, N/V . -3/21/20 at 10:41 AM: Oxygen 2L (Liters) NC (Nasal Cannula) continuous for hypoxemia (decreased oxygen in the blood) Review of Resident #704's Medication Administration Record [REDACTED]. Review of Resident #704's medical record revealed the following progress note documentation: -3/16/20: Health Status Note .Resident . had emesis times one . did complain of coughing with the one emesis . -3/16/20: Nurse Practitioner Note . Reason for visit: Was asked to evaluate resident for c/o (complaints of)N/V (Nausea/Vomiting) . reports they have been vomiting for last 2 days. (Resident #704) has had no appetite and poor oral intake . -3/17/20: Health Status Note .resident c/o nausea . -3/18/20: Nurse Practitioner Note . Reason for visit: Was asked to evaluate resident for persistent c/o N/V . seen today per nurse request for above complaints. (Resident #704) reports they have been vomiting for last 4 days . has had no appetite and poor oral intake . -3/19/20: Health Status Note . resident not feeling so good today. c/o nausea . -3/20/20: Nurse Practitioner Note . Reason for visit: Was asked to evaluate resident for persistent c/o N/V; AMS (Acute Mental Status change) .Pt (patient) seen today per nurse request for above complaints. (Resident #704) has been vomiting for last 5-6 days . no appetite and poor oral intake . Will order labs to be drawn and start gentle hydration with normal saline . Monitor T (temp), HR (heart rate), SPO2 (pulse ox)closely. Pt is at risk for . Covid19. Will need close monitoring . -3/21/20 at 4:52 AM: Nurses Note . Resident was started on hypodermoclysis Sodium Chloride 0.9 at 50 mL/hr . (Authored by Nurse A) -3/22/20 at 11:31 AM: Nurses Note .Resident pulse ox @ 85% on non re breather mask. Unable to increase oxygenation . Order to transfer resident to (hospital) . An interview was conducted with LPN C on 3/31/20 at 9:48 AM. When queried if they had cared for Resident #704, LPN C revealed they had. LPN C further indicated they were assigned to care for the Resident the day they were transferred to the hospital. When queried what occurred the day the Resident was transferred, LPN C stated, Resident #704 wasn't as alert as they normally were. Their oxygen stats were up and down between 80 and 85 percent. When asked what actions were taken at the facility, LPN C detailed, I put (Resident #704) on a non-rebreather (oxygen delivery device mask used to deliver high flow oxygen) at 15 liters. (Resident #704) would only go up 85- 87% on the non-rebreather. LPN C further revealed the Resident was in the isolation unit of the facility when they were transferred to the hospital and had been in the isolation unit for a few days. With further inquiry, LPN C stated, (The Resident) had a positive chest X-ray and a cough before they were moved the isolation unit. When queried regarding the facility policy/procedures related to be moved/transferred into the isolation unit, LPN C replied, The requirements to move down are cough, hypoxic, X-ray changes, fever. When queried if Resident #704 had a temperature documented in the medical record, LPN C reviewed the record and stated, No, I don't see one (elevated temperature) but I know they (facility management/administration) said it was a requirement to move down here (isolation). When asked, LPN C indicated Residents on the isolation unit are confirmed/suspected Covid-19 infection. With further inquiry, LPN C indicated the Resident may have had a temperature but it might not have gotten documented in the Resident's chart. LPN C was then asked if Residents who are transferred to the hospital are supposed to have a Transfer or Change of Condition Assessment documented in the medical record per facility policy/procedure and stated, We haven't been doing them (assessments) because they (have) been emergency transfers. When asked if they were aware of Resident #704 having a decline or hypoxemia prior to having to be transferred on 3/22/20, LPN C stated, In report (Nurse EE) said to watch (Resident #704) because they were worried about them. (Nurse EE) said (Resident #704 don't look to good. With further inquiry, LPN C specified that in report, Nurse EE revealed Resident #704 was on 5 liters of oxygen and they couldn't get them above the high 80's SPO2. A phone interview was attempted to be completed with Nurse EE on 3/31/20 at 10:40 AM. A voicemail message with return phone number was left. On 3/31/20 at 10:55 AM, an interview was completed with Resident #704's Family Member D. When queried regarding Resident #704's care in the facility, Family Member D revealed they were informed (Resident #704) had pneumonia by the facility and were sent to the hospital on [DATE]. Family Member D then stated, (Resident #704) is on a ventilator now and is in isolation. They (hospital) tested (Resident #704) for Coronavirus and are treating them like they have it. With further inquiry regarding the Resident's care in the facility, Family Member D stated, It's not the greatest. They use a lot of temporary people. The housekeeping was terrible. A phone interview was attempted to be completed with LPN E on 3/31/20 at 11:12 AM. A voicemail message was left with return phone number. An interview was conducted with LPN F on 3/31/20 at 11:15 AM. When asked if they had provided care to Resident # 704, LPN F stated, All I did was document the Covid Assessment. With inquiry regarding their actions when completing the Covid Assessment, LPN F replied, I come in and document the temp. I go to every Resident, take their temp, and put it on their sheet. When asked if they do anything other than take Resident temperatures, LPN F stated, No. If I have any temp, I let the nurse know. When queried if they auscultate Resident lung sounds and documentation of Lung Assessment on the Covid-19 assessment in Resident's medical record, LPN F stated, I don't take lung sounds. I know what a wheeze sounds like. If I don't hear anything, I say their lungs are clear. When asked if they are supposed to auscultate lung sounds per facility policy/procedure and how they are able to determine changes in Resident condition without auscultating of lung sounds, LPN F replied, It might be a good idea to do that. No one has said anything to me about it. An interview was conducted with the Director of Nursing (DON) on 3/31/20 at 11:50 AM. When queried regarding facility policy/procedure and expectations when completing the Lung assessment section of the Covid-19 assessment, the DON stated, I expect them (staff) to let me or Infection Control know if there is something changed. The DON added, We actually have a nurse (LPN F) who is coming in just to do the assessments Monday to Saturday. When queried if the expectation is that nursing staff auscultate lung sounds when completing the Lung assessment section, the DON stated, Yes, they are listening to lung sounds. The interview with LPN F was discussed with the DON at this time. When queried regarding LPN F stated they are not auscultating lung sounds the DON replied, I was not aware of that. They are supposed to be listening. The DON was then asked if Nurse EE and LPN E were currently working due to being unable to reach them by phone and replied, (Nurse EE) is off sick and (LPN E) is in the hospital. With further inquiry regarding employee illnesses in the facility, the DON revealed the reason for LPN E being hospitalized and Nurse EE being off was related to Covid-19. When queried regarding the accuracy of documented assessments when lung sounds were not being auscultated, the DON did not provide further explanation. An interview was completed with LPN A on 3/31/20 at 12:00 PM. When queried if they had provided care to Resident #704 on 3/21/20 and if they had initiated the Resident's NS (Normal Saline) infusion, LPN A revealed they worked midnight shift on 3/20/20 into the morning of 3/21/20. LPN A stated, I got there late, probably between 9:00 PM and 10:00 PM. LPN A then stated, (Resident #704) was in their room with their roommate. The roommate told me (Resident #704) was supposed to be on fluids. When asked how the roommate was aware of the fluid order but nursing staff was not, LPN A stated, Another nurse confirmed the order but didn't never start it. I only knew because of the roommate. It didn't show on the MAR (Medication Administration Record). LPN A further revealed the NS order did show on Resident #704's orders but had not been done. When queried regarding Resident #704's condition, LPN A stated, (Resident #704) didn't look so good. They were gray, kinda pale like. LPN A proceeded to detail, (Resident #704) had an oxygen tank in their room but it (oxygen) wasn't on (the Resident) so I put it on. When queried what the Resident's oxygen saturation (SPO2) was at that time, LPN A replied, Their oxygen was low. It was 60-70 something (percent). I saw the SPO2 down and I was worried. I put the oxygen on (Resident #704) and it (SPO2) came up to the 80 percent's. With further inquiry, LPN A then stated, I was worried, (Resident #704) was dehydrated. Their mouth was so dry, they couldn't even talk. My main concern was getting the fluids going because that was something that was supposed to have been done. When asked if they reassessed the Resident during their shift, LPN A stated, I checked (Resident #704) throughout the night. After the fluids started, (Resident #704) started getting color. When asked if they had rechecked the Resident's oxygen saturation, LPN A indicated they did and stated, It never got up to 90 (percent). When asked if they were saying the Residents oxygen saturation remained between 80 to 89 percent on oxygen, LPN A confirmed that was correct. When queried if the nurse caring for Resident #704 had informed them of any concerns with the Resident when they received report, LPN A stated, There was no nurse for me to get report from that shift. I had to do rounds and find out stuff on my own. With further inquiry, LPN A stated, There may have been a nurse on the other cart, but they weren't taking care of those people. They couldn't tell me anything. When queried if the Resident had a temperature or any other abnormal vital signs during their shift and why no vital signs were documented during their shift, LPN A stated, No, but (Resident #704) must have (had a temperature) when the lady (LPN F) came in in the morning to do temps. When queried why they said the Resident must have had a temperature, LPN A replied, I came back to work that night and (Resident #704) had been moved down to isolation (isolation unit of facility). When asked why Resident #704's HCP was not contacted and/or why they were not transferred to a hospital for care due to their change in condition, LPN A revealed the facility has a protocol in place. With further inquiry regarding the protocol LPN A stated, We couldn't send Residents out unless SPO2 is under 80. (Resident #704) was between 80 and 89 (percent) after put on two liters (oxygen). When queried why they did not document administration of NS in the Medication Administration Record [REDACTED]. When queried why they did not document a note or assessment in Resident #704's medical record pertaining to the Resident's condition, LPN A indicated the facility has been short staffed, they have been very busy, and were concerned with ensuring the Resident's fluids were started and most likely forgot. On 3/31/20 at 1:30 PM, a phone call was received from Family Member D. Family Member D revealed they were calling to provide an update that Resident #704 was being taken off the vent today due to decline in condition. A phone interview was attempted to be completed with Nurse EE on 3/31/20 at 1:54 PM. A second voicemail message with return phone number was left. A phone interview was attempted to be completed with LPN E on 3/31/20 at 1:55 PM. A second voicemail message with return phone number was left. On 3/31/20 at 5:15 PM, an interview was conducted with the ADON (Assistant Director of Nursing). When queried regarding Resident #704's normal saline not being initiated when ordered, the ADON reviewed Resident #704's medical record and stated, I don't know why. It definitely should have been started. The ADON further revealed the order was STAT and STAT is a four hour turnaround time. When queried regarding LPN A's statements regarding Resident #704's condition and facility procedure, the ADON was heard reviewing the protocol with the Director of Nursing (DON). The ADON then stated, The protocol states if the SPO2 is less than 80% or shortness of breath. When queried why Resident #704's change in condition was not identified sooner and why they were not transferred to the hospital sooner, the ADON stated, I mean, they are taking care of so many people and there are so many people being transferred to the hospital. When queried regarding LPN A stating they did not receive report from the nurse working day shift upon arriving to the facility to begin their shift, the ADON stated, They should have received report. On 4/2/20 at 9:30 AM, a phone call was received from Family Member D. Family Member D revealed Resident #704 had passed away after being removed from the ventilator on 3/31/20. Family Member D further detailed the hospital told them they believed the cause to be Covid-19 but the test results would be reported to them by the Centers for Disease Control (CDC). Review of facility policy/procedure entitled, Acute Change in Condition (no date) revealed, An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death . Guidelines . 4. Utilize care paths, Document findings, assessments and interventions on the CHANGE OF CONDITION . 5. Changes (symptoms) are communicated to the physician .

Based on observation, interview and record review, the facility failed to operationalization policies and procedures for Resident focused assessment and timely implementation of relevant interventions for pressure ulcer (wounds caused by pressure) prevention for three (#'s 58, 48, and 87) of five Residents reviewed for pressure ulcers, resulting in Resident #58 developing two unstageable (full thickness tissue loss with base of the ulcer obscured) pressure ulcers, Resident #48 developing two stage three (full tissue loss) pressure ulcers, Resident #84 developing a stage two (partial thickness tissue loss) pressure ulcer, unnecessary pain, potential infection, and the likelihood for decline in overall health status. Findings include: Resident #58 On 3/10/20 at 11:47 AM, Resident #58 was not in their room. Observation of the Resident's room revealed the Resident's bed was positioned directly against the wall in the room. An alternating air mattress (specialty mattress for pressure reduction) was in place on the Resident's bed. Review of facility provided documentation entitled, Facility Acquired Pressure Ulcers revealed Resident #58 had developed a pressure ulcer while a Resident at the facility. At 2:55 PM on 3/10/20, Resident #58 was observed sitting in a wheelchair in the main dining/activity room. An interview was conducted with the Resident at this time. When asked if they were having pain, Resident #58 replied, Yes, my legs. I got a sore there. Resident #58 was noted to be sitting with their legs together and knees touching in the wheelchair. When asked what the sore was from and the severity of their pain on a scale from zero to 10, Resident #58 was unable to provide an explanation. Resident #58 was then asked where the pain was located in their legs and replied, Where the sores is. Record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Additional review of the medical record revealed the resident had a history of [REDACTED]. An interview was conducted with the facility Wound Care Nurse, Licensed Practical Nurse (LPN) B on 3/11/20 at 9:07 AM. When queried regarding Resident #58 current pressure ulcers, Wound Care Nurse LPN B revealed the Resident had, Medial inner knee pressure ulcers status [REDACTED]. On 3/11/20 at 2:03 PM, an observation occurred of Resident #58 in their room. Upon knocking and entering the room, Resident #58 was observed in their bed, positioned on their right side with their knees bent. The right knee was bent at approximately a 95-degree angle and their left knee was at approximately 100-degree angle. The Resident was displaying non-verbal signs/symptoms of pain. When asked if they were in pain, Resident #58 replied, Yeah. Nursing Assistant E was present in the room. An open wound not covered by a dressing was noted on the Resident's right medial (inside) knee. The open wound was slightly larger than a half dollar in width and irregularly shaped. The wound bed had dark brown/black colored tissue in the center and was surrounded by red tissue with visible tissue loss and unattached edges. A dressing was in place on the Resident's left medial knee. The dressing was visibly saturated with red colored drainage. A [MEDICATION NAME] (non-latex adhesive) dressing, not contained in a package, with the removable backing intact was noted laying directly on the Resident's over-bed table. The dressing had 3/11 written on it. Nursing Assistant E picked up the dressing and continued to hold it in their hand. At this time, Wound Care LPN B was noted in the shared bathroom between Resident #58 room and the adjoining Resident room. LPN B exited the bathroom and took the dressing from Nursing Assistant E's hand. When asked what the dressing was for, LPN B did not initially provide a response and then stated, Well it was for (Resident #58). LPN B then revealed the pressure ulcer looked different. When asked about the stage of the pressure ulcer, LPN B stated, It's unstageable now. LPN B then proceeded to exit the room without applying a dressing over the open wound. Nursing Assistant E then covered the Resident with the blankets that were present on their bed. When asked about the Resident's pressure ulcer, Nursing Assistant E revealed the dressing came off every time they took off the Resident's pants. When queried if the wound looked different and how, Nursing Assistant E replied, No. Resident #58 was then queried if they were able to bend their knees and the Resident indicated they were not really able to move their legs. When queried if their legs rubbed or if their knees touched when they sat in their wheelchair, Resident #58 replied, Yeah. With further discussion, Resident #58 revealed their mother told them to sit with their legs together. At this time, Nursing Assistant E was queried if the Resident's legs were contracted and revealed they were. Nursing Assistant E further revealed they had been trying to put a pillow in-between the Resident's knees when they were in bed during the day. Review of Resident #58's medical record revealed the following care plan, I have impaired skin integrity on my Right Medial Knee Unstageable pressure, (cicatrix- healed pressure ulcer tissue) Left Medial Knee, s/p (status [REDACTED]. (Initiated: 3/11/20; Revised: 3/12/20). Care plan interventions included: -Administer my treatments as ordered and monitor for effectiveness (Initiated: 10/18/19) -Assess/record/monitor my wound healing. Measure length, width and depth where possible. Assess and document the status of my wound healing progress. Report my improvements and declines to my Dr. (Initiated: 10/18/19) -Assist in repositioning me frequently in my bed or chair (Initiated: 10/18/19) -Ensure my wheelchair arms are padded (Initiated: 10/18/19) -I need a pressure reducing mattress on my bed (Initiated: 10/18/19) -I need a full body sling for transfers (Initiated: 10/18/19) An interview was completed with Physician D and Wound Care Nurse LPN B on 3/11/20 at 3:00 PM. When queried regarding Resident #58, Physician D stated, (Resident #58's) wounds don't look good. They (wounds) are from pressure. When queried regarding interventions, Physician D replied, Have to keep the pressure off (the area). When queried regarding observation of the Resident sitting with their legs together in their wheelchair and no interventions in place in the care plan pertaining to the pressure reduction for the Resident's knees and legs, LPN B revealed they were not aware of the Resident sitting with their legs together and would implement interventions. When asked why interventions were not in place previously, with the Resident's history of pressure ulcers, LPN B indicated the Resident had other interventions in place including an air mattress. An interview was completed with Wound Care Nurse LPN B on 3/12/20 at 10:29 AM. When queried how often wound care assessments are completed and documented for Resident's with pressure ulcers, Wound Care Nurse LPN B replied, Once a week. When asked where wound care assessments are documented, Wound Care Nurse LPN B revealed assessments are documented in the Weekly Wound Healing Record- Wound Care Nurse under the assessment tab in the Electronic Medical Record (EMR). On 3/12/20 at 10:38 AM, wound care treatment observation was completed with Wound Care Nurse LPN B and Nursing Assistant E. Upon entering the room, Resident #58 was observed in bed, positioned on their right side with no pressure reduction interventions in place between the Resident's legs. LPN B removed the dressing from the Resident's right medial knee pressure ulcer. The wound was irregularly shaped. The wound bed had dark brown/black colored tissue in the center with off-white and red colored tissue surrounding the dark tissue. LPN B measured the length and width of the wound and stated, It's 3.5 (centimeters -cm) by 2 (cm). LPN B proceeded to cleanse the wound and apply a new dressing. LPN B then removed the dressing covering the pressure ulcer on the Resident's left medial knee. A healed wound proximal to the open wound was observed on the Resident's left knee. When queried regarding the healed wound, LPN B revealed the area was cicatrix (scar tissue) from a healed pressure ulcer. The open wound was irregularly shaped, and a small amount of light red drainage was noted on the removed dressing. The wound bed had a dark brown/black area in the center and was surrounded by red and then off-white colored tissue. LPN B measured the wound and stated, It's 3.5 (cm) by 1.5 (cm). Nurse B then cleansed and applied a new dressing to the wound. An interview was conducted with Unit Manager LPN G on 3/12/20 at 12:10 PM. When queried what interventions were in place to prevent pressure ulcer development for Resident #58 prior to the current pressure ulcers developing on their left and right medial knees, Unit Manager LPN G reviewed the Residents medical record and stated, A pillow between knees around the clock was ordered on [DATE]. When asked why no interventions were implemented prior to the Resident developing two unstageable pressure ulcers when they had a history of [REDACTED]. Review of Resident #58's medical record revealed the following progress note documentation: -3/6/20 at 12:28 PM: Nurses Note . Writer called to therapy gym r/t (related to) open areas observed on bilateral inner knees. Wound consult ordered. Treatment in place for cushioned gauze pending wound care consultation. -3/11/20 at 3:32 PM: Skin/Wound Note . Writer observed Right Medial knee unstageable necrotic wound base with yellow slough surrounding tissue with scant drainage, flat edge. Left Medial, Upper Leg S/P (status [REDACTED]. (Physician D) present at bed side .Therapy, Dietitian, and guardian notified. Review of Resident #58's Weekly Wound Healing Record- Wound Care Nurse Assessment documentation revealed last wound care assessment completed for Resident #58 was dated 11/26/19. An interview was conducted with the Director of Nursing (DON) on 3/12/20 at 3:35 PM. When queried regarding Resident #58 developing two unstageable pressure ulcers in the facility, having a history of pressure ulcers as well as contractures, and interventions implemented by the facility to prevent pressure ulcer development, the DON indicated the Resident has a care plan for fall prevention which included an intervention of the provision of pillows to encourage good body alignment. When queried if that care plan and intervention was implemented in regards to pressure prevention, the DON indicated they were not able to answer the question. When asked if interventions should have been implemented to prevent pressure ulcer development due to the Resident's history, contractures, and risk for pressure ulcer development, the DON indicated other interventions were in place including an alternating air mattress. No further explanation was provided. When queried why a Weekly Wound Healing Record- Wound Care Nurse assessment had not been completed, the DON was unable to provide an explanation. Resident #48 At 11:15 AM on 3/10/20, Resident #48 was observed in the central dining/activity room of the facility. The Resident was sitting in a geri-chair (large, reclining, wheeled chair). The geri-chair did not have a pressure reduction pad in place on the seat base. Wound dressings were noted on both of the Resident's feet. Review of facility provided documentation entitled, Facility Acquired Pressure Ulcers revealed Resident #48 had developed a pressure ulcer while a Resident at the facility. Record review revealed Resident #48 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident was at risk for pressure ulcer development but did not currently have a pressure ulcer. Additional record review revealed Resident #48 was admitted to Hospice services on 10/9/19. On 3/11/20 at 8:49 AM, Resident #48 was observed in their room, sitting in a geri-chair. The geri-chair did not have a pressure reduction pad in place on the seat base. Dressings were noted on both of the Resident's feet. When spoke to, the Resident would make eye contact and smile but did not provide meaningful responses when asked questions. An interview was conducted with Wound Care Nurse LPN B on 3/11/20 at 8:51 AM. When queried regarding Resident #48, Wound Care Nurse LPN B stated, (Resident #48) came back to the facility from the hospital and their heels were red. (Resident #48) developed some (pressure) ulcers there. When asked if there were pressure ulcers on both of the Resident's heels, LPN B replied, Yeah, stage three. Review of Resident #48's care plans revealed the following, I have impaired skin integrity, h/o (history of) altered skin integrity on my Sacrococcyx/bilateral buttocks . (Initiated: 8/17/19; Revised: 11/5/19). The care plan included the interventions: -Administer my treatments as ordered and monitor for effectiveness (Initiated: 8/17/19) -I need a full body sling for transfers (Initiated: 8/17/19) -I need assistance to turn/reposition at least every 2 hours, more often as needed or requested (Initiated: 8/17/19) -I require a pressure reducing device in my chair - including a geri-chair (Initiated: 8/17/19) -Observe my dressing to ensure it is intact and adhering. Report my loose dressing to my nurse (Initiated: 8/17/19) -There will be weekly documentation as to the progress of my healing (Initiated: 8/17/19) -I need a pressure reducing mattress on my bed (Initiated: 8/17/19) The care plan did not include interventions specific to pressure reduction/prevention for the Resident's heels. Review of Resident #48's medical record revealed the following progress note documentation: -12/12/19: Nurses Note . Black area noted to L (left) heel. Uni-boots ordered. Wound care notified. Hospice nurse notified. Review of Weekly Wound Healing Record-Wound Care Nurse Assessment documentation dated 11/7/19 revealed the pressure ulcer on Resident #48's right heel was acquired on 11/5/19. The assessment detailed, Type: Eschar (tissue seen in stage four or unstageable pressure ulcers) . Measurements . Length: 4.5 (cm) . Width: 5 (cm) . Review of the most recent Weekly Wound Healing Record-Wound Care Nurse Assessment for Resident #48's right heel, dated 2/27/20, detailed the following, Type: Pressure . Overall Impression: Unchanged . Necrotic tissue present . Measurements . Length: 1.4 (cm) . Width: 2.5 (cm) . Depth: 0.2 (cm) . Irregular edges . Treatment . [MEDICATION NAME] gel (wound treatment) daily and PRN (as needed) - Right heel, Left heel . Wound Progress: Right heel is a Stage 3 . not healed . Review of Weekly Wound Healing Record-Wound Care Nurse Assessment, dated 2/27/20, for Resident #48's left heel pressure ulcer revealed the pressure ulcer was acquired on 12/12/19. The assessment detailed, Type: Pressure . Pressure Ulcer Stage: 3 . Overall Impression: Unchanged . Measurements . Length: 0.5 (cm) . Width: 1 (cm) . Depth: 0.2 (cm) . Wound Progress: Left heel is a Stage 3 . not healed . At 2:42 PM and 4:01 PM on 3/11/20, Resident #48 was observed in their room. The Resident was in bed, positioned on their back. On 3/12/20 at 8:47 AM and 9:15 AM, Resident #48 was observed in their room in bed. The Resident was positioned on their back. Wound care observation for Resident #48 occurred on 3/12/20 at 9:21 AM with Wound Care Nurse LPN B and Nursing Assistant F. LPN B removed the dressing from the Resident's right heel. A small amount of red colored, thin consistency drainage was noted on the removed dressing. The wound was directly over the Resident's heel, slightly larger than a quarter in size and had irregular edges. The wound bed was black in color with unattached edges on the lateral side of the wound. The black area of the wound bed was surrounded by red/purple colored tissue. LPN B measured the black area of the wound bed and stated, It's 2 (cm) by 2.8 (cm). LPN B then cleansed the wound, applied [MEDICATION NAME] (medicated ointment), and covered the pressure ulcer with a dressing. LPN B proceeded to complete the dressing change on the Resident's left heel and removed the dressing covering the wound. The removed dressing had a small amount of gray/green colored drainage which was noted to have a slightly foul odor. The wound was irregularly shaped and slightly larger than a pencil eraser. The wound bed was black in color and surrounded by dark red colored tissue. LPN B measured the wound at this time and stated, It's 1 (cm) by 1 (cm). LPN B then cleansed the wound and applied a new treatment and dressing. Following completion of wound care, Resident #48 was positioned on their back in bed by LPN B and Nursing Assistant F. On 3/12/20 at 10:08 AM, Resident #48's geri-chair was observed in the hall outside of their room. The geri-chair did not have a pressure reduction cushion in place on the seating area of the chair. An interview was conducted with Wound Care Nurse LPN B at this time. When asked if the geri-chair in the hall belonged to Resident #48, LPN B indicated the geri-chair did belong to Resident #48. When queried if Resident #48 was supposed to have a pressure reduction cushion in their geri-chair, LPN B replied, Supposed to. When asked why there was not a pressure reduction cushion in the Resident's geri-chair, LPN B looked in the Resident's room for a cushion. After not locating a pressure reduction cushion, LPN B stated, I will get one. No further explanation was provided. R87 On 03/10/20 at 11:05 AM, R87 was observed lying in bed on their back with the head of the bed elevated about 30 degrees and on a low air loss mattress (to prevent or treat pressure ulcers) and heel protectors on both legs. R87 was interviewed regarding pressure ulcers and stated, I had the ones on my feet but now my butt has a sore. R87 was asked if the staff help with turning an repositioning and stated, I can turn. At 1:48 PM, and 4:16 PM, R87 was observed in the same position, and no positioning wedge was observed on the bed. On 03/11/20 at 6:31 AM, R87 was observed sleeping on their back with the head of the bed elevated 30 degrees. At 12:58 PM, R87 was observed attempting to reposition self in bed with great difficulty and settles back onto their back. At 2:45 PM, R87 was observed sleeping in bed on their back with the head of the bed elevated 30 degrees. No positioning wedge was observed on the bed. On 03/12/20 at 7:54 AM, R87 was observed sleeping in bed on their back with the head of the bed elevated 30 degrees. No positioning wedge was observed on the bed. On 03/12/20 at 8:30 AM, Certified Nurses Aide (CNA) C was asked if R87 needed assistance turning and repositioning and stated, (R87) needs help with the legs mostly and will ask for help. (R87) is cooperative and doesn't refuse. On 03/12/20 at 11:40 AM, a pressure ulcer care observation was scheduled with LPN B but R87 was difficult to awaken and needed medical attention. R87 was sent to the hospital. Record review revealed that R87 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Most recent Minimum Data Set (MDS) assessment dated [DATE], revealed R87 had a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognition and needed extensive assistance with Activities of Daily Living (ADLs) including bed mobility. The MDS section B-1 dated 11/13/19 revealed R87 had no Stage 2 pressure ulcers upon admission. Review of the MDS section B-1 dated 02/13/20 revealed R87 had one Stage 2 pressure ulcer. R87's Medication Administration Record [REDACTED]. R87's care plan initiated on 01/31/20 and revised on 02/27/20, Focus. I have impaired skin integrity on my Left Buttock r/t (related to) Stage 2 Pressure Ulcer . Goal. I will show signs of healing and remain free from infection . Interventions. Assist in repositioning me frequently in my bed or chair. Encourage me to make small frequent position changes, I need assistance to turn/reposition at least every two hours, more often as needed or requested, and Use positioning wedge to off load left buttock. An interview was conducted with the Director of Nursing (DON) on 3/12/20 at 3:35 PM. When queried regarding Resident #48's facility acquired pressure ulcers, the DON indicated the Resident was receiving Hospice services. When queried regarding the Resident's history of pressure ulcers and lack of implemented interventions, the DON did not provide an explanation. Review of the facility's undated policy and procedure titled, Facility-Acquired Pressure Ulcers revealed 5. When a pressure ulcer is identified, the licensed nurse will document in the progress notes and on the Weekly Wound/Skin Healing Record, to include size, stage, location, drainage, and odor; obtain treatment order, initiate a care plan, and notify the interdisciplinary team, including the dietitian. The policy and procedure did not specify interventions.

Based on observation, interview and record review, the facility failed to implement a restorative nursing program for four (#'s 58, 48, 36, and 45) of eight Residents reviewed for limited Range of Motion (ROM) resulting in lack of treatment and services to maintain, increase and/or prevent reduction in ROM, increased limitations in ROM, Resident #58 developing contractures, and the likelihood for functional decline, diminished mobility, and pain. Findings include: Resident #58 On 3/10/20 at 2:55 PM, Resident #58 was observed in the main dining/activity room of the facility. The Resident was sitting in a wheelchair with their legs together and knees touching. An interview was conducted with the Resident at this time. When asked if they were having pain, Resident #58 replied, Yes, my legs. I got a sore there. When asked what the sore was from and the severity of their pain on a scale from zero to 10, Resident #58 was unable to elaborate. When asked if they were able to move their legs, Resident #58 revealed their legs were stiff and they were unable to walk. Record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform all Activities of Daily Living (ADLs) with the exception of eating. The MDS further revealed the Resident had functional limitation in ROM on one side of their lower extremities and was not receiving Physical, Occupational, and/or restorative nursing therapy/services. On 3/11/20 at 2:03 PM, Resident #58 was observed in their room in bed. Nursing Assistant E was present in the room. Resident #58 was positioned on their right side with their knees bent. Their right knee was bent at approximately a 95-degree angle and their left knee was bent at approximately 100-degree angle. When asked if they were able to bend their knees, Resident #58 revealed they had limited ROM in their legs. An interview was completed with Nursing Assistant E at this time. When queried if the Resident's legs were contracted, Nursing Assistant E revealed they were. When asked if the Resident was receiving therapy or restorative nursing, Nursing Assistant E divulged they were not aware of the Resident receiving therapy. Review of Resident #58's care plans revealed the Resident did not have a current care plan in place related to completion of Range of Motion (ROM). An interview was conducted with Restorative Nursing Manager U and MDS Nurse H on 3/11/20 at 3:26 PM. Restorative Nursing Manager U was asked if Resident #58 was receiving restorative nursing services and replied, No. With further inquiry, Restorative Nursing Manager U stated, (Resident #58) was discharged from restorative at the end of January. When queried regarding the Resident's limitations in ROM, Restorative Nursing Manager U indicated the Resident was currently receiving therapy services. Documentation pertaining to the Resident's limitations in ROM and restorative nursing documentation was requested at this time. On 3/12/20 at 10:48 AM, the facility Administrator provided documentation of Resident ROM documentation. Review of requested documentation did not include any information/documentation for Resident #58. On 3/12/20 at 2:43 PM, an interview was conducted with Therapy Director V. When queried regarding Resident #58's ROM, Therapy Director V stated, (Resident #58) has severe limitations in ROM in their lower extremities. When asked if the Resident has always had limitations in lower extremity ROM, Therapy Director V replied, Well, I have worked here for five years and not always. Therapy Director V was asked when the limitations developed, and Therapy Director V revealed they were not sure when the limitations developed. Resident #58's therapy documentation was reviewed with Therapy Director V at this time. During review, Therapy Director V revealed Resident #58 was evaluated by therapy in October 2019. Therapy Director V stated, (Resident #58) was picked up (by therapy services) for increased pain in their right knee. When queried regarding the Resident's lower extremity ROM at that time, Therapy Director V stated, Lower extremity ROM was within functional limits. Therapy Director V revealed the Resident received Physical Therapy from 10/16/19 until 11/14/19 and were referred to restorative nursing upon discharge. Therapy Director V further revealed the Resident was currently receiving therapy services. When queried regarding the date Resident #58 was evaluated for current therapy care, Therapy Director V revealed the start of care for therapy for Resident #58 was 2/19/20. When asked about Resident #58's ROM when evaluated on 2/19/20, Therapy Director V reviewed the Resident's medical record and stated, Impaired ROM in the right and left lower extremities. When asked if the Resident's ROM decreased while receiving therapy, Therapy Director V indicated it had not. When asked how the Resident could develop those limitations in ROM if they were receiving restorative nursing services, Therapy Director V indicated they were unsure how those limitations would have developed if ROM was being completed. Review of Resident #58's Physical Therapy Evaluation and Plan of Treatment documentation revealed the following: -Start of Care Date: 10/16/19: Musculoskeletal System Assessment . LE (Lower Extremity) ROM . RLE (Right Lower Extremity) ROM = WFL (Within Functional Limits); LLE (Left Lower Extremity) = WFL . Functional Limitations Present d/t (due to) contracture = No . Clinical Impressions .recently refer to skilled therapy secondary pt (patient) demonstrated decline in functional status, pain in right knee increased . -Start of Care Date: 2/19/20: Musculoskeletal System Assessment . RLE ROM = Impaired; LLE = Impaired . RLE ROM . Knee = Impaired (80-degree extension) . LLE ROM . Knee = Impaired (95-degree extension) . Functional Limitations Present d/t (due to) contracture = Yes . Review of Resident #58's progress note documentation revealed the following: -12/20/19: Nurse Practitioner Notes . Right knee . Unable to fully extend knee; in flexed position. Stiff . Assessment/Plan: Stiffness of right knee vs. muscle contracture . The progress notes did not contain any documentation pertaining to restorative nursing. Resident #48 On 3/10/20 at 11:15 AM, Resident #48 was observed in the central dining/activity room of the facility. The Resident was sitting in a geri-chair with their eyes closed. The Resident's toes were pointed away from their body, with their ankle joint at approximately a 180-degree angle. Record review revealed Resident #48 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had functional limitation in ROM in one side of their upper extremities, both lower extremities and was not receiving Physical, Occupational, and/or restorative nursing therapy/services. Additional record review revealed Resident #48 was admitted to Hospice services on 10/9/19. On 3/11/20 at 8:53 AM, Resident #48 was observed in their room. The Resident was sitting in a geri-chair (large, reclining, wheeled chair) with their feet pointed away from their body and their ankles at approximately a 180-degree angle. The Resident's upper body was leaning to the left side in the geri-chair. An interview was attempted to be completed with the Resident at this time. When spoke to, the Resident would make eye contact and smile but did not provide meaningful responses to questions. Review of Resident #48's care plans revealed the Resident did not have a current care plan in place for restorative nursing services. Review further revealed the last Restorative care plan for Resident #48 was resolved (discontinued) in December 2018. An interview was conducted with Restorative Nursing Manager U and MDS Nurse H on 3/11/20 at 2:58 PM. When queried regarding Resident #48, Restorative Nursing Manager U revealed the Resident was not receiving restorative. When queried if Resident #48 had previously received restorative nursing, Restorative Nursing Manager U reviewed their documentation and revealed they did not have documentation prior to January 2019 due to when they assumed the restorative manager role. Restorative Nursing Manager U then stated, Not since January 2019 and indicated they did not have any records of the Resident receiving restorative nursing. Restorative Nursing Manager U further indicated the Resident was on Hospice and that Hospice Residents do not receive restorative nursing services. When queried if limitations in ROM and contractures are painful, Restorative Nursing Manager U and MDS Nurse H both replied, Yes. When asked why restorative services were not provided to prevent limitations in ROM and contractures for comfort and pain prevention, Restorative Nursing Manager U indicated Passive ROM (PROM) is completed by nursing assistant staff during daily care. When asked if ROM during daily care is the same purposeful ROM which is completed by restorative staff, Restorative Nursing Manager U and MDS Nurse H both replied, No and further revealed ROM performed during daily care does not provide the same benefit as ROM completed by restorative nursing staff. When queried if Resident #48's ROM had been evaluated by therapy staff, Restorative Nursing Manager U revealed therapy staff evaluate Residents quarterly. Documentation of Resident #48's ROM evaluations/assessments and any restorative documentation were requested from Restorative Nursing Manager U at this time. On 3/12/20 at 10:48 AM, the facility Administrator provided Resident ROM documentation. Review of requested documentation did not include any information/documentation for Resident #48. An interview was conducted with Therapy Director V on 3/12/20 at 2:43 PM. When queried regarding Resident #48's ROM, Therapy Director V reviewed the Resident's medical record and revealed Resident #48's last therapy certification period was from 10/1/19 to 10/30/19. When asked if the Resident had contractures at that time, Therapy Director V stated, Their Right Lower Extremity (RLE) was Within Functional Limits (WFL) and their Left Lower Extremity (LLE) was impaired but their hip was normal. When asked about the ROM in the Resident's ankles, Therapy Director V stated, Ankles were within functional limits at that time. Documentation pertaining to most recent therapy evaluations for Resident #48 were requested again at this time. Review of provided Resident #48's Physical Therapy Evaluation and Plan of Treatment documentation revealed the following: -Start of Care Date: 10/1/19: Musculoskeletal System Assessment . RLE ROM = WFL; LLE = Impaired . LLE ROM . Knee = Impaired; Ankle = WFL . Functional Limitations Present d/t (due to) contracture = No . Reason for Skilled Services . increase LE ROM and strength . Resident #36 On 3/11/20 at 10:05 AM, Resident #36 was observed in their room. The Resident was laying in bed, positioned on their back. The Resident was dressed in a hospital gown. Resident #36's right hand was clenched in a fist position and their left hand was covered with a blanket and not visible. The Resident did not respond verbally or non-verbally when asked questions. Record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 1/10/20, revealed the Resident was rarely/never understood and required extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had functional limitation in ROM on both sides of their upper and lower extremities and were not receiving Physical, Occupational, and/or restorative nursing therapy/services. On 3/11/20 at 1:39 PM and 2:40 PM, observation occurred of Resident #36 in their room. The Resident was in bed and wearing a hospital gown. Resident #36's right hand was clenched in a fist position and their left hand was covered with a blanket and not visible. Review of Resident #36's care plans revealed the Resident did not have a care plan in place related to completion of range of motion. An interview was conducted with Restorative Nursing Manager U and MDS Nurse H on 3/11/20 at 3:26 PM. When queried regarding Resident #36's ROM and if they were receiving restorative nursing services, Restorative Nursing Manager U and MDS Nurse H reviewed the Resident's medical record and indicated the Resident was not receiving restorative services. MDS Nurse H stated, No, (Resident #36) is Hospice. When asked about completion of ROM including PROM for comfort, MDS Nurse H stated, That would be with daily care. When asked how the Resident is getting lower extremity ROM when they have been wearing the same hospital gown, Restorative Nursing Manager U replied, With daily brief changes. When queried if ROM completed while changing a brief is the same as ROM completed by restorative nursing staff, Restorative Nursing Manager U and MDS Nurse H both replied, No. When asked if contractures are painful, Restorative Nursing Manager U and MDS Nurse H both replied, Yes. When asked if restorative nursing services are provided, per facility policy/procedure, to Residents receiving Hospice services to prevent limited ROM, contractures, and pain, Restorative Nursing Manager U and MDS Nurse H indicated they understood but did not provide further explanation. Documentation of Resident #36's ROM evaluations and assessments as well as facility policy/procedure pertaining to nursing staff completion and documentation of ROM were requested from Restorative Nursing Manager U at this time. On 3/11/20 at 4:01 PM, observation occurred of Resident #36 in their room. The Resident was in bed and wearing a hospital gown in the position as previously observed. On 3/12/20 at 10:48 AM, the facility Administrator provided documentation of Resident ROM documentation. Review of requested documentation did not include any information/documentation for Resident #36. An interview was conducted with Therapy Director V on 3/12/20 at 2:43 PM. When queried regarding Resident #36, Therapy Director V reviewed the medical record and stated, (Resident #36) was never evaled (by therapy). They came into facility on Hospice. No further explanation was provided. Resident #45 On 3/11/20 at 1:55 PM, Resident #45 was observed in their room, sitting in a geri-chair. Both of the Resident's feet were pointed straight down with their ankles at a 180-degree angle and the Resident's right hand was positioned in a fist. An interview was completed with the Resident at this time. When asked if they could open their right hand, Resident #45 opened their hand slightly, without fully extending their fingers and stated, It hurts. When the Resident opened their right hand, the right pointer finger was noted to be bent at the first joint towards the other fingers on their right hand. When asked if they were able to move their ankles, Resident #45 revealed they could not and were unable to walk. Record review revealed Resident #45 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the Resident was severely cognitively impaired and required extensive to total assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had impaired range of motion on one side of their lower extremities. Review of Resident #45's care plans revealed the Resident did not have a current care plan in place for restorative nursing services. An interview was conducted with Restorative Nursing Manager U and MDS Nurse H on 3/11/20 at 3:20 PM. When queried regarding Resident #45's ROM and if they were receiving restorative nursing services, Restorative Manager U reviewed the Resident's medical record and stated, Previously on restorative until July 2019. Restorative Nursing Manager U and MDS Nurse H further indicated the Resident had not received restorative nursing services since that time. Documentation of Resident #45's ROM evaluations/assessments and any restorative documentation were requested from Restorative Nursing Manager U at this time. On 3/12/20 at 10:48 AM, the facility Administrator provided Resident ROM documentation. Review of requested documentation did not include any information/documentation for Resident #45. An interview was conducted with Therapy Director V on 3/12/20 at 2:43 PM. When queried regarding Resident #45, Therapy Director V reviewed the medical record and stated, Last time on therapy was September 2019. With further inquiry, Therapy Director V revealed the Resident was seen by therapy at that time for positioning. When queried regarding the Resident's ROM limitations at that time, Therapy Director V stated, RLE and LLE impaired. When asked if the Resident was referred to restorative nursing following therapy completion, Therapy Director V indicated the Resident was admitted to Hospice care. Review of provided Resident #45's Physical Therapy Evaluation and Plan of Treatment documentation revealed the following: -Start of Care Date: 9/10/19: Musculoskeletal System Assessment . RLE ROM = Impaired; LLE = Impaired . RLE ROM . Knee = Impaired (15 degree knee flexion); Ankle = Impaired . LLE ROM . Knee = Impaired (0 degree flexion, patient keeps knee stiff); Ankle = Impaired . Functional Limitations Present d/t (due to) contracture = Yes . BLE Ankle PF (Plantar Flexion- foot drop) contracture . An interview was conducted with the Director of Nursing (DON) on 3/12/20 at 3:35 PM. When queried regarding Resident #58 developing contractures within the facility and being discharged from restorative nursing services with Health Care provider documentation in December 2019 indicating stiffness vs contracture, the DON stated, We follow the recommendations from therapy pertaining to length of time Resident's receive restorative services. No further explanation was provided. When queried regarding Resident #45 and 48's limitations in ROM, documentation of decrease in ROM between therapy evaluation and MDS, and lack of documentation of ROM and/or implementation of restorative nursing, the DON did not provide further explanation. Restorative nursing documentation for Resident #58 was requested on 3/11/20 at 3:26 PM but not received by the conclusion of the survey. Review of facility policy/procedure entitled, Establishing a Restorative Nursing Program (No Date) revealed, Identifying Residents for the Program . Residents who could benefit from receiving Nursing Restorative Care can be identified in the following ways: On admission, From information on the MDS . Who is Responsible to Identify Residents for the Program? All staff has the responsibility . Admission Guidelines to Restorative Care . Those who are ready to finish a skilled nursing program . Residents who should receive skilled rehabilitation therapy services but is not strong enough . Residents who require minimal to moderate assistance . Residents who require supervision at mealtimes . Those who could do better working with one-on-one staff .

This citation pertains to intake: 0 Based on observation, interview and record review, the facility failed to properly strap a resident in during transport for one sampled resident (R703) of one resident reviewed for accidents resulting in, the resident falling, experiencing pain, discomfort and psychosocial harm. Findings include: On 1/17/20 at 12:48 PM, an interview was completed with Confidential Witness A who explained that R703 was being transported in the facility van by the Activities Director improperly. As a result, the resident fell and 911 had to be called. Confidential Witness A further explained that R703 was extremely upset about the incident and felt as nothing had been done by the facility. A review of R703's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, R703 is a bilateral [MEDICAL CONDITION] missing both legs. A review of R703's Minimum Data Set assessment dated [DATE] revealed that they required supervision with Activities of Daily Living and was Cognitively Intact. A review of the Incident Report dated 8/1/19 outlined the following: Resident fell out of wheelchair on transportation bus. 911 called and resident transported to (local hospital). A review of R703's medical record revealed the following progress notes: 8/1/2019 15:05 (3:05pm) Nurses Note Text: Writer received phone call from staff/driver of facility transportation bus. Resident had fall on bus while out on leave. Resident noted to have hit their head. 911 notified and transferred resident to (local hospital) ER (emergency room ). Writer faxed over face sheet as well as list of medications . 8/2/2019 16:57 (4:57pm) Nurse Practitioner Notes Note Text: Was called to evaluate resident s/p (status [REDACTED]. Resident was taken to ER for evaluation. Diagnostic studies negative for acute fracture, dislocation. Pt reports feeling sore all over. + (plus) pain to right shoulder and upper back. Aching, worse with movement. Moderate in intensity. Pain medication has been helping. 8/19/2019 15:11 (3:11pm) Alert Note Text: patient expressed that they wanted to end therapy and return to room after completing 30 mins out of 60 mins in gym. pt wheeled (to) nurse for pain medication .crying expressing discomfort. 8/21/2019 17:24 (5:24pm) Nurse Practitioner Notes Note Text: CC (chief complaint): upper back pain, right shoulder pain .Pt participating in PT.OT (physical therapy and occupational therapy) skilled therapy for muscle strengthening, therapeutic exercise. Pt reports feeling sore all over. + pain Right to right shoulder and upper back. Aching, worse with movement. Moderate in intensity. Pain medication has not been helping much but relates to increased activity from PT/OT. Pt had to stop therapy a couple of days ago because of pain. No increased swelling, bruising. MAR indicated [REDACTED]. Usually at night. [MEDICATION NAME] ES (pain reliever) added last visit, 1 gram BID (2 times a day). Further review of R703's medical record revealed that they were seen on 8/5/19 for therapy where they expressed concern about their health after the fall. The progress note indicated the following, (R703) talks at length about a recent fall (R703) had when returning from an outing last week. Resident expresses concern about physical recovery but states, 'I guess I been through worse . R703 was seen again for therapy on 8/12/19. The progress note outlined the following, presents with saddened affect .Resident is tearful throughout the session and talks about recent fall. (R703) focuses on the response from staff as well as their family. (R703) states, 'I'm disappointed.' .Resident expresses they feel as if people do not care about the occurrence because (R703) was not seriously injured and minimizes (R703's) feelings stating, 'Maybe I just want everyone to feel sorry for me, I do feel lonesome.' On 1/17/20 at 2:31 PM, an interview was conducted with the Activities Director, in which he was asked what occurred when R703 fell on the van. He stated, We were headed back from (local store). I hooked (R703) to the floor, and was having trouble getting the seat belt across their body. I was making a Michigan left and (R703) fell out of the wheelchair. We immediately called 911. It was an accident that we wished hadn't happened. The Activities Director was asked if he received any type of discipline and stated, I signed a discipline form and completed education at another facility for basic safety. On 1/17/20 at 3:00 PM, an interview was completed with unsampled resident D who observed R703's fall in the van. They explained that R703's wheelchair was not strapped down, nor did they have a seat belt across their body. They further stated, I told the staff that (R703's) chair was moving, and the Certified Nursing Assistant (CNA) stated, (R703) will be alright. Unsampled Resident D further explained that shortly after that, R703's wheelchair tipped over and they fell . On 1/17/20 at 3:15 PM, an interview was conducted with R703 who had been out on an activity. They were asked about the incident in which they fell on the van. R703 stated, My entire wheelchair fell over, the driver was in a hurry and didn't strap me in on the wheel or the strap across my body. R703 was asked if they had told the Activities Director to not worry about buckling them in and stated, No, he was in a hurry and just waved his hand like forget it. R703 further explained that their roommate told the staff (CNA) on the van that their chair was moving while he was driving, and stated, They'll be alright. R703 further stated, As he turned the corner, the entire chair moved, and I fell and hit my shoulder blade. R703 was asked if they injured themselves and stated, I had a small bump on my head. I went to the hospital and returned the same day. R703 was asked how they felt after the incident and stated, I was kinda mad. I didn't get anything for pain, and I was in bed for several days and couldn't transfer. R703 pulled up a picture on their cell phone dated for 8/7/19 that was taken of their back. The picture was observed and showed deep purple bruising covering approximately 50% of the top half of R703's back. On 1/17/20 at 3:25 PM, CNA B was interviewed about the incident and explained that they were sitting in the front of the van, so they did not see what was going on with the Activity Director securing the resident. CNA B further stated that they heard R703's roommate say that R703's wheelchair was moving and then right after that R703 fell . On 1/17/20 at 1:52 PM, the Director of Nursing (DON) was interviewed regarding the incident. The DON explained that it was the Activities Director's first time driving the bus, and he was having problems trying to get R703's seat belt that went across their body buckled. The DON stated that R703 implied that it was ok to pull off, and he felt comfortable strapping R703's wheelchair down to get going. He further explained, as the Activities Director made a Michigan U, R703 fell out of the wheelchair. The DON stated, They didn't know if (R703) hit their head so (R703) went to the hospital. An investigation was completed, and the Activities Director was written up and re-educated. The DON further explained that the law is that you put on your seat belt and he had a duty as an employee to not pull off unless (R703) was fully strapped in. A review of the facility's Unusual Occurrence policy which was undated outlined the following, The facility will take the measures necessary to provide residents, staff and visitors with a safe and incident free environment .

This citation pertains to intake MI 891. Based on observation, interview, and record review the facility failed ensure that the Physical Therapist place the correct amount of layers between a heating pad and the resident's skin to prevent a burn to 1 (#701) of 3 sampled residents reviewed for accidents, resulting in a second degree burn of the right shoulder. Findings include: On 6/12/19 at 9:31 AM, Resident #701 was observed sitting up in their bed eating breakfast. Resident #701 had no clothes on with exposed upper and lower body. Resident #701's right shoulder was observed to have a large pink oval shaped wound. Resident #701 stated, I got a heating pad in therapy. It was placed directly on the skin it was wrapped with a towel. I don't think she was trying to hurt me. My (spouse) said that there wasn't enough training, she should have checked the temp. I was thinking the hotter the better. On 6/12/19 at 9:50 AM, the Therapy Manager, was asked to observe the heating pad that was used with Resident #701 (R701). The Therapy Manager stated, We removed them completely after this incident the next day on (MONTH) 5th. I was told by the Administrator on (MONTH) 4th. I came in to do an investigation. When I came in, I went to the resident to look at the burn. After that I came into the therapy room. Therapy Staff (Staff A) came up to me and said, 'I think something may have occurred with (R701)'. Staff A told me that she used the right amount of towels. The Therapy Manager was asked what is the procedure for wrapping the heating pad. The Therapy Manager stated, Procedure is to have six to eight layers between the hot pack and the patient, depending on the patient. Therapy Manager was asked how many layers did Staff A use. Therapy Manager stated, It appeared she had three layers. Therapy Manager was asked how were they able to determine the amount of layers. Therapy Manager stated, It was on camera. Therapy Manager was asked if this was Staff A's first time working with Resident #701. Therapy Manager stated, No. She was the primary therapist. (R701) couldn't do any other exercise because (they) were unable to turn (their) neck and (they) have a pacemaker, so the Physician ordered heat therapy and massage. On 6/12/19 at 10:30 AM, phone interview with Staff A was conducted, and they were asked about the incident with Resident #701. Staff A stated, The Doctor (Dr.) had order the hot pack and massage because (they) had neck tension. I had been doing it for a few weeks with a cervical pack (heating pad). I checked (their) skin before the start, I asked is it too hot or is it fine, and during. Never noticed any redness during the hot pack or the massage. Order for bio-freeze after the heat session. Staff A was asked how they place the heating pad on Resident #701. Staff A stated, Cervical hot pack is triangle (shaped) and placed on the back of the neck and down the spine. It was not touching the shoulders. (R701) is a large person and it will not reach the shoulder. I put a clip on the towels to hold it on (R701's) neck. I went to get (R701) on Friday I noticed two band-aids on the shoulder with skin showing in between them. I asked (R701) what happened. (They) said I don't know it may have been the hot pack. On 6/12/19 at 11:08 AM, Nurse B was asked about Resident #701's shoulder. Nurse B stated, I think it was Monday, when I came back to work. I wrote out the incident and accident (I/A) report and notified the Director of Nursing. I was doing my rounds and (R701) said you know I burned my shoulder and then (they) explained to me what happened. (They) said that when (they) were in therapy she put the pad on (them) and that it burned (them). Nurse B was asked how did it look. Nurse B stated, It was yellow and had some black spots in it. On 6/12/19 at 11:21 AM, Nurse C was asked when were they made aware of Resident #701's wound. Nurse C stated, It was reported to me on the fourth that they were investigating (R701's) shoulder and how it happened and that it was a burn possibility. I looked at it the 4th, it was yellow slough with black in areas. Looked like a burn. I called the Dr. and got new orders. On 6/12/19 at 12:18 PM, a review of a video (visual only) with a displayed a start time of 12:46:20 (video time) and date 5/29/19, revealed, at 12:46:20 Resident #701 appears in the screen with Staff A. 12:48:32 Staff A seen laying out one towel opening it on top of a tall gray bin. 12:48:56 Staff A laid the heating pad on top of the towel, inserted it inside a cover, and folded the towel around the heating pad. 12:49:42 Staff A laid the towel with the pad in it directly on the residents right shoulder and pulled it around the back of the neck and walked away. 12:50:03 Staff A back to resident and while pulling it close around the front of (their) neck, tucked the towel ends under each other and walked away. 12:51:34 Staff A back over to Resident #701 to place foot rest in back of chair and walked away at 12:51:55. 12:52:15 resident observed touching the right shoulder moving the heating pad with (their) left hand. Staff A seen on the opposite side of the room during this time. 12:53:52 resident observed touching heating pad on right shoulder with left hand. 12:56:50 Staff A touching the resident heating pad and at 12:57:14 walking away out of the picture. 13:01:19 resident grabbed the heating pad up off the shoulder and letting go at 13:01:25. Resident grabbing heating pad at 13:02:16 rubbing the shoulder moved hand away at 13:02:29. 13:08:43 Staff A walked back into the picture toward resident touching the heating pad in different spots around the pad. 13:08:59 picked up the foot rest and walked away. Resident started self propelling away towards the other side of the room. Staff A putting on gloves 13:09:50. Staff A took off heating pad at 13:10:11. Back is towards the camera, Staff A arms moving. 13:18:04 Staff A step to the side of the resident and hands observed on the back of the resident's neck in a massaging motion. 13:21:13 Staff A observed squeezing a substance out of the bottle into her hands rubbing hands together and then going to the back of the resident's neck. Hands out of view but arm observed moving. 13:25:50 Staff A walked to put something away. 13:25:58 Staff A taking the heating pad away off the table. 13:29:05 resident being pushed out of the door. out of view at 13:29:19. No observation made of Staff A checking skin prior to treatment, during treatment, post treatment and duration of 20 minutes. On 6/12/19 at 1:03 PM, Therapy Manager was showed the video and was asked to count the layers that Staff A placed around the heating pad. Therapy Manager stated, The cover it was placed in is two layers and the towel was one layer. The Therapy Manager was asked if it was three layers total. The Therapy Manger stated, Yes. The Therapy Manager was asked if there were any other residents receiving heat therapy. Therapy Manager stated, No. (R701) was the only one. A review of Resident #701's clinical record revealed Resident #701 was admitted into the facility 10/19/2017 and readmitted on [DATE] with diagnosis (dx) that included [MEDICAL CONDITION], Type 2 diabetes mellitus, and Cervicalgia (neck pain). Minimum Data Set (MDS) assessment dated [DATE] noted, moderately impaired cognition, and required assistance with activities of daily living. A review of a Pain Tool assessment dated [DATE] . A. Location Right shoulder. Hurts a little bit. What makes the pain better? Tylenol . A Progress note dated 6/4/19 Writer met with resident after nurse informed writer of a mark on residents back, writer observed there was mark on the back of (their) right shoulder blade, when asked what happened (they) stated I was told to put the towel on it was my fault. Resident was alert and oriented xs (times) 3 . A Progress note dated 6/4/2019 11:47 NURSE PRACTIONER (NP) NOTES: (R701) Was called to evaluate wound to right shoulder ., long term care resident in nursing home with multiple comorbidities. Nursing requested eval of right shoulder wound. Wound reported this morning during hygiene care. Per patient, wound is a burn from heating pack. Pt (patient) noted the wound Saturday but did not report it. Nurse had noted a small area of [DIAGNOSES REDACTED] (redden area) near area on Thursday evening and applied a protective dressing. Wound today extends over shoulder joint. Pt reports mild to moderate pain. Right shoulder wound approx size of tennis ball. Wound bed with [MEDICATION NAME] exudate and areas of medium brown colored eschar. Wound edges [MEDICAL CONDITION] (swollen) with surrounding [DIAGNOSES REDACTED]. Mild callor present. NO drainage, no odor. Assessment/Plan: 1. Burn of second degree of right shoulder, Epidermis and Dermis affected (top layer and next layer of skin) Assessment consistent with wounds that form after blistering has opened given presence of [MEDICATION NAME] exudate. Other factors such as friction from clothing, rubbing may have played a part in size of wound. Daily wound treatment with [MEDICATION NAME] ointment; Topical [MEDICATION NAME] ointment for pain. Start [MEDICATION NAME] course for 7 days. (Wound Dr.) Wound treatment team to eval (evaluate). Monitor VS (vitals) closely for next 5 days . A Progress note dated 6/4/2019 14:50 (2:50 PM) physician progress notes [REDACTED]. (R701) was getting heating pad in therapy when (they) forgot to tell the therapist about any pain/warmth in the area, and when (they) realized, (they) had gotten burn. (They) did not tell to the nursing staff till today. The NP and wound nurse has evaluated (them), I am seeing (them) for monthly evaluation. (R701) has pain in the right shoulder . (R701) has diabetes and has fluctuating sugars 1. Right shoulder thermal burn: 2/2 hot pad during therapy. - is started on [MEDICATION NAME] and wound nurse will see (them) for contd (continue) wound care. On 6/12/19 at 2:39 PM, the Administrator was asked how many layers were required for the heating pad. The Administrator stated, I Haven't found a specific number on how many times the heating pad should be wrapped. The Administrator was asked if the Therapy company gave a number. The Administrator stated, No person from the company gave me a number on how many times it should be wrapped. The Administrator was asked when did Resident #701 receive heat therapy. The Administrator stated, On Wednesday 5/29/19 and Saturday 6/1/19. The Administrator was asked if there was any other videos for the treatment that happened on Saturday. The Administrator stated, No. On 6/12/19 at 3:25 PM, the Regional Director of Operations (RDO D) (Contracted Therapy Company) was asked how many towels are a standard of practice to wrap the heating pad with. RDO D stated, The recommendation from the manufacturer is six, but it can depend on the patient. The RDO D was asked what is the temperature of the heating pad. The RDO D stated, 155.0°F to 165.0°F, but some things can impact the temp for sure. The RDO D was told about the video observation of Staff A only using three layers and was asked if that was correct. The RDO D stated, It depends. The RDO D was asked why was Staff A terminated. RDO D stated, For inaccurate reporting in the statement not matching the video feed. Further review of Resident #701's medical record noted, Order date: 5/09/2019, OT (occupational Therapy) Treatment 3-5 x's (times) per week for 30 days, effective 5/9/19 to address ., manual therapy and hot/cold packs as needed. Tx (treatment). Dx cervicalgia. Facility Summary report noted, On (MONTH) 4, 2019, Resident (R701) reported to (their) nurse that (they) had a mark on (their) shoulder, and (they) had been burned with the hot pad in Therapy on the previous Saturday, (MONTH) 1, 2019. Resident (R701) said it was (their) fault, (they) knew it was too hot but didn't tell the therapist because (R701) wants to feel better and was talking a no pain no gain mentality . [MEDICATION NAME] removed and is permanently out of service . I/A dated 6/4/19, Location: Therapy, Incident Type: Skin injury. Brief Description: Resident states (R701) was burned by a hot towel during the therapy session on Saturday. Injury Type: Burn. Order: Dated 06/04/2019. Slivadene Cream 1% Apply to R (right) shoulder topically as needed for Burn AND to R shoulder topically every day shift for Burn. Wound Note: dated 6/6/2019. Chief Complaint: This patient was seen today as a consultation for evaluation of patient's wounds. Location: R shoulder . Integumentary (Hair, Skin) Wound #3 Right shoulder is a Burn and has received a status of Not Healed. Initial wound encounter measurements are 4.2 cm length x 2.2 cm width, with an area of 9.24 sq cm. there is a small amount of serous drainage noted. Wound bed has Pink Base [MEDICATION NAME], Moderate Yellow Slough . Diagnosis: [REDACTED]. A review of Staff A written interview noted, I retrieve 6 towels from the clean linen closet. Retrieve the cervical hot pack from hydraculater, place inside the cover. Check patients skin prior to placing 6 layer of towels. Place hot pack that is inside cover on top of 6 layer, fold towels in half to protect all skin area. I clip in place. I leave it on for 13-15 minutes. I ask patient at lease 3 times if it's too hot. I check skin once during TX then again at end. This patient has never said it was too hot. The Facility and the contract Therapy company were asked for the manufacturer manual and both reported not to have one. A review of the policy titled [MEDICATION NAME] (Moist Heat) Policy and Procedure, undated, revealed, Policy Hot packs are filled with [MEDICATION NAME] gel and maintained in heated water. Hot packs are recommended form of heat application however, hot packs can [MEDICAL CONDITION] therefore, only trained, licensed staff may apply them . Procedure: 9 . Remove the [MEDICATION NAME] pack from the [MEDICATION NAME], place the [MEDICATION NAME] pack in the protective cover or towels per manufacturer instructions and place on the area to be treated. Adjust the [MEDICATION NAME] pack as necessary. 10. Provide supervision by checking the patient's skin. Ask the patient for their level of comfort. Remove [MEDICATION NAME] pack if the patient complains of being too hot/ or skin becomes very red .

This citation refers to MI 453 and MI 777. Based on observation, interview, and record review the facility failed to implement interventions to prevent a leg fracture or facial bruising during care and ensure two persons were utilized per the care plan to provide care and or transfer to prevent the injury for two sampled residents (R701, R705) of four residents reviewed for quality of care in a total sample of seven, resulting in injury, (leg fracture or facial bruising and hematoma) to the residents. Findings include: Resident #701 On 05/18/18 at 7:40 a.m. and 3:03 p.m., the facility MIACTS (facility event reporting form) report dated 04/07/18 was reviewed and revealed: Resident R701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R701 is alert with confusion with a Brief interview of Mental Status (BIMS) score of four out of 15 which indicated severely impaired cognition. The incident summary revealed: On 4/5/18 Nurse G reported that Certified Nursing Assistant (CNA) E stated R701 twisted an ankle when the CNA was transferring R701 from the wheelchair to the bed. CNA E stated R701 asked to go to bed and CNA E proceeded to transfer R701 from the wheelchair to the bed. CNA E noticed that when they went to lift R701 to the standing position, R701 stood up but placed their body weight onto CNA E. CNA E then placed a leg between the legs of R701 and proceeded to transfer R701 to the bed. CNA E could not recall if R701 moved their legs to help assist with the transfer. CNA E transferred R701 legs from the sitting positron into the bed and upon doing so R701 complained of left ankle pain. CNA E then reported the incident to the nurse. Nurse G assessed R701 and the skin was pink, pedal pulse 60, slight swelling, no redness and moderate pain. Nurse G received orders for stat x-ray. X-ray results: Acute distal fibular fracture (lower leg bone). R701 was transferred to the hospital. Conclusion: During transfer of R701 from the wheelchair to the bed, R701 injured the left distal fibular resulting in a fracture. On 05/18/18 at 2:09 p.m., R701 was observed seated in a wheelchair is the day room. A hard plaster type cast was observed to cover the left lower leg and foot. The toes of the left foot were exposed. R701 reported they were walking before the fracture happened but could not recall the exact details of the event and the cast may be off in about two weeks. On 05/18/18 at 2:13 p.m., Nurse G was queried about how the ankle fracture occured and stated, I am not sure. I think it has to do with a transfer. You will have to talk with the Director of Nursing (DON) or Administrator about the details. (R701) has been in a cast about six weeks. Nurse G also reported R701 never walked and was alert but with confusion. On 05/18/18 at 2:19 p.m. CNA H was queried about about the ankle fracture for R701 and stated, It happened on the afternoon shift and wasn't transferred properly. (R701) is a two person assist and was a two person assist at the time. It is in the Kiosk (CNA care guide). CNA H also reported having been regularly assigned to R701 over the last six months. On 05/18/18 at 4:15 p.m., a review of the facility provided investigation of the ankle fracture for R701 was reviewed and revealed: Employee failed to transfer resident according to the resident care guide. Resident was a two person assist. An x-ray dated 04/06/18 indicated, Acute Distal Fibular Fracture. An incident report dated 04/05/18 at 5:35 p.m., revealed, Left ankle twisted during transfer to bed per CNA. On 05/18/18 at 4:20 p.m., a review of the medical record for R701 revealed: R701 was admitted into the facility on [DATE] and 09/11/14 and readmitted on [DATE] after hospitalization to repair the fractured left lower leg. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] did not indicate the cognition status but indicated the need for extensive two person assist for transfer and extensive one person assist for locomotion via wheelchair. A nursing progress noted dated 04/10/18 revealed: Readmit day #1. Left leg hard cast in place (related to) r/t distal tibia (fracture) fx. (Complaint of) C/O pain at site. Pain level 6/10. A nursing progress note dated 04/13/18 revealed, c/o left leg pain. An I am at risk for falls nursing care plan with intervention initiated 05/12/15 and revised 08/10/17 which indicated, Transfer me using two person Sit to Stand. (This is a mechanical lift transfer.) The Kardex (electronic CNA care guide) indicated, Transfer Status: Hoyer (Always two person assist). On 05/18/18 at 4:48 p.m., a phone call was made to CNA G and a message was left to return the phone call. CNA G did not return the phone call. Resident #705 On 05/18/18 at 7:50 a.m. and 3:30 p.m., the facility MIACTS forms dated 05/09/18 and 05/16/18 revealed: On 5/8/18 at 2:30 pm the resident was observed with discoloration and swelling to the forehead and left eye. Resident stated was in bed when the nursing assistant was giving care. The nursing assistant went to push (R705) over onto the right side and (R705) rolled out onto the floor. The facility MIACTS form dated 05/16/18 revealed: On 5/8/18 at approximately 2:30 p.m. the resident was observed with discoloration and swelling to the forehead and left eye. Resident stated was in bed when the nursing assistant was giving care. (R705) stated that two nursing assistants went to push (R705) over onto the right side and (R705) rolled out of bed onto the floor. (R705) was interviewed on separate occasions by the Social Worker, Unit Manager and Director of Nursing. During the interview, (R705) stated was pushed out of the bed by two nursing assistants onto the floor. The Director of Nursing and Maintenance Supervisor reviewed the video footage at the time of the incident and did not identify two nursing assistants entering the room. During the video footage, it was observed that (CNA Z) enter(ed) the room with clean linen to assist (R705) at approximately 2:11 p.m. At 2:14 p.m. (Housekeeper D) was observed entering the room and exiting at 2:17 p.m. During that time (Housekeeper D) and (CNA Z) were holding a conversation in the hallway from 2:17 pm to approximately 2:27 p.m. At 2:27 p.m. (CNA Z)re-enter(ed) (R705's) room. At approximately 2:35 p.m. (CNA Z) stood in the doorway and put dirty linen in a bag. At that time (CNA Z) was observed telling a CNA in the hallway to go get the nurse. The nurse arrives to the room and shortly thereafter, the unit manager reported to the room. At approximately 2:50 p.m. the incident was reported to the Director of Nursing. The Director of Nursing spoke with (CNA Z) and stated (CNA Z) went to pull (R705) up in bed and accidently hit (their) head on the head (board). The Nurse reported that (R705) stated (R705) was pushed out of bed while care was being given. The nurse assess(ed) the resident and noted, lump on the left side of forehead and discoloration to the left eye, notified the MD, and received orders for stat skull x-ray. The test results were negative for fractures. The nurse did another assessment and noted discoloration and swelling to the right leg. Resident stated it was from the fall. The nurse notified the MD and orders given for stat x-ray and the results was negative for fracture. Conclusion: (CNAZ) was giving care to (R705). (CNA Z) attempted to turn (R705)onto her right side and she rolled out of bed. (CNA Z) received education to provide (R705) with two person assist with bed mobility. On 05/18/18 at 1:40 p.m., R705 was observed in bed. A lump/knot was observed to the left side of the forehead above the left eye. It appeared about the size of a golf ball and had purple and yellow coloration on and around the lump. Similar discoloration was observed under the left eye and onto the left cheekbone of R705. R705 was asked about the bruising and lump on the left side of the face and stated, They dropped me. On 05/18/18 at 1:53 p.m., Nurse K was queried about the bruising and stated, I am not sure how it happened. At this time the electronic record was checked by Nurse K and revealed a transfer report dated 05/08/18 which indicated a discharge to the hospital with a fall assessment and neuro checks (mental status checks). Nurse K further reported R705 can be resistant to care. On 05/18/18 at 2:24 p.m., CNA L was queried about the assist status for R705. CNA K stated, R705 is a two person assist in the Kardex. and had been at least since (MONTH) of last year. CNA K reported R705 would scream and holler during care and didn't like to be changed. On 05/18/18 at 4:30 p.m. the medical record and facility investigation were reviewed and revealed: R705 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition with a two out of 15 BIMS and the need for extensive assistance of two persons for bed mobility. Transfer status indicated transfer did not occur. The MDS further indicated impairment to the upper and lower extremity on one side and R705 was always incontinent of bowel and bladder. The My Transfer Status care plan initiated 12/22/17 with intervention dated 12/22/17 which indicated, I transfer with two person extensive assist. The I need assistance with my (Activities of Daily Living) ADL's care plan revised 12/30/17 revealed Bed mobility (revised 06/29/16): I require 2 person assistance by staff to turn and reposition me frequently in bed. The Kardex indicated, Transfer Status: I transfer with two person extensive assistance. Bathing/Showering: I require 2 person assistance by staff with bed bath/showering .Bed Mobility: I require extensive 2 person assistance by staff to turn and reposition me frequently in bed. A physician progress notes [REDACTED]. Assessment/Plan: 1. Multiple contusions in various stages of resolution. No secondary problems. No sequelae from falling out of bed. The incident report dated 05/08/18 2:35 p.m., revealed, Writer summoned to room, resident has tennis ball size mass to left eye with discoloration. Resident stated she did not fall out of bed. On 05/18/18 at 4:45 p.m. CNA Z was asked via the phone about the incident with R705. CNA Z stated, I went in about 9:30 a.m. and did a complete bed change. I couldn't find help. When I went to scoot (R705) up, hit head on the headboard. I came back around 2:30 p.m. I was real busy that day, didn't have chance to check every two hours. Around 2-230 I went to change (R705). (R705) was my last resident. That is when I noticed the head. I went myself to the DON. I couldn't find help. CNA Z reported they had provided care without assistance from a second staff but denied the resident rolled out of bed. On 05/18/18 at 4:57 p.m., the Administrator and DON were queried about the incidents with R701 and R705. The DON confirmed for R701, (CNA G) transfered (R701) and (R701) complained of leg pain afterwards, an x-ray was done and revealed a fracture, R701 was sent to the hospital and R701 was a two person assist. The DON was also queried if R701 was transfered with only one person and stated, Correct. The DON was then asked if the Nursing Care Plan and Kardex indicated R701 was a two person transfer and was now in a cast as a result of the transfer and stated, Yes. The DON reported for R705 that CNA Z had reported the incident and stated they had bumped the head of resident R705 against the head board during morning care but noticed no bruising at the time. A review of the cameras revealed CNA Z as the only CNA in the room and to have carried in clean items to care for R705 and removed dirty items to the soiled utility for R705. The DON confirmed only one CNA provided care to R705 and R705 needed two resulting in a hematoma and bruising to the forehead.

This citation has two deficient practice statements. DPS#1 This citation pertains to intake # . Based on interview and record review, the facility failed to prevent falls with injury by not implementing new interventions, by not following current care plan interventions and by not updating the fall care plan following a fall for one of two residents (#703) sampled for falls, from a total sample of seven, resulting in continued falls with major injury, including a [MEDICAL CONDITION] requiring hospitalization and surgery. Findings include: On 1/18/18 at 9:30 a.m., a record review of the face sheet was completed for Resident #703. According to the face sheet, Resident #703 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. There was no completed Minimum Data Set assessment in the medical record at the time of the survey. On 1/18/18 at 9:35 a.m., a record review of the medical record was completed for Resident #703. Resident #703 was discharged from the facility on 10/11/17 and transferred to the hospital. According to the physician orders, Resident #703 had an order to transfer with 1 person assist and was in physical therapy. A record review of the progress notes revealed the following: 10/9/17-(Resident #703) observed sitting on wet floor next to bathroom. Asked Resident what ? Resident states he was trying to go to the rest room when he slipped and landed on his bottom. Resident states he did not hit any part of his body except his butt. assessed with [REDACTED].Alarms would be a really good idea . 10//11/17-At 4:00 a.m., Resident observed sitting on floor by his closet, wanted to pick out his own clothes, complete body assessment done, no apparent injury noted, denies pain at this time. MD (Medical Doctor) and Family notified .continue with every 15 safety monitor. 10/11/17 9:40 a.m.-Resident verbalized complains of pain to left leg, able to move extremity, observed with facial grimacing, no visible injury to site, MD notified, ordered X-ray to left leg. Resident medicated for pain, observed with effective result. Every 15 minute safety check to continue with safety alarm added to wheel chair x 10 days. 10/11/17 11:40 a.m.-Order noted for safety alarm while up in wheelchair and while in bed at all times x 10 days. Resident, family and staff notified of order. 10/11/17 8:54 p.m.-Alert, able to make some needs known. Complains of pain, moaning and groaning and grabbing BLE (bilateral lower extremities) . 10/11/17 10:13 p.m.-X-ray results arrive, acute left femoral neck fracture. Doctor notified, new order to transfer to (hospital) . On 1/18/18 at 10:05 a.m., a record review of the fall assessments for Resident #703 was completed and revealed the following: 10/5/17 score 65 10/11/17 score 75 Noted on the form is a key indicating a score above 45 requires fall interventions as the resident is considered a high risk to fall. On 1/18/18 at 10:25 a.m., a record review of the fall care plan for Resident #703, created 10/6/17 revealed the following: Problem-I am at risk for falls r/t (related to) limited mobility, weakness . Goal-I hope to be free from falls without a serious injury by next review. Call light within reach at all times, every 15 minutes check rounds. Interventions- .call light is within reach . Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheel chair). I need a safe environment with floors free from spills and/or clutter, adequate, glare-free light . Keep my bed in it's lowest position after giving care. Observe me or ask me if I am having any s/s (signs and symptoms) of pain. PT/OT (physical/occupational therapy) to evaluate and treat as needed. All interventions were dated for 10/6/17, except for the first intervention, which was dated 10/12/17, after Resident #703 was transported out to the hospital. On 1/18/18 at 10:30 a.m., a record review of the incident reports for Resident #703 was completed and revealed the following: 10/9/17-Resident observed sitting on floor next to bathroom door. Resident states he was trying to go to the rest room, when he slipped and sat on the floor. No apparent injury. He states he did not hit his head. Under Action taken, there was a check mark placed next to the statements Care Plan Update and Resident Education. A check mark was placed in the box that says No next to the statement, Was bed/personal alarm in use? 10/11/17-During unit rounds charge nurse observed resident sitting on floor in front of pt. (patient) closet, patient stated I'm trying to get my clothes and dress up . Under Action taken, there was a check mark placed next to Resident Education. A check mark was placed in the No box that stated, Was bed/personal alarm in use? On 1/18/18 at 11:00 a.m., a record review the Radiology Report completed on 10/11/17 on Resident #703 stated under conclusion: Acute left femoral neck fracture. On 1/18/18 at 1:15 p.m., an interview was completed with the Director of Nursing (DON) in regards to the interventions put into place to prevent further falls with Resident #703. The DON stated, I really don't know about that, this happened before I came. There should be a post fall assessment that states what the new interventions are. On 1/18/18 at 1:20 p.m., an interview was completed with Unit Manager Nurse A in regards to the interventions put into place for Resident #703. According to Nurse A, I interviewed the nurse and asked her why and how the fall happened .she is an agency nurse and is no longer allowed to work here because of this situation. On 1/18/18 at 2:40 p.m., an interview was completed with the DON in regards to the process of what should happen following a fall. The DON stated, They (the nurses) do interventions right away. When they do them they go in the care plan. During this time the DON was asked about the charting that documented following the fall on 10/9/17 that talked about alarms being a good idea. The DON stated, That (the alarms) would have been the intervention put into place. The Fall care plan was reviewed with the DON and did not indicate an intervention alarms. The DON was asked if the alarms were not indicated in an order for [REDACTED]. On 1/18/18 at 3:30 p.m., an interview was completed with the Administrator in regards to the interventions for Resident #703's falls on 10/9/17 and 10/11/17. During that time the notes were reviewed with the Administrator. The Administrator replied, I would have to look into this. On 1/18/18 at 4:30 p.m., an interview was completed with Family Member C in regards to Resident #703's falls that occurred at the facility. Family Member C stated, He (Resident #703) still hasn't recovered from his [MEDICAL CONDITION]. He is in a tremendous amount of pain with that hip. When he fell the first time they didn't put any alarms or give him anything to help him. Now he is in another nursing home. On 1/18/18 at 3:45 p.m., a review of the facility policy titled, Fall Management Guidelines (with no revision date) was completed and revealed the following: Overview: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the falls. Residents will be evaluated by the interdisciplinary team (IDT) for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. Practice Guidelines: 5. The licensed nurse will document the incident on .Nurse's notes, Post-Fall Assessment .Charting in the nurses notes over the next 72 hours .Update the care plan. 12. The IDT will review/modify the plan of care to minimize the risk of repeated falls. 13. The IDT will complete the Interdisciplinary Post-Fall Assessment. DPS #2 This citation pertains to intake MI 488 Based on interview and record review the facility failed to properly transfer a resident per the resident's documented assessed needs for two (Resident #701 and 707 ) of two resident reviewed for accidents from a total sample of seven, resulting in a hematoma on the left leg and pain for Resident #707 and the potential for injury for Resident #701. Findings include: Resident #707 On 1/18/18 at approximately 9:30 a.m., the clinical record for Resident #707 was reviewed and revealed the resident had been admitted into the facility on [DATE] and had been readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated cognitive impairment and the need for extensive assistance of two persons for transfer. Further review of Resident #707's clinical record revealed the following: Progress Notes: 12/28/2017 Health Status Note Text: Resident complaint of left lower leg pain. Observed large raised area, pinkish white color, sore to touch and painful per patient state. Also states she didn't know what happen, then changed to the care giver hit my leg and told me to shut up. No bruise or redness noted, pedal pulse felt, surrounding tissue pink. 12/28/2017 Social Services Late Entry: Note Text: Writer spoke with resident in regards to bruise on left leg. Writer interviewed resident in her room regarding incident. Resident stated I think my aide hit me . Resident verbalized feelings of pain. Left leg noted to have a large gray area on shin, warm to touch. Resident unable to relate how she obtained the bruise . Resident noted to have increase anxiety, psych services to follow . 12/28/2017 Health Status Note Text: Left leg with increase swelling. Per Doctor . send to . Hospital to r/o (rule out) [MEDICAL CONDITIONS] . 12/30/2017 Health Status Note Text: pt (patient) resting/sleeping most of night. L (left) lower lateral leg with faint purple bruising, fluid noted just under skin. Dry protective dressing applied . 12/29/2017 Health Status Note Text: Returned from St John Hospital via stretcher alert and verbal response. [DIAGNOSES REDACTED]. Leg with decrease swelling, bluish discolor with medium fluid filled area. Surrounding tissue pink, warm . 1/2/2018 Interdisciplinary Note Text: IDT team met to discuss incident on 12/28/17. Resident was observed with a large swollen area on her left shin. Res c/o (complained of) increased pain. Pain meds given to resident as ordered. Physician and guardian made aware. New orders from an STAT xray, ultra sound and Doppler noted. The area on her leg continued to grow in size with c/o increased pain . She verbalized that a CNA (Certified Nursing Assistant) hit her but she also stated she didn't know what happened at that time. Investigation began at that time. DON in room with writer to observe residents leg. DON and writer agreed that resident should be transferred to hospital r/t the rapid increase in swelling and pain . Upon further investigation the allegation that a CNA hit the resident was not substantiated . Resident then stated that she bumped her leg on the sit to stand lift when she was being transferred to her w/c (wheelchair) on the morning of 12/28/17 . 1/16/2018 Health Status Note Text: dressing to Left extremities removed, pt has large open area filled with marble size blood clots. Unable to visualize wound bed. No active bleeding at time of dressing change . 1/16/2018 Health Status Note Text: Clinical alert noted about area on resident left shin. Wound on left leg observed by writer, wound care nurse, and DON. Physician made aware of open area. New order to transfer res to the hospital to evaluate the area on her left shin . Care Plan for Transfer Status: TRANSFERS: EZ stand lift with 2 persons 9/28/2017. EZ stand lift with 2 persons 4/19/2017. Original Care Plan Item, Description HOYER LIFT - ARE ALWAYS 2 PERSON ASSIST AND TOTAL DEPENDENT 4/18/2017. On 1/19/18 at 11:06 a.m., during an interview, Certified nursing assistant (CNA) D said, Normally it's with 2 people , but everybody was busy . and this was not my first time transferring Resident #707 by myself using the lift. On 1/19/18 at 10:59 a.m., during an interview, the Director of Nursing (DON) stated, the conclusion of the investigation was that CNA D transferred Resident #707 alone and bumped Resident #707's leg on the wall or the lift during the transfer. After that we did a one on one inservice on transfers with CNA D. During the interview the DON, verified that Resident #707 was a two person transfer at the time of the incident. ON 1/19/18 at 11:43 a.m., during an interview, the Administrator stated, CNA D was one of the newer CNAs and that her expectations is for the CNA's to follow the Resident's care guide. The Administrator verified that Resident #707 was a two person transfer. On 1/18/19 at 1:30 p.m., the facility's undated policy and procedure titled Lifting Policy - No tolerance Safety was reviewed. Fundamental Information, Repositioning, transferring, and lifting residents must be done safely in order to prevent harm to residents . 1. Know how many people are needed- the car plan will identify the number of people needed to safely reposition, transfer, or lift a resident. If two pop;e are needed, no less than two people should be involved. 2. A Sit to Stand will only require one assistant unless otherwise determined by the therapist and will be reflected on the resident plan of care . This citation pertains to Intake #MI 086. Resident #701 On 1-19-18 at 8:44 a.m., an interview with R#701 was conducted regarding getting out of bed. R#701 stated, One day a man (Proper name) got me up in the Hoyer (a mechanical lift ) alone. I was scared. I told him not to do it alone, but he did it anyway. R#701 was asked if she was injured during that transfer and stated, No. R#710 was asked if the incident was reported and stated, I told the Nurse. On 1-19-18 at 9:30 a.m., The DON (Director of Nursing) was asked for any Incident and accident reports with investigations regarding R#701 and Hoyer lifts and the facility's policy and procedure for using the Hoyer lift On 1-19-18 at 11:45 a.m., The DON provided a document titled ONE ON ONE INSERVICE RECORD dated 1-8-18 Review of the document revealed, 1-4-18 Resident reported that CNA B transferred her by himself using hoyer. Res transfer status is a 2 person with a lift. All lifts are to be used with 2 people at all times. Kardex is to be checked for transfer status prior to transferring. The DON was asked if this was a form of discipline and stated, No, education. Asked about an Incident and Accident report and stated, There were no malfunctions and no injuries. Asked if the CNA admitted to transferring R#701 alone in a Hoyer and stated, Yes. On 1-19-18 at 12:15 p.m., the Administrator was asked about the above findings and stated, I expect them to follow the care guide, that CNA was fairly new, hired 11-15-17. On 1-18-19 at 1:30 p.m., the facility's undated policy and procedure titled Lifting Policy - No tolerance Safety was reviewed. Under Fundamental Information, section 2. ALL HOYER TYPE LIFTING DEVICES REQUIRE AT LEAST TWO PEOPLE TO ASSIST IN LIFTING.

This citation pertains to MI 307 Based on interview and record review the facility failed to transfer one resident (#707) in a safe manner of two reviewed for falls from a total sample of seven, resulting in an incident that caused three skin tears, multiple left arm fractures, and an undetected fractured pelvis. Findings include: On 11/13/17 at 4:00 pm, Family Member K was interviewed and explained that the facility informed him that Resident #707 acquired skin tears and on the following day he was informed that the facility was sending Resident #707 to the hospital due to left arm fractures. Family Member 'K added that the facility never informed him of how Resident #707 sustained fractures to the left arm and that it wasn't until Resident #707 was assessed at the hospital that he was made aware that Resident #707 had fallen at the facility and sustained multiple left arm fractures and a fractured pelvis. Family Member K then provided Resident #707's Death Certificate which indicated that Resident #707 had sustained a fall at the facility, Other significant conditions contributing to death but not resulting in the underlying cause: (included) Pelvis and Left Upper Extremity Fractures, and the certificate documented the Manner Death: Accident. On 11/13/17 at 4:05 pm, clinical record review revealed Resident #707 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set ((MDS) dated [DATE], Resident #707 had impaired cognition, was able to make her needs known and required extensive two person physical assistance with transfers and toileting. According to an Activities of Daily Living Care Plan, dated 5/23/17, Resident #707 required Extensive assist for toileting. A nurses note dated 6/6/17 at 1330 documented, Resident (#707) was in the rest room with assigned CNA (Certified Nurse Assistant) being transferred from toilet back to wheelchair and resident was holding onto bar in restroom and received three skin tears on left forearm. According to the nurses note, only one (unidentified) CNA was present during transfer of Resident #707 from the toilet to the wheelchair. A nurses note dated 6/6/17 at 1630, Late Entry. Resident had complaints of pain discomfort and limited ROM (Range of Motion) due to incident that occurred. Administered PRN (as necessary) pain medication. This nurse ordered a hand wrist and forearm X-ray of left arm. There was no explanation/description of the incident that occurred. Review of an Unusual Occurrence report, dated 6/6/17, was reviewed and revealed that Resident #707 had sustained three skin tears. On 11/14/17 at 11:00 am, the Director of Nursing (DON), who was not the DON at the time of the incident, reviewed the Unusual Occurrence report and the clinical record and acknowledged that Resident #707 had sustained multiple left hand fractures and stated, There must have been a fall. On 11/14/17 at 12:30 pm, after the Administrator reviewed the Unusual Occurrence report the Administrator acknowledged that only one CNA was identified as toileting Resident #707 when according to the MDS, Resident #707 was a two person physical assist while toileting.

This citation pertains to intakes MI 252 and MI 037 Based on interview and record review the facility failed to ensure that the feet for one (#401) of three residents out of a total sample of three residents were protected during wheelchair transportation resulting in fractures to the resident's right foot. Findings include: On 9/25/17 at 10:00 a.m., a review of the clinical record revealed that Resident #401 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), indicated that Resident #401 had severely impaired cognition and required extensive assistance from staff to complete all Activities of daily living (ADL's). On 9/25/17 at 8:48 a.m., during an interview, a Interested Party (IP), mentioned Resident #401's foot was broken and no one knew it or had reported it to a nurse. Review of the facility's investigation included the following: 1. Incident report: date of incident 8/26/17, Brief Description: Writer observed right foot toes ankle purple swollen and tender to touch. Injury type: Fracture. 2. Radiology report revealed 2 results: date 8/26/17, Results: There are acute avulsion fractures of second and third proximal phalanx base (toes) and fifth metatarsal neck (long bone on the outside of the foot that connects to the little toe). Conclusion: Acute fractures. Results: There is fracture involving medial malleolus (side of the ankle). There is associated soft tissue swelling. Conclusion: Acute medial malleolar fracture (side of the ankle). 3. Situation, Background, Assessment, Recommendation (SBAR), dated 8/26/17, . 2. Functional status changes . 2c. Decreased mobility, . 2g. Trouble swallowing. R. Request: . 2. Nursing Notes: Observed right foot and ankle swollen, great toe and 2 next toes, purple and tender to touch. alert, propelling self very little in wheelchair due to increased pain and discomfort to right foot and toes, pain management in progress . The facility's investigative report indicated that interviews were conducted with the following employees. 1. Certified Nursing Assistant (CNA) C, dated 8/28/17. On 8/25/17 I had Resident #401, she was up in her wheelchair rolling up and down the hall . I assisted pushing her in the wheelchair to her room . 2. CNA D, dated 8/27/17. On 8/25/17 around 9:30-10:00 p.m., I was standing in the doorway of the dining room when I noticed CNA C wheeling Resident #401 down the hallway to put her to bed. I noticed that the resident dropped her feet to the floor suddenly causing CNA C to stop pushing the wheelchair. CNA C told Resident #401 to lift her feet up and the resident did pick up her feet. CNA C continued to push Resident #401 down the hall . Resident dropped her feet again suddenly causing CNA C to stop pushing the wheelchair . 3. CNA E, dated 8/27/17. On 8/26/17 I had Resident #401. I got the residents up around 9 a.m. I got her dressed as I normally do. When putting on her pants I noticed that her right toes were swollen . I did not notify the nurse about her toes, because there was no discoloration to her toes . I went to make rounds on Resident #401 and she was in the dining room with her daughter. The daughter took her slipper off and she saw that her toes were purplish and I said that looks way worse than this morning . Nurse F was feeling the resident's foot, all the way up to her knee. The resident complained of pain when her ankle was touched . 4. Nurse F, dated 8/27/17. Resident #401's daughter approached me around 2:45 p.m., while in the dining room she reported Resident #401's foot look swollen . I took off her slippers and I noticed her right great toe and the two next to it were purple in color and swollen. I went to CNA E and asked her if the resident's feet look like this in the morning . CNA E said her foot was swollen a little, but not purple and that it did not look like that . Once I touched her ankle she (Resident #401) yelled out, saying AHHHHHHHHHH, I said ok . On 9/25/17 at 3:25 p.m., during a phone interview, CNA D said, I did not help Resident #401 that day, but I did see CNA C pushing Resident #401 in her wheelchair down the hall. Resident #401 put her foot down two times, while the wheelchair was moving. The wheelchair stopped both times, because Resident #401's foot was caught under the wheelchair. CNA C was moving kind of fast (CNA D was unable to explained how fast). Resident #401 was trying to stop her from taking her to bed, so Resident #401 put her foot down (like no). On 9/25/17 at 5:01 p.m., during an interview, CNA C said, I did push Resident #401 in a wheelchair that day (8/25/17). I did not have the foot rest on. I am kind of new and didn't know until after this incident that I had to have the foot rest on the chair when I transporting residents. On 9/25/17 at 5:03 p.m., during an interview, the Administrator was asked if a wheelchair foot rest was required for transporting residents in wheelchairs. The Administrator said, I am not sure what was in place prior to me coming here, but we in-serviced and made staff aware that foot rests are required now. On 9/25/17 at 4:57 p.m., a policy was requested to address, safety during transporting residents in wheelchairs. The Administrator said, we do not have one.

This citation pertains to intakes MI 873, MI 172, MI 067 and MI 774. Based on observation, interview and record review, the facility failed to identify timely the development of an unstageable pressure ulcer, a stage four pressure ulcer and implement interventions to prevent the worsening of those ulcers for two sampled residents (#'s 905 and 925) from six sampled for pressure ulcer development from a total sample of 27. This resulted in development of unstageable pressure ulcers that could have been avoided. Findings include: On 6/12/17 at 9:00 a.m., during initial tour of the facility, resident # 905 was observed in her room, asleep, lying on her back in a regular mattress. Observations continued throughout the rest of the day on 6/12/17 for the following times that resident #905 remained on her back on a regular mattress: 11:30 a.m., 12:30 p.m., 1:34 p.m., and on 4:43 p.m., resident was awake, however, continued to lie in her bed on her back. On 6/13/17 at 8:40 a.m., 9:45 a.m., 10:30 a.m., and 12:00 p.m., resident 905 was observed lying on her back asleep and was on a regular mattress. On 6/13/17 at 3:00 p.m., review of resident #905 clinical record revealed a re-admission date of [DATE] with the following Diagnoses: [REDACTED]. A Minimum Data Set ((MDS) dated [DATE] revealed resident #905's cognition was intact, however, was completely dependent on staff for all her activities of daily (ADL's) living needs, including; transferring needs and moving in bed. Review of resident #905's care plans revealed a care plan titled, I need assistance with my ADL's related to Limited Mobility. I like to sleep in until around noon daily. I am alert and able to inform staff when I am ready to get out of bed. I may choose not to get up for my showers. Date initiated: 10/20/2015. The interventions included the following: BED MOBILITY: I require extensive assistance by one to two staff to turn and reposition me frequently while in bed. TOILET USE: I need extensive assistance by one to two by you for toileting. Further review of care plans revealed a care plan titled, I have a actual skin impairment to my right ischium I have a unstageable pressure ulcer related to incontinent of stool and immobility, MS, Lupus. Date initiated 10/20/2015. The Goal - Allow staff allocated interventions and further skin break down will be reduced, targeted date 8/9/17, The Interventions: Frequent repositioned me as tolerated, Keep my skin clean and dry. Use lotion on dry skin, Place a pressure reducing cushion in my chair and observe the condition of my pressure reducing mattress - report if replacement is needed. Continued review of resident #905's clinical record revealed physician's orders [REDACTED]. On 6/14/17 at 2:10 p.m., a wound care observation with the wound care nurse P revealed a pressure ulcer stage three to the right gluteal fold and that her buttocks bilaterally were reddened on the entire buttocks. Measurements for wound were: right buttock 2 centimeter (cm) by 1.5 cm by 0.6 cm, per nurse P, had it for a month and that it was unstageable. I was the one who found it like that. When queried regarding the redness on her buttocks, nurse P responded, Oh, her Foley was leaking and she was exposed to her urine. On 6/13/17 at 3:00 p.m., documentation from nursing and physicians in resident #905's clinical record revealed inconsistencies on where the wound was located, when the development of such wounds actually were, and lack of timely interventions. The facility's the entirety of nursing notes and physician notes revealed the following: Weekly HEAD - TO - TOE ASSESSMENTS done by nursing: 2/2/17 at 7:50 a.m., skin intact, 3/3/17 at 10:00 p.m., redness noted, open area noted posterior upper right thigh below right gluteal fold. Treatment in place. Some redness noted to bilateral buttocks (no measurements), 3/10/17 No new skin issues, 3/16/17 at 12:23 p.m., Physician notified left gluteal fold date acquired on 3/9/17, pressure ulcer stage 2, 0 length by 0 width by 0 depth area healed, On 3/24/17, resident was sent to the hospital for a reinsertion of her suprapubic catheter. 3/30/17 at 9:47 p.m., right ischium acquired on 3/29/17 unstageable (first mentioned in any documentation), 3.0 cm length by 2.8 cm width by 0.0 cm depth, 4/4/17 this dated form in system had no documentation, 4/6/17 right ischium unstageable 3.0 cm length by 2.7 cm width by 1.3 cm depth improving, 4/27/17 right gluteal fold 2.0 cm length by 2.1 cm width by 1.0 cm depth stage four, 5/1/17 right gluteal fold 2.0 cm length by 2.1 cm width by 1.0 cm depth stage four, 5/9/17 left buttock wound pressure ulcer (no other notes or measurements documented), 5/25/17 right trochanter hip pressure ulcer (no other notes or measurements documented), 6/5/17 right trochanter hip pressure ulcer (no other notes or measurements documented), There were no other nursing notes documenting wound care or measurements until request to observe wound treatment date of 6/14/17. Physician's Notes Concerning Wound Care: 3/9/17 History - She reopened a wound on her left buttock close to the gluteal fold. General Examination - Skin: her left gluteal fold is unstageable pressure and measures 2.0 cm length by 2.2 cm width by unable to determine the depthness. Assessments - 1. unstageable pressure ulcer left gluteal fold. Treatment - . Reposition the patient every two hours continue with low loss air mattress. 3/16/17 History - She reopened a wound on her left buttock close to the gluteal fold. General Examination - Skin: Her left gluteal fold is unstageable healed, DC treatments, Assessments - 1. unstageable pressure ulcer left gluteal fold. Treatment - . Reposition the patient every two hours continue with low loss air mattress. On 3/24/17, resident #905 was sent to the hospital for a reinsertion of a suprapubic catheter. 3/30/17 History - no mention of pressure ulcers, General Examination - Skin: Her right ischium is unstageable pressure ulcer measures 3.0 cm length by 2.8 cm width by unable to determine the depth. Assessments - 1. unstageable pressure ulcer left gluteal fold. Treatment - . Reposition the patient every two hours continue with low loss air mattress. 4/10/17 History - no mention of pressure ulcers, General Examination - Skin: Her right ischium is unstageable pressure ulcer measures 3.0 cm length by 2.7 cm width by 1.3 cm depth. Assessments - 1. unstageable pressure ulcer left gluteal fold. Treatment - . Reposition the patient every two hours continue with low loss air mattress. 4/12/17 History - no mention of pressure ulcers, General Examination - Skin: Her right ischium is unstageable pressure ulcer measures 2.0 cm length by 2.1 cm width 1.0 cm depth. Assessments - 1. unstageable pressure ulcer left gluteal fold. Treatment - . Reposition the patient every two hours continue with low loss air mattress. 5/18/17 (different physician group) Wound Assessment - Right gluteal 1.0 cm length by 0.7 cm width by 0.5 cm depth pressure ulcer stage three, 5/25/17 Wound Assessment - Right gluteal 2.5 cm length by 1.2 cm width by 0.8 cm depth pressure ulcer stage three, 6/1/17 Wound Assessment - Right gluteal 2.0 cm length by 1.0 cm width by 0.4 cm depth pressure ulcer stage three, 6/8/17 Wound Assessment - Right gluteal 2.0 cm length by 2.2 cm width by 0.9 cm depth pressure ulcer stage three, Low Loss Air Mattress and Frequently reposition were the physicians recommendations continuously for all the aforementioned dates. All physician orders [REDACTED]. Treatment Acceptance Record (TAR) revealed for April 2017: Cleanse right gluteal fold with normal saline apply Santyl ointment cover with dry dressing daily and as needed (PRN) every day shift for open area right gluteal fold D/C date 4/20/17 Cleanse right ischium with Normal saline pat dry, apply Therahoney, cover with 4x4 and bordered gauze every day shift started on 4/21 DC (discontinue) date 5/10/17 (No nursing signatures for 24, 25, 29th of April) May TAR Wound care same as ordered for April, (missed nursing signature on dates 5th, and 10th). First mention of low air loss mattress every day and night shift (on 5/11 no nursing signatures and on 18th, 27th), June TAR revealed Cleanse right gluteal with Normal saline apply [MEDICATION NAME] ag, cover with dry dressing everyday and as needed, (not signed by nursing on the 2nd, 4th, and 11th), On 3/27/17 Wound care consult re: R gluteal fold wound. 5/10/17 Cleanse right gluteal with Normal saline, apply [MEDICATION NAME] ag, cover with dry dressing QD (everyday) and PRN, 5/10/17 Low air loss mattress, 6/1/17 Cleanse periwound with Normal saline, dry, apply Z-Guard and [MEDICATION NAME] 50/50 to periwound to right gluteal QD and PRN. On 6/14/17 at 3:54 p.m., a review of the facility's policy and procedure, titled, Pressure Ulcer Preventative Measures, no date indicated, revealed Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers. Procedures - 2. Residents should be monitored during care and consistently by licensed nurses to identify potential areas for skin breakdown and integrity of overall skin. 3. The nurse aide inspects the resident's skin during bathing, dressing and undressing, assisting with toilting or incontinent care. 4. The nurse aide reports to the nurse any reddened areas and or breaks in the resident's skin. 5. The nurse inspects any reddened areas and or breaks in the resident's skin and documents the inspection. 14. Establish a repositioning schedule. * Periodically reposition residents who are unable to shift their weight. Review of the facility's policy and procedure titled, Pressure Ulcer and Skin Care Management, no date, revealed the following for their procedure, 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions: Weekly on residents, 2. The licensed nurse documents that the body check was completed on the resident's weekly head to toe skin record, 3. The presence of any pressure ulcer, wound, or any other skin condition is documented in the designated area, 4. A licensed nurse completes a pressure ulcer risk assessment: Every 90 days and with any significant change of status assessment (this was not done), 9. A licensed nurse assess and documents that status of existing wounds weekly and 12. Document skin status in the resident record. Resident #925 On 6/14/17 at 8:20 am, clinical record review revealed Resident #925 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS Admission assessment dated [DATE], Resident #925 had impaired cognition and required extensive physical assistance with transfers, bed mobility, and dressing. In addition, the assessment period indicated Resident #925 was incontinent of bowel and bladder most of the time. The assessment also indicated Resident #925 was at risk for the development of pressure ulcers and was readmitted with two unstageable wounds with eschar where the largest wound measured 3.0 cm (centimeters) x 3.6 cm. According to the Nursing Readmission assessment, dated 2/28/17, Resident #925 was admitted with a left thigh pressure ulcer suspected deep tissue injury, a right heel pressure sore Stage IV, and a left heel pressure ulcer Stage III. According to the National Pressure Ulcer Advisory Panel (NPUAP), 2007 a suspected deep tissue injury is a, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (NPUAP, 2007.) Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling (NPUAP, 2007.) Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed (NPUAP, 2007.) Review of Resident #925's care plans revealed the following: I require 24/7 supervision and assistance with ADL's initiated 3/9/17. I need assistance during transfers. Hoyer Lift with 2 person dated 3/29/17. I have impaired cognitive function I need assistance with all decision making dated 4/26/17. I have impaired skin integrity on my right heel related to limited mobility and impaired skin integrity to my left heel related to impaired mobility dated 3/1/17. Both care plan also indicated that the right heel skin impairment resolved on 3/7/17. In addition, I have impaired skin integrity on my left thigh related to impaired mobility dated 3/1/17. The interventions included assist in repositioning me frequently in my bed or chair, encourage me to avoid positioning me on my left thigh, I need a specialty mattress for my bed. However, the care plan indicated that the area resolved on 3/7/17. I have potential for impairment to skin integrity related to limited mobility, generalized weakness, history [MEDICAL CONDITION] dated 3/1/17. The interventions included keeping heels elevated while in bed, use a draw sheet to avoid sheering, follow the Skin Management Program, Keep the skin clean and dry. The care plan indicated that the concern resolved on 3/7/17. I have incontinence, My skin will remain free from breakdown due to incontinence and brief use through the review date. There were no interventions listed on how staff were to maintain Resident #925's skin integrity due to incontinence. In addition, the care plan indicated that the concern was resolved on 3/7/17. There was no active care plan with interventions to promote the healing of pressure ulcers nor any interventions to prevent the development of pressure ulcers for Resident #925 between 3/7/17 until 4/13/17. On 4/10/17 it was discovered that Resident #925 had developed facility acquired pressure ulcers which prompted the following care plan to be initiated: On 4/13/17, I have actual skin impairment to my right heel, left heel, right ischium, saccrococcyx/left buttock, and bilateral hips related to immobility, incontinence initiated on 4/13/17. Interventions included a pressure reducing cushion in my chair and observe the condition of my pressure reducing mattress, use a draw sheet or lifting device to avoid sheering, and weekly treatment documentation to include measurement of each area of my skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the MAR (Medication Administration Record) revealed an order that read, Give one tablet (Tylenol 650 mg) every four hours as needed for general discomfort related to PRESSURE ULCER OF SACRAL REGION UNSTAGEABLE. On 3/4/17 Resident #925 received one tablet for the complaint. However, there was no nursing or wound care note that described a wound related to Resident #925's coccyx during this time. Review of the MAR for the month of March, 2017 revealed that left and right heel wound care was not performed on 3/3, 3/5, 3/13, 3/19, and 3/31. Moreover, an order to apply Santyl (a [MEDICATION NAME] agent used to remove dead skin tissue) was to be applied daily to Resident #925's right heel was started on 3/30/17. Review of the MAR for the month of April, 2017 revealed that the Santyl treatment was not performed according to physician's orders [REDACTED]. Review of the Weekly Head to Toe Assessments revealed that the assessments used to identify concerns with Resident #925's skin were not performed weekly. Instead, they were only documented as completed on the following dates between 3/1/17 through 4/13/17: On 3/16/17, Vertebra (upper mid) excoriation. Right buttock redness, left buttock redness. Both areas were noted as Stage I's, there was no descriptive documentation, and the areas were noted as improving. On 4/4/17, the assessment noted, Other skin is intact. On 4/6/17 the assessment noted, coccyx redness. However, there was no evidence that interventions were put into place. On 4/10/17 the assessment noted, Right buttock, left buttock, other pressure, Noted reddened and opened areas, dressing applied and treatment order for wound care to follow-up. However, there was no evidence that interventions to promote healing and prevent the development of additional pressure ulcers were implemented. Review of Weekly Wound Healing documents were reviewed and revealed: An incomplete document dated 3/2/17 titled Wound #5. No weekly wound healing assessment for 3/9/17. A weekly wound healing assessment dated [DATE] that indicated a decrease in size of the left heel area. However, the assessment indicated there was no change. The weekly wound healing assessment dated [DATE] for the right heel area indicated foul smelling. [MEDICATION NAME] (an antibiotic that Resident #925 was allergic to) was ordered for the wound infection. The weekly wound healing assessment dated [DATE] for the left heal documented the wound to have 10% slough, 90% necrosis and measured 1.7 cm x 1.5 cm x 0.0 cm. A note regarding the right heel indicated that the wound was worsening to continue [MEDICATION NAME]. The size of the wound had increased from 3.0 cm x 3.0 cm x 0.0. cm (noted on 3/30/17) to 6.0 cm x 6.5 cm x 0.0 cm (noted on 4/6/17.) Review of the Weekly Wound Healing Notes revealed no documented evidence that any other skin conditions or impairments were assessed, treated, or monitored A physician order [REDACTED]. After the wound care consult order there were no additional medication/treatment orders that addressed Resident #925's skin integrity until 4/13/17 where both heels were documented in a worsened condition, the development of three facility acquired unstageable pressure ulcers and one deep tissue injury. Review of the physician orders [REDACTED]. Left hip deep tissue injury Right hip unstageable pressure ulcer Saccrococcyx/left buttock unstageable pressure ulcer Right ischium unstageable On 6/14/17 at 11:15 am, Treatment Nurse P was interviewed. Treatment Nurse P explained that she was newly hired and that she would attempt to answer questions to the best of her ability since she was not the wound care nurse at the time Resident #825 developed the facility acquired pressure ulcers. When asked to identify the treatment to the left anterior thigh, Treatment Nurse P reviewed the clinical record and stated, There is nothing in the orders. When queried regarding the weekly skin assessments and weekly wound skin assessments,Treatment Nurse P explained that the skin assessments should be done by nursing staff to identify any problems with skin integrity and the wound assessments should be done in order to monitor any improvement or worsening related to the wounds. Treatment Nurse P reviewed the MAR's and TAR's (Treatment Administration Records) and acknowledged that the aforementioned treatments were not performed as ordered for Resident #925. In addition, Treatment Nurse P noted that there was no plan of care in effect with interventions to promote healing of the pressure ulcers Resident #925 was admitted with; nor were there any interventions to prevent the development of pressure ulcers at the time of Resident #925 acquired one deep tissue injury and the three unstageable pressure ulcers. On 6/14/17 at 4:20 p.m., the Director of Nursing (DON) was queried regarding Resident #925's wound care. When asked about the care of the left thigh wound, the DON reviewed the clinical record stated that treatment was started (a treatment) and stopped. The DON was unable to locate documentation that indicated the condition of the wound. When asked if there was a physician note to describe the wound, and whether or not the wound was resolved, the DON stated, It doesn't say anything in (Wound Physician ) note. The wound doctor (who is no longer employed at the facility) did not address the wound. The DON was informed of the interview that took place with Treatment Nurse P and offered no further explanation.

This citation pertains to intake MI 067 Based on observation, interview, and record review the facility failed to provide tube feeding nutrition as ordered for one (Resident #902) of four reviewed for weight loss from a total of 27 sampled residents resulting in significant weight loss (16.8 pounds) and the potential for further complications. Findings include: On 6/12/17 at 8:50 am, Resident #902 was observed in bed in a side-lying position. Her eyes were closed and she appeared thin. On 6/14/17 at 11:00 am, clinical record review revealed Resident #902 was admitted on [DATE] and readmitted into the facility 5/23/17 with [DIAGNOSES REDACTED]. Per the most recent Minimum Data Set (MDS) data 3/26/17, Resident #902 had severely impaired cognition and required extensive to total assistance with all activities of daily living. Resident #902 was assessed as being an extensive one person physical assistance with feeding. However, Nutrition Notes dated 9/21/16 revealed that Resident #902 was primarily fed via a tube feeding (a tube surgically inserted into the stomach whereby nutrition is delivered) and stated, Tube Feeding orders changed to meet 100% of needs. A Nutrition Note dated 12/8/16 revealed Resident #902 was to receive [MEDICATION NAME] 1.5 (nutrition) bolus feeding (one can four times a day) with 100 milliliters (mls) every shift of Med Pass (a supplement used to provide additional calories). During this assessment, Resident #902 was documented as weighing 107.8 pounds. A physician order dated 1/12/17 read, Every day shift [MEDICATION NAME] 1.5 give one can four times daily via bolus per PEG Tube (tube feeding) at 0800-1100-1400-1700. For weight loss. A Nutrition Note dated 4/24/17 revealed Resident #902 had an ideal body weight of 125 pounds. However, the assessment documented that Resident #902 had a current body weight of 91 pounds. Between 12/8/16 through 4/24/17, Resident #902 had not been discharged to the hospital and lost 16.8 pounds. Further review of the Medication Administration Record [REDACTED]. This practice indicated that only one can had been administered instead of four. However, for the Month of May 2017, a separate line for each can of [MEDICATION NAME] 1.5 was used which yielded four initials. This practice indicated that four cans had been administered at four different times (as ordered.) On 6/14/17 at 1:00 p.m., the Registered Dietician (RD) was interviewed. The RD explained that the regular Registered Dietician was on maternity leave and that she would try to answer questions. The RD reviewed Resident #902's clinical record and confirmed that Resident #902 had experienced a weight loss of 16.8 pounds between 12/8/16 through 4/24/17. The RD also confirmed that Resident #902 was ordered to receive four cans of [MEDICATION NAME] 1.5 to meet 100% of Resident #902's nutritional needs. The RD acknowledged that Resident #902 was to receive a pleasure tray, but the nutritional and caloric needs were to be met by the tube feeding. The RD was asked if Resident #902 had any supplements added during this time to help meet caloric (nutritional) needs and was unable to identify any orders other than the Med Pass (dietary or medical) to address Resident #902's weight loss until after a weight loss of 16.8 pounds. On 6/14/17 at 3:30 p.m., the second floor Unit Manager Nurse F was interviewed. Nurse F reviewed the MAR for the months of February, March, and April 2017 and when queried if Resident #902 received one can of [MEDICATION NAME] 1.5 at four different times as ordered, Nurse F stated, It looks like she only received one can each day. The (Regional Registered Dietician) input the order into the computer and it's all on one line (requiring one initial for four cans during the shift instead of requiring one initial for each can given). When I noticed it I (modified) the MAR indicated [REDACTED]. On 6/14/17 at 4:30 p.m., the Director of Nursing (DON) was queried regarding Resident #902's significant weight loss. The DON was asked how did she ensure that the facility provided Resident #902 with 100% of the required nutrition in order to prevent weight loss. The DON explained that the (Regional) Dietician entered the cans to be administered all on one line and it does not show that one can was administered at each time. I could not be sure if (Resident #902) received the can at each prescribed time. When asked how do you know if she received the four cans the DON stated, I count the cans now. On 6/14/17 at 6:30 p.m., review of the facility policy titled, Weight Management (undated), documented, Residents will be monitored for significant weight change on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible Unintended weight loss/gain is unavoidable if the facility properly assessed, care planned, implemented the care plan, evaluated the resident outcome, and revised the care plan throughout the duration of a resident's weight loss/gain. If not, the weight loss/gain is avoidable.

This citation pertains to MI 161 & MI 199 Based on observation, interview, and record review the facility failed to ensure that 1 (#501) of 3 sampled residents reviewed for abuse was immediately assessed for injuries, monitored, and provided treatment when Certified Nurse Aide (CNA A) reported that she witnessed the Midnight Shift Supervisor RN (Registered Nurse), known as RN F grab the neck of Resident #501 and choke him. This resulted in immediate jeopardy when licensed nursing personnel failed to immediately assess Resident #501 for injuries and assurance he was safe. This deficient practice resulted in Immediate Jeopardy and required immediate corrective action that resulted in both physical and emotional harm for Resident #501, and had the potential to place all residents at risk for serious, harm injury and/or death. Findings include: The Immediate Jeopardy (IJ) cited at F-223 was identified at 9:25 a.m., on 5/5/16, and the Administrator was notified of the IJ at 1:30 p.m., on 5/5/16. A plan of correction was requested to remove the IJ. The IJ was removed on 5/5/16, at 4:27 p.m., when the facility submitted an acceptable plan of correction that was implemented and verified on site by the survey team. Although the IJ was removed, the facility's deficient practice was not corrected and the deficient practice remained at actual harm and the potential for harm that is not Immediate Jeopardy. On 5/4/16 at 8:30 a.m., a review of the clinical record for Resident #501 indicated that he was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #501 had moderately impaired cognition and required extensive assistance with most activities of daily living. On 5/4/16, 8:30 a.m., a review of the facility investigation file revealed the following information pertaining to the abuse incident the involved RN F and Resident #501: #1. Incident Accident Report indicated the following: On 4/28/16 at 2306 (11:06 p.m.) Certified Nursing Assistant CNA (CNA A) witnessed Nurse Supervisor, Registered Nurse RN (RN F) choke Resident (#501) with one hand. She (CNA A) told him (RN F) to stop it. #2. Unusual Occurrence Investigation Report indicated the following: She (CNA A) witnessed Nurse Supervisor (RN F) grab resident #501 around his neck with his right hand choking him. Resident #501 was turning red and I told him (RN F) to stop. #3. Social Worker (SW) SW E written interview with Resident #501: .The nurse (RN F) came in and we (Resident #501 and RNF) started to argue. I called him (RN F) some names and told him Nobody likes you anyway. The nurse (RN F) lunged toward me and choked me with one hand as hard as he could. He choked me very hard. I called for help and no one came .Resident is visible with red marks on neck and purple mark on the middle of forehead. Resident complaining of pain and discomfort to the head, neck and mouth .Resident mood was calm during interview. Resident appeared unsettled about the incident as evidence by lack of eye contact and speaking in low tone . #4. North Unit Manager LPN K written statement: On 4/29/16, it was reported by LPN C, the supervisor (RN F) had grabbed the resident (#501) by his neck. We (DON and writer) went to see the resident who had red marks on his neck and a scratch on his neck . Resident appeared afraid . On 5/5/16 at 3:30 p.m., Unit Manager K stated, I was made aware of the incident on 4/29/16, at about 7:00 a.m., while in the Director of Nursing's (DON) office. LPN C came in and reported that the Supervisor (RN F) had grabbed Resident #501 by his neck. #5. DON (Director of Nursing) written report of her interview with RN F: Arrived in the building at 6:00 a.m., LPN C came to my office at 6:30 a.m., stating that four employees needed to talk to me. I asked her about what. LPN C very hesitant to express concerns, she finally told me that a Resident (#501) had been choked/grabbed .by the Midnight Supervisor (RN F). I went immediately to resident (Resident #501). Resident noted to have redness areas around his neck with two scratches on both sides of neck . I asked resident what happened .Very hesitant to speak to me. He was afraid .Upon leaving the room, it was noted that Nurse Supervisor (RN F) was outside of room. I stood at door until LPN K came out and immediately escorted RN F to my office. When I asked him point blank, there is an allegation of abuse that you grabbed Resident #501 by his neck RN F became very quiet, put his head down and after a minute stated, 'how many N's (N word), SOBs (Son-of-B----), MFs (Mother fu----), and CS (Co-- suc---) are we to be called before it's enough and someone does something about it. I have told everyone about this and no one did anything .These women and myself have cleaned him up, picked up his urine off the floor, his food that he throws, he is verbally abusive to all of us. I (DON) stated that's what we signed up for. He (RNF) refused to write a statement. RN F never once denied that he had grabbed Resident #501, but acknowledged that he pointed his finger in his (Resident #501's) face, which too is abuse . #6. DON's written statement of the Police interview with Resident #501 at 9:00 a.m., on 4/29/16 indicated the following: Police officer (PO) asked Resident #501 what happened and Resident #501 said the Big Shot (RNF) grabbed me by my throat very hard. Officer noted two scratches and the redness around resident's neck. PO took pictures. On 5/4/16 at 9:55 a.m., an interview was conducted with the DON (Director of Nursing). The DON reported that she was informed at the beginning of the midnight shift at 11:06 p.m., CNA A witnessed RN F choke Resident #501. CNA A told what happened to LPN C and LPN D around 4:30 a.m I got into the building between 5:30-6:00 a.m. and there was a note under my door saying to come down to Resident #501 room. At 6:30 a.m., LPN C came into my office asking for me to come down to Resident's #501 room. She was shaking and looking scared. I asked her what was wrong, she finally came out and said the nurse supervisor (Nurse F) grabbed Resident #501 neck . I interviewed RN F, suspended him and walked him to the door around 8:00 a.m. The DON was asked who staff had notified of the incident. The DON revealed that staff waited for her to arrive at the facility. The DON stated, I don't think they are aware that they could have called the police. I told them they should've call me right away, I don't know why they didn't. On 5/4/16 at 10:00 a.m., a during a telephone interview with CNA A she explained, Around 11:00 a.m. I was just getting in and getting ready for the shift. Resident (#501's) call light was on and he was yelling out. I went in to see what he needed. I asked what's wrong. He said my window. Please close my window. I went to close the window. As I was doing so, I heard the Resident say What are you in here for? I turned around and saw the Nurse supervisor (RN F) choking the Resident. I said, 'what are you doing, stop it' . I asked the resident if he was ok and left out to go to the nurses' station. No one was there. The Nurse (RN F) then told me to come with him. We walked around for about an hour together and when I said I needed to go, he would tell me to wait or that he needed me to do something else. I went and did my rounds and waited at the nurse's station. Then I reported it to the nurses (LPN C & D) that I was afraid, what I had witnessed, and that I wanted to go home. I am not sure about the time, because I was so afraid and I lost track of time. I was afraid. I called my mom. I didn't know what to do, I just wanted us to be safe, because he is a man and we are all women . On 5/4/16 at 3:00 p.m., during an interview with Resident #501 he explained, I called him (RNF a Moron. He (RNF) grabbed my neck and choked me. I thought my eyes were going to pop out of my head. I will never forgive him for doing it. Resident #501 further explained, Afterwards, I felt like I was dying like my head was going to pop off my shoulders. I'm still in pain. During the interview observation revealed that the resident's neck appeared to have red marks. There were no open areas identified on the resident's neck. The resident further stated, I think he is going to come back and do it again. Resident #501 further explained, He (RNF) came back in the room and said to me no one should be treated like that and said he was sorry. The resident stated, This had never happened before .I still feel nervous, I don't know if he is going to come back in. I have no idea. On 5/5/16 at 11:05 a.m., during another interview with Resident #501 he stated, My ear still is hurting from being choked. I am still afraid of what he (RNF) may do. I told the Social Worker that I was fearful. On 5/4/16 at 4:05 p.m., during a telephone interview with LPN C she reported, I was told about the incident by CNA A around 2:00 a.m., or 3:00 a.m., and she said that RN F choked Resident #501. LPN C further explained that LPN D was present when CNA A reported the incident to her. LPN C explained, We (LPN C & D) both decided to report the incident to the DON. I thought it was protocol to report to the DON. We knew she came in early and so we waited to talk to her. We wrote a note and put it under her door. When queried if she went into the room and assessed Resident #501 for injuries she replied, No. LPN C stated that at approximately 6:00 a.m., on 4/29/16, and we (LPN D and LPN C) informed the DON about the incident. On 5/5/16 at 9:45 a.m., during a telephone interview, LPN D stated that after CNA A informed her about the incident that RN F choked Resident #501 she did not go in the room to assess the resident. LPN D stated, I know I should have done better. LPN D further explained that, RN F's behavior was irate, he was walking fast, never left CNA A alone, he was butting into conversations, and he kept following her around and acting anxious. This was different from his normal behavior On 5/5/16 at 9:25 a.m., during an interview with the Administrator and Regional Nurse Consultant I, they were queried if Resident #501 was immediately provided a physical assessment by licensed nurses (LPN C and LPN D) after they became aware that RN F had choked Resident #501. The Administrator reported that a Situation Background Assessment Request (SBAR) should've have been done. Review of the Electronic Medical Record (EMR), dated 4/26/16 to 5/4/16, did not reveal a SBAR/assessment had been completed related to the 4/28/16 physical abuse incident. Review of the nurses progress notes did not indicate progress note entries that reflected that a physical assessment of Resident #501 had been completed by LPN C or LPN D. Review of the facility's incident report indicated that the physician was not notified about the incident until 11:00 a.m., on 4/29/16. The Regional Consultant I stated that a Head to toe assessment should've been done. The previous education did not address it. They (staff) did not know they have the ability to call law enforcement without notifying the manager. During the survey multiple attempts were made to interview RN F on 5/4/16 at 2:35 p.m., 4:00 p.m., 5/5/16 at 9:30 a.m., and 5/5/16 at 10:45 a.m. Voice mail messages were left that requested a return phone call. However, no calls were received from RN F. On 5/5/16 at 10:00 a.m., during a phone interview, Police Officer (PO) he explained, A call has been made for an arrest warrant to the Attorney General's office. The investigation uncovered that Resident #501 had been assaulted by RN F. The PO was asked if RN F entered the room after the abuse incident and the PO stated, I believe the video showed him (RN F) going back into the room again. On 5/5/16 at 3:00 PM, a review of the facility s policy titled Abuse and Neglect Prohibition Policy and Teaching Tool, dated 12/2011, stated, Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse .Staff will report all allegations of abuse, neglect and misappropriation of property to the Administrator immediately .Always Do the Following - See to the immediate need of the resident. Upon receiving information or observing an incident, the staff member is to immediately tell their supervisor. The charge nurse is to go directly to the affected resident to assess: 1. Physical status: a. bruises and welts, b. lacerations and burns, c. Other body injuries; 2. Vital signs; 3. Emotional status: a. Verbal and affect elements, b. Physical expressions of emotion/distress .Make appropriate notification. The charge nurse is to immediately call: 1. The physician, 2. The Administrator, 3. The family/responsible party. The following plan of correction was submitted by the facility to remove the Immediate Jeopardy: Element 1 On 4/28/16 11:06 p.m., CNA who was present in Resident 134-B ' s room observed the Midnight RN Supervisor grabbing the resident around his neck. She told him to stop The CNA reported the incident to the LPN charge nurse between 2-3 am. A physical assessment was not conducted by the charge nurse at the time of notification. The charge nurse reported the incident to the DON at 600 a.m., who then arrived at facility. Administrator was notified by the DON at 8:00 a.m.,. The DON conducted a physical assessment of the resident and made sure his needs were met. The DON immediately got statements from the alleged perpetrator. DON immediately suspended the RN supervisor pending investigation. After a thorough Physical Exam, it was observed that resident sustained [REDACTED]. Physician notified via phone at 11:00 a.m.,. Element 2 Initially SW conducted audits on the South unit and no further concerns were found. Resident interviews will continue until all residents who can be interviewed are. Findings will be reported to Administrator. Resident Council meeting was held and 5 residents including Resident council president attended there were no further allegations of mistreatment reported. During each monthly resident council meeting, the minutes will include questions regarding abuse, Neglect and Mistreatment. Minutes will be discussed in QAPI meetings. Residents will be interviewed on will be conducted to ensure Mon- Friday Managers will be conducting resident interviews through the Guardian angel program. Findings of allegations, abuse or mistreatment are immediately reported to the Administrator. The 3 staff members involved have received training regarding importance of making sure the resident involved is assessed appropriately and received a disciplinary action in regards to not following abuse policy. The 2 Nurses will receive additional training and will be shadowed by DON/designee to ensure appropriate assessments are completed and documented. Element 3 4/29/15 at time of incident Nurses and Certified Nurse Aides received training on Abuse and Neglect Prohibition Policy and Elder Justice Act. 5/5/16 Additional training has been started regarding Abuse and Neglect Prohibition Policy (taken from page 10) Teaching tool which emphasizes immediate reporting to Charge Nurse and assessment conducted to evaluate Physical, and emotional status of resident . This is mandatory training and staff will receive training prior to start of their shift, starting 5/5/16 and completed 5/11. If staff is on LOA or vacation they will receive a certified letter to report to manager prior to returning to work. Element 4 The Administrator is responsible to assure the plan of correction is implemented and compliance maintained. Findings will be reported to the QAPI committee monthly x 3 or until further directed. The facility identified that they would achieve compliance by 5/11/16. ( , )

This citation pertains to intake numbers MI 109, MI 169, and MI 190. Based on interview, record review and observation, the facility failed to provide correct wound care treatments over a six day period (07/17/15 through 07/22/15) for 1 of 3 residents (703) reviewed for pressure sores from a total sample of 4 residents resulting in increased pain and uncomfortable tactile feelings to resident 703's right heel pressure ulcer and subsequent mental anguish when multiple maggots (fly larvae) were discovered within the pressure ulcer on 07/25/15. Findings include: During an interview with resident 703 on 07/30/15 at 9:05 am, resident 703 said, on 07/24/15 during the day and afternoon shifts, she asked the nurses to change her right heel wound on several occasions because the area was aching and stinging with a strange persistent tickling feeling, like something was crawling around inside the right heel. Resident 703 said the previous right heel dressing change was completed on 07/23/15 around 4 or 5:00 pm. Resident 703 said, on 07/24/15, the nurses kept telling her they were extremely busy and would get to it later and instead provided her with pain control. Resident 703 said she wanted the dressing changed by 2:30 pm so she could attend bingo as the wound emitted a foul odor which caused her embarrassment in a group setting. Resident 703 said the nurses kept telling her she had to wait for the dressing change, so tired of waiting, resident 703 went outside the facility into the courtyard area on 07/24/15 around 4:00 pm to enjoy the sun. Resident 703 said while in the facility courtyard, flies swarmed around her right foot dressing. Resident 703 said the dressing was loose with juices draining through the gauze and the wound smelled really bad. Also, Resident 703 said she was outside the building in the courtyard the prior day, on 07/23/15, and had a similar incident with flies swarming around the dressing on her right foot. Resident 703 said, after making further requests, licensed practical nurse (LPN) 'D' eventually entered her room on 07/24/15 around 9 pm to change the dressing on her right heel. Resident 703 said all she (LPN 'D') did was remove the old saturated dressing from the right foot and place a new dressing over the right foot. Resident 703 said LPN 'D did not cleanse the wound or apply the Santyl (enzymatic [MEDICATION NAME] ointment) and [MEDICATION NAME] ointment (antibiotic). Resident 703 said, she (LPN 'D') did a rushed job and left the room fast. Resident 703 said the aching and stinging pain and uncomfortable tactile feeling to the right heel persisted throughout the night into the next day. Resident 703 said, on 07/25/15, after breakfast .around 11:00 am, LPN 'E' entered her room to change the right heel dressing and when LPN 'E' lifted her right foot resident 703 visualized lot's of maggots falling off her right heel into the towel underneath. Resident 703 said LPN 'E' ran out of the room and came back with another nurse. Resident 703 said, no one told me about the maggots, they played me for stupid .it freaked me out seeing that .I became scared and all worked up .I couldn't think straight . I kept thinking about the weird tickle in my foot and all along it was bugs crawling inside. During an interview with LPN 'A' on 07/30/15 at 10:10 am, LPN 'A' said she entered resident 703's room on 07/25/15 at approximately 11:00 am and observed LPN 'E' in room with resident 703 sitting up at the edge of the bed soaking right foot in water. LPN 'A' said she observed approximately 10-15 fly larvae on resident 703's right heel area and multiple fly larvae floating in the water. LPN 'A' said she had changed resident 703's right heel dressing on many occasions and the treatment order in place on 07/25/15 was to cleanse the right heel with normal saline, dry, apply Santyl and [MEDICATION NAME] 50/50 cream every day, cover with 4 x 4 gauze, ABD (abdominal) pad, and Kerlix. LPN 'A' said the previous treatment to resident 703's right heel (ordered 07/16/15 through 07/23/15) was to cleanse the right heel with normal saline, dry, apply dry dressing, ABD pad, and Kerlix every other day. During an interview with LPN 'E' on 07/30/15 at 11:10 am, LPN 'E' said, on 07/25/15 at approximately 11:00 am or 12:00 pm, she entered resident 703's room to perform a dressing change to resident 703's right heel. LPN 'E' said resident 703 told her that LPN 'D' had performed the dressing change the night before on 07/24/15 at 9:00 pm. LPN 'E' said she received no report from the previous shift regarding any identified concerns with resident 703's right heel wound. LPN 'E' said she could not remember the treatment order in place for resident 703's right heel nor could she remember the treatment she provided for resident 703 on 07/25/15. However, LPN 'E' said she does recall, on 07/25/15 during the dressing change, that resident 703's right heel wound had a foul odor, the dressing was intact with some moderate saturation around the right heel area, and when the dressing was removed, there were greater than 50 fly larvae observed permeating the right heel area. LPN 'E' said she could not remember if the removed dressing contained an ABD pad or Kerlix. LPN 'E' said she notified management once she observed the fly larvae. During an interview with the wound care physician (MD) 'F' on 07/30/15 at 11:40 am, MD 'F' said resident 703 had unstageable pressure ulcers to the right and left heel areas. MD 'F' said she had provided specific treatment orders for the right heel and the left heel as each area had different clinical needs. MD 'F' confirmed that an order written [REDACTED]. MD 'F' said the treatment order written on 07/16/15 applied to resident 703's left heel, not the right heel. MD 'F' said she could see how others may have misinterpreted her handwriting to indicate the right heel but her notes clearly differentiated the treatments in place for the right heel and the left heel. MD 'F' said no staff contacted her to clarify the order. MD 'F' said the treatment orders intended to be in place for resident 703's right heel were written on 06/25/15 and reaffirmed again on 07/23/15 and included cleansing of the right heel with normal saline, dry, apply Santyl mixed with [MEDICATION NAME] 50/50 cream, cover with gauze, ABD pad and Kerlix every day. MD 'F' said she did not discontinue the treatment order for resident 703's right heel on 07/16/15. MD 'F' confirmed the order transcribed on the treatment administration record (TAR) was incorrect which lead to the treatment intended for the left heel to be, instead, provided to the right heel. MD 'F' said the chemical composition of Santyl mixed with [MEDICATION NAME] 50/50 cream would have most likely destroyed any fly larvae in the wound. MD 'F' said, based on the number of fly larvae identified in the wound, it is likely they existed within the wound for greater than 24 hours. During interviews with the director of nursing (DON) on 07/30/15 at 9:55 am and 07/30/15 at 3:00 pm, the DON said, on 07/25/15 in the morning, staff called her reporting that resident 703 had multiple fly larvae in her right heel wound. The DON said the wound was identified as an unstageable pressure ulcer by the wound care physician (MD 'F') and, as part of her (DON) investigation, LPN 'D did not identify any fly larvae in the wound during the dressing change that occurred on 07/24/15 at 9:00 pm. The DON said LPN 'D' signed the treatment as being performed in the treatment administration record (TAR) and made no further documentation on the matter. The DON said, though it happens sometimes, it is not appropriate for a resident receiving wound care services to develop fly larvae in their wound in a long term care facility. When asked why facility nurses did not clarify MD 'F''s treatment order, the DON had no answer. Attempts to contact LPN 'D' via phone on 07/30/15 starting at 11:00 am were unsuccessful. A phone message with return contact number was left on the answering machine and, as of exit from the survey, no contact had been established. On 07/30/15 at 12:00 pm, the surveyor observed LPN 'A' and MD 'F' perform wound care to resident 703's heels. The right heel pressure ulcer was approximately 5.0 cm x 4.0 cm in diameter with moderate drainage and a very foul odor. During this observation no fly larvae were observed in the wounds. Review of resident 703's record on 07/30/15 starting at 10:00 am revealed the following documents. Face sheet dated 06/23/15 that indicated resident 703 was a [AGE] year old female, with most recent admitted to the facility of 06/23/15 with [DIAGNOSES REDACTED]. Physician determination of decision making capability signed by physician on 03/30/15 that indicated resident 703 was capable to understand the Bill of Rights and participate in Medical Treatment Decisions. Minimum data set (MDS) assessment dated [DATE] that indicated resident 703 was cognitively intact having a BIMS (brief interview for mental status) score of 15. Physician order [REDACTED]. both heels: cleanse with normal saline, dry, apply Santyl mix with [MEDICATION NAME] ointment 50/50, cover with 4 x 4 (gauze), ABD and Kerlix every day. Wound care physician notes dated 07/09/15 that indicated resident 703 had unstageable pressure ulcers to both heels with the right heel measuring 6.0 cm by 6.5 cm, unable to determine depth, moderate amount of serous drainage, mild odor, 20% necrotic tissue at the base, 30% granular tissue at the base, and 50% slough. These notes indicated both the left and right heel were cleansed with saline, dried, Santyl mixed with [MEDICATION NAME] was applied, and covered with 4 x 4 gauze, ABD pad, and Kerlix wrap and to change daily. These notes indicated, under treatment section, we will do the dressings as mentioned above. Physician order [REDACTED]. discontinue left heel dressing, start left heel wound treatment, cleanse with normal saline, dry, apply dry dressing with ABD and Kerlix every other day. Further review of the record revealed no new orders for treatment to the right heel on 07/16/15. Wound care physician notes dated 07/23/15 that indicated resident 703 had unstageable pressure ulcers to both heels with the right heel measuring 6.5 cm by 6.85 cm, unable to determine depth, 20% necrotic tissue, 80% slough, severe moderate yellowish drainage, positive odor, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] around. These notes indicated the right heel was treated with saline cleanse, dried, Santyl mixed with [MEDICATION NAME] was applied, cover with gauze, 4 x 4, ABD pad, and a Kerlix wrap to change daily. These notes indicated, under treatment section, we will do the dressings as mentioned above. Treatment administration records (TAR) dated 07/01/15 through 07/31/15 that indicated the following treatment orders, numbered for clarity: 1. The physician order [REDACTED]. Per the TAR, nursing staff documented the treatments as being completed, and, per the TAR, the order was discontinued on 07/16/15. Based on the above physician order [REDACTED]. order was never intended to be discontinued on 07/16/15. 2. The next TAR transcription, directly underneath #1, indicated: Cleanse right heel with normal saline, dry, apply dry dressing, ABD, and Kerlix every other day. Per the TAR, this order was started on 07/16/15, nursing staff documented the treatments as being given every day from 07/17/15 through 07/22/15, and the order was discontinued on 07/23/15. Based on the above physician order [REDACTED]. order was intended to reflect treatment to the left heel, not the right heel. Also, per the TAR documentation, this reflects 6 consecutive days (07/17/15 through 07/22/15) in which the Santyl mixed with [MEDICATION NAME] 50/50 cream was not administered to resident 703. 3. The next TAR transcription related to the treatment of [REDACTED]. Per the TAR, this order was started 07/23/15 and nursing staff documented the treatments as being completed. Facility investigation report (undated, unsigned) that indicated resident 703 had what looked like to be maggots on her foot wound, that resident 703 started to feel a burning in her wound during the night and it continued until the next day, and that resident 703 wasvisibly concerned on Saturday (07/25/15), however she began to calm down regarding the issue upon speaking with social work. Care plan for alteration in skin integrity related to unstageable pressure ulcers initiated on 06/23/15 that indicated, under intervention section, apply treatments per physician's orders [REDACTED]. Review of facility policy and procedure for pressure ulcer and skin care management dated July 2011 indicated, under policy section, .a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and reduce the risk of new pressure ulcers developing. Review of facility policy procedure transcribing physician orders [REDACTED]. Accuracy is a most important factor when transcribing physician orders. Contact Physician for any clarification of orders. On 07/30/15, according to the Orkin pest control website (located on the Internet at http://www.orkin.com/flies/house-fly/house-fly-larvae), regarding house fly larvae, eggs hatch within 24 hours, and house fly larvae emerge. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES: DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE HOT WATER TEMPERATURES WERE WITHIN THE SAFE RANGE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. HOT WATER TEMPERATURES RANGED FROM 122.4 DEGREES FAHRENHEIT TO 132.8 DEGREES FAHRENHEIT AT FOUR HANDWASHING SINKS AND IN ONE SHOWER STALL IN FOUR OF FIVE COMMUNITY SHOWER ROOMS AND ONE OF THREE RESIDENT DINING ROOMS. THE HOT WATER TEMPERATURES HAD THE POTENTIAL TO AFFECT TWO (#S 707 AND 712) OF 26 SAMPLED RESIDENTS AND 15 (#S 15, 23, 24, 28, 35, 39, 40, 70, 78, 79, 99, 102, 121, 131, AND 140) SUPPLEMENTAL SAMPLED RESIDENTS IN 17 OF 72 RESIDENT ROOMS WHERE HANDWASHING SINKS (AND ONE SHOWER) WERE ACCESSIBLE TO RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) AND THE POTENTIAL FOR HARM, SERIOUS INJURY AND/OR DEATH FROM SERIOUS BURNS AND SCALDING. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 7/30/13 AT 11:00 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 7/30/13 AT 4:30 P.M.. THE ADMINISTRATOR WAS REQUESTED TO PROVIDE A PLAN OF CORRECTION TO REMOVE THE IMMEDIATE JEOPARDY. THE IJ WAS REMOVED ON 7/30/13 AT 5:00 P.M., BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 7/30/13 AS VERIFIED ON SITE ON 7/31/13. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED WITH NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE ONE NORTH NURSING UNIT ON 7/30/2013, AT 8:45 A.M., WATER TEMPERATURES WERE MEASURED AND FOUND TO BE ABOVE A SAFE RANGE OF 105 TO 120 DEGREES FAHRENHEIT (F) FOR RESIDENTS #S 707, 712, 15, 23, 24, 28, 35, 39, 40, AND 79, RANGING FROM 125 DEGREES FAHRENHEIT TO 132.8 DEGREES FAHRENHEIT. AN INTERVIEW ON 7/30/13 AT 11:00 A.M., WITH UNIT MANAGER (B) REVEALED THAT RESIDENT #'S 707, 712, 15, 23, 24, 28, 35, 39, 40, AND 79 WERE ABLE TO ACCESS THE WATER AT THE TOILET ROOMS HANDWASHING SINKS IN THEIR ROOMS INDEPENDENTLY AND WERE AT RISK FOR BURNS FROM HOT WATER DUE TO THEIR COGNITIVE STATUS: THE HOT WATER TEMPERATURES AT THE HAND WASHING SINK FOR RESIDENT # 707 MEASURED 125.9 F. ON 8/02/13 AT 1:30 P.M., RECORD REVIEW FOR RESIDENT 707 REVEALED RESIDENT #707 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT Minimum Data Set, dated dated dated , 4/18/2013, REVEALED RESIDENT #707 HAD SEVERELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURES AT THE HAND WASHING SINK FOR RESIDENT # 15 MEASURED 126.5 F. ON 8/02/13 AT 1:30 P.M., RECORD REVIEW FOR RESIDENT # 15 REVEALED RESIDENT #15 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET, DATED 6/08/2013, REVEALED RESIDENT # 15 HAD MODERATELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURES AT THE HAND WASHING SINK FOR RESIDENT # 28 MEASURED 126.1 F. ON 8/02/13 AT 1:30 P.M., RECORD REVIEW FOR RESIDENT 28 REVEALED RESIDENT #28 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #28 HAD MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURES AT THE HAND WASHING SINK FOR RESIDENT # 23 MEASURED 127.0 F. ON 8/02/13 AT 1:30 P.M., RECORD REVIEW FOR RESIDENT #23 REVEALED RESIDENT #23 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #23 HAD MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURES AT THE HAND WASHING SINK FOR RESIDENT # 24 MEASURED 125.9 F. ON 8/02/13 AT 1:30 P.M., RECORD REVIEW FOR RESIDENT # 24 REVEALED RESIDENT #24 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #24 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #712 MEASURED 127.4 DEGREES FAHRENHEIT. ON 8/2/13 AT 1:00 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #712 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE INITIAL RESIDENT MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #712 AS BEING "VERY CONFUSED". THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #35 MEASURED 132.8 DEGREES FAHRENHEIT. ON 8/2/13 AT 1:00 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED THE RESIDENT WAS admitted INTO THE FACILITY 9/27/12 WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THE RESIDENT HAD MODERATELY IMPAIRED COGNITION FOR DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #39 MEASURED 124.2 DEGREES FAHRENHEIT. ON 8/2/13 AT 1:05 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #39 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] INDICATED THE RESIDENT HAD MODERATELY IMPAIRED COGNITION FOR DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #40 MEASURED 122.4 DEGREES FAHRENHEIT. ON 8/2/13 AT 1:10 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #40 HAD MODERATELY IMPAIRED COGNITION FOR DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #79 MEASURED 125.6 DEGREES FAHRENHEIT. ON 8/2/13 AT 1:25 P.M., REVIEW OF THE ADMISSION FACE SHEET DOCUMENTED RESIDENT #79 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MDS dated [DATE], REVEALED THE RESIDENT HAD MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING.. ON 7/30/13 AT 10:30 A.M., DURING THE INITIAL TOUR OF THE FIRST FLOOR NORTH SHOWER ROOM, THE HOT WATER TEMPERATURE AT THE SINK REGISTERED 131 DEGREES FAHRENHEIT. DURING THE INITIAL TOUR ON THE ONE SOUTH UNIT ON 7/30/13 AT 9:40 AM, THE HOT WATER TEMPERATURES WERE MEASURED ON THE 1 SOUTH UNIT AND FOUND TO BE ABOVE THE SAFE RANGE OF 105 TO 120 DEGREES FAHRENHEIT FOR RESIDENTS #70 AND 78 AND RANGED BETWEEN 124.9 DEGREES AND IN THE DINING ROOM. THE HOT WATER TEMPERATURES RANGED BETWEEN 124.9 DEGREES FAHRENHEIT AND 126.5 DEGREES FAHRENHEIT AS FOLLOWS: THE HOT WATER TEMPERATURE AT THE HAND WASHING SINK FOR RESIDENT #78 MEASURED 124.9 DEGREES FAHRENHEIT. ON 8/02/13 AT 1:30 P.M., RESIDENT #78'S CLINICAL RECORD WAS REVIEWED. ACCORDING TO THE FACE SHEET RESIDENT #78 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #70 MEASURED 126.5 DEGREES FAHRENHEIT. ON 8/02/2013 AT 1:30 P.M., RECORD REVIEW REVEALED RESIDENT #70 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS dated [DATE] REVEALED THAT RESIDENT #70 WAS COGNITIVELY IMPAIRED. IN ADDITION, THE HOT WATER TEMPERATURE AT THE HAND SINK IN THE SOUTH DINING ROOM MEASURED 126.1 DEGREES FAHRENHEIT. THE HOT WATER TEMPERATURE FROM THE SHOWER STALL LOCATED ON THE SOUTH UNIT MEASURED 123 DEGREES FAHRENHEIT. DURING THE INITIAL TOUR OF THE TWO SOUTH UNIT ON 7/30/13 AT 9:30 A.M., HOT WATER TEMPERATURES WERE MEASURED ON THE SECOND FLOOR AND WERE FOUND TO BE ABOVE A SAFE RANGE OF 105 AND 120 DEGREES FAHRENHEIT FOR RESIDENTS #''S 99, 102, 121, 131, AND 140. THE HOT WATER TEMPERATURES RANGED FROM 125.4 TO 127.0 DEGREES FAHRENHEIT. AN INTERVIEW WAS CONDUCTED WITH THE SECOND FLOOR UNIT MANAGER ON 7/30/13 AT 10:45 A.M. AND RESIDENTS 99, 102, 119, 121, 133, AND 140 WERE IDENTIFIED BY THE UNIT MANAGER AS BEING ABLE TO ACCESS THEIR HAND WASHING SINK INDEPENDENTLY AND WERE AT RISK FOR BURNS FROM HOT WATER DUE TO THEIR COGNITIVE STATUS: THE HOT WATER TEMPERATURE AT THE HAND WASHING SINK FOR RESIDENT #131 WAS 125.4 DEGREES FAHRENHEIT. ACCORDING TO RESIDENT #131'S FACE SHEET, REVIEWED 8/2/13 AT 3:30 P.M., THE RESIDENT WAS readmitted INto the facility on [DATE] WITH A [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET (MDS), dated [DATE], RESIDENT #131 HAD MODERATELY IMPAIRED COGNITION FOR DAILY DECISION-MAKING. THE HOT WATER TEMPERATURE AT THE HAND WASHING SINK FOR RESIDENT #140 WAS 129.4 DEGREES FAHRENHEIT. ACCORDING TO RESIDENT #140'S FACE SHEET, REVIEWED 8/2/13 AT 3:30 P.M., RESIDENT #140 WAS readmitted INto the facility on [DATE] WITH A [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET (MDS), dated [DATE], RESIDENT #140 HAD MODERATELY IMPAIRED COGNITION FOR DAILY DECISION-MAKING. THE HOT WATER TEMPERATURE AT THE HAND WASHING SINK FOR RESIDENT #99 MEASURED 125.6 DEGREES FARENHEIT. ON 8/2/13 AT 1:15 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #99 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED RESIDENT #99 HAD MODERATELY IMPAIRED COGNITION FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #102 MEASURED 126.9 DEGREES FARENHEIT. ON 8/2/13 AT 1:20 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #102 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MDS dated [DATE] INDICATED RESIDENT #102 HAD MODERATELY IMPAIRED COGNITION FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK FOR RESIDENT #121 MEASURED 127 DEGREES FARENHEIT. ON 8/2/13 AT 1:25 P.M., REVIEW OF THE ADMISSION FACE SHEET REVEALED RESIDENT #121 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MDS dated [DATE] INDICATED THAT RESIDENT #121 HAD SEVERELY IMPAIRED COGNITION FOR DAILY DECISION MAKING. DURING A TOUR OF THE MAIN BOILER ROOM, ACCOMPANIED BY THE MAINTENANCE DIRECTOR ON 7/30/13 AT 12:00 P.M., THE MAINTENANCE DIRECTOR WAS ASKED HOW THE HOT WATER TEMPERATURES WERE MONITORED THROUGHOUT THE FACILITY AND STATED, THE MAINTENANCE DIRECTOR RESPONDED, "I TAKE TEMPERATURES MONTHLY AND WHEN THERE'S A PROBLEM." THERE WAS A MIXING VALVE (A VALVE THAT MIXES COLD WATER WITH THE HOT WATER FROM A BOILER SYSTEM TO ACHIEVE A LOWER DESIRED TEMPERATURE), BUT THERE WAS NO THERMOMETER ON THE SYSTEM TO INDICATE THE TEMPERATURE OF THE WATER THAT WAS SUPPLYING TO RESIDENT'S ROOMS. WHEN ASKED HOW DO YOU MEASURE THE TEMPERATURES OF THE WATER SUPPLIED TO THE RESIDENT'S ROOMS AND SHOWERS, THE MAINTENANCE DIRECTOR STATED, "ITS MEASURED AT THE TAP." ( , , , , ) THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY IMPLEMENTED THE FOLLOWING: RESIDENT NUMBER 15, 16, 19, 20, 21, 23, 24, 25, 28, 29, 34, 35, 36, 39, 40, 41, 42, 44, 47, 50, 51, 53, 61, 62, 64, 69, 70, 73, 74, 75, 76, 77, 78, 79, 80, 82, 99, 102, 119, 121, 131, 133, 137, AND 140 WERE ASSESSED BY FULL BODY SKIN ASSESSMENT ALONG WITH RESIDENT INTERVIEWS REGARDING WATER TEMPERATURES. ALL OTHER RESIDENTS' WHO WERE RESIDING IN THE FACILITY ON 7/30/13 WERE ASSESSED AND INTERVIEWED AS ABOVE. MEDICAL DIRECTOR WAS NOTIFIED IMMEDIATELY REGARDING THE CONCERN WITH WATER TEMPERATURE AND SKIN ASSESSMENTS WERE INITIATED IMMEDIATELY BY LICENSED STAFF NURSES AND NURSE MANAGERS ON 7/30/13 AND WERE COMPLETED BY 6:30 PM SAME DAY. THERE WERE NO SCALDING, BURNS OR ANY HARM IDENTIFIED IN ANY OF RESIDENTS IN THE FACILITY AND INTERVIEWS REVEALED NO CONCERNS OR COMPLAINTS OF WATER TEMPERATURES BEING TOO HOT; NO CHANGES WERE MADE TO RESIDENTS' CARE PLAN. RESCHEDULED ALL SHOWERS FROM 7/30 TO 7/31 AND PROVIDED CLEANSING WIPES AS A CLEANING ALTERNATE FOR RESIDENTS. IMMEDIATELY NOTIFIED STAFF NOT TO USE ANY HOT WATER IN THE FACILITY AND POSTED SIGNS IN RESIDENT ROOMS, SHOWER ROOMS, AND DINING ROOMS. THE CONTRACTED PLUMBER FOR HFCCC ROSEVILLE WAS NOTIFIED AND ARRIVED HERE AT 5:00 PM AND IMMEDIATELY ADJUSTED THE TEMPERATURE CONTROL ON MAIN TANK TO CONTROL BETWEEN 110 AND 115 DEGREES FARENHEIT WHICH IMMEDIATELY REDUCED THE SOURCE TEMPERATURE BELOW 115 DEGREES AND WAS CLEARED FOR OPERATION. THE PLUMBER MONITORED THE TEMPERATURE FOR TWO HOURS TO ASSURE SAFE WATER TEMPERATURE AT SOURCES AFTER ADJUSTING THE TEMPERATURE CONTROLS ON THE MAIN TANK AND MIXING VALVE WAS REPLACED. REVIEWED CURRENT FACILITY POLICY FOR WATER TEMPERATURE MONITORING AND POLICY REVISED ON 07/30/13 BY THE FACILITY'S QA COMMITTEE WITH ADDITIONAL MONITORING SYSTEMS AND PREVENTATIVE COMPONENTS IN PLACE. STAFF MEMBERS FROM NURSING, HOUSEKEEPING, DIETARY, SOCIAL WORK, ACTIVITIES, REHABILITATION SERVICES, AND MAINTENANCE CURRENTLY ON SHIFT WERE IN SERVICED ON 7/30 AND THE REST OF THE STAFF WERE IN-SERVICED ON 7/31/2013 (MIDNIGHT AND DAYS) PRIOR TO START OF THE SHIFT. STAFFS WERE IN SERVICED ON NOT USE HOT WATER IF A RESIDENT COMPLAINS OF WATER TEMPERATURE OR WATER TEMPERATURE FEELS TOO HOT, SAFE BATHING TEMPERATURES AND TO IMMEDIATELY NOTIFY MAINTENANCE IS THE WATER TEMPERATURE FEELS WARMER THAN EXPECTED. STAFF WAS EDUCATED ON AVAILABILITY OF QUICK CHECK THERMOMETERS IN THE SHOWER ROOM, ALL NURSE MANAGERS' OFFICES, AND ADMINISTRATOR'S OFFICE FOR QUICK AND EASY ACCESS. IN-SERVICE PACKETS WERE MAILED OUT ON 7/30 TO STAFF MEMBERS WHO WERE NOT SCHEDULE WHICH COVERED ALL THE ABOVE CONTENTS. QUICK READ THERMOMETERS ARE ACCESSIBLE TO THE STAFF TO CONDUCT HOT WATER TEMPERATURE CHECKS IF A RESIDENT OR STAFF MEMBER PERCEIVE WATER IS WARMER THAN COMFORT NECESSITATES. QUICK READ THERMOMETERS WERE IMMEDIATELY MADE AVAILABLE IN ALL THE ABOVE LOCATIONS AS SPECIFIED. HFCCC ROSEVILLE HAS REVIEWED BATHING TEMPERATURES AND POSTED BATHING TEMPERATURE PARAMETERS IN SHOWER ROOMS FOR STAFF REFERENCE. QA COMMITTEE REVISED THE MAINTENANCE POLICY ON TEMPERATURE MONITORING AND PREVENTATIVE MAINTENANCE. CREATED A MAINTENANCE LOG TO MONITOR OUTGOING TEMPERATURE DAILY FROM TANK. CERTIFIED PLUMBER WILL INSPECT THE SYSTEM ONCE EVERY 6 MONTHS TO ENSURE THE SAFETY AND FUNCTION OF THE HOT WATER SYSTEM. MAINTENANCE SUPERVISOR/STAFF WILL MONITOR AND RECORD OUTGOING WATER TEMPERATURE DAILY IN THE BOILER ROOM TO ENSURE SAFE OUTGOING TEMPERATURE. MAINTENANCE SUPERVISOR/STAFF WILL MONITOR WATER TEMPERATURE AT SOURCES SUCH SINKS IN RESIDENTS' ROOM; SHOWER ROOM; DINING ROOM ETC. WILL BE MONITORED DAILY X 4 WEEKS THEN 2/WK THEREAFTER AS PER THE REVISED POLICY AND THE MAINTENANCE SUPERVISOR WILL REPORT FINDINGS TO THE QA COMMITTEE. QA COMMITTEE MET ON 7/30/2013 AND REVISED POLICY ON DOMESTIC HOT WATER TEMPERATURE MONITORING AND PREVENTATIVE MAINTENANCE TO ENSURE SAFE WATER TEMPERATURE IS MAINTAINED AT ALL TIMES. CERTIFIED PLUMBERS WILL WATER SYSTEM EVERY 6 MONTHS TO ENSURE SAFETY AND FUNCTION OF THE HOT WATER SYSTEM. ONGOING COMPLIANCE WILL BE MAINTAINED BY THE MAINTENANCE SUPERVISOR AND ADMINISTRATOR IS RESPONSIBLE TO MAINTAIN OVERALL COMPLIANCE. ( , , , , , ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE USE OF POWERSTRIPS FOR PATIENT CARE EQUIPMENT AFFECTING TWO SUPPLEMENTAL SAMPLED RESIDENTS #63 AND #129 RESULTING IN POSSIBLE ELECTROCUTION AND INTERRUPTION OF CARE. FINDINGS INCLUDE: DURING A TOUR OF THE FACILITY ON 7/31/13 BETWEEN 9:30 A.M. AND 12:30 P.M., POWERSTRIPS WERE OBSERVED USED FOR RESIDENT BEDS (RESIDENT #S 63 AND 129). DURING AN INTERVIEW WITH THE MAINTENANCE DIRECTOR ON 7/31/13 AT 2:00 P.M., THE MAINTENANCE DIRECTOR SAID, "THIS BUILDING IS OLD AND SOMETIMES DON'T HAVE ENOUGH PLUGS IN THE ROOMS FOR ALL THE CARE EQUIPMENT THAT THE NURSES WANT TO PLUG IN, SO THE NURSES TEND TO PLUG SOME THINGS INTO POWERSTRIPS THAT SHOULDN'T BE." A REVIEW OF THE MAINTENANCE OF ELECTRICAL OUTLETS POLICY/PROCEDURE, DATED NOVEMBER 2012, REVEALED THAT DURING WEEKLY ENVIRONMENTAL ROUNDS RESIDENT ROOMS AND OTHER AREAS WILL BE CHECKED TO ENSURE THAT POWER STRIPS ARE APPROPRIATELY USED. A MAINTENANCE LOG, UNDATED, WAS PROVIDED BY THE MAINTENANCE DIRECTOR ON 7/31/13 AT 3:30 P.M. WITH A PENCILED IN AREA FOR POWER STRIP MONITORING. THE LOG WAS BLANK WITH NO ENTRIES UNDER THE POWERSTRIP MONITORING COLUMN. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS AND REASSESS EFFECTIVENESS OF INTERVENTIONS TO PREVENT WEIGHT LOSS FOR ONE (#607) OF THREE RESIDENTS REVIEWED "AT NUTRITIONAL RISK" FROM A TOTAL OF 24 SAMPLED RESIDENTS RESULTING IN AN UNPLANNED WEIGHT LOSS OF GREATER THAN 9 PERCENT IN 60 DAYS AND DECREASE IN PROTEIN LEVELS. FINDINGS INCLUDE: ON 9/11/12 AT 4:10 PM, AND ON 9/12/12 AT 9:30 AM, RESIDENT #607 WAS OBSERVED IN BED, POSITIONED ONTO HER BACK. THE RESIDENT'S EYES WERE CLOSED AND OXYGEN WAS INFUSING VIA NASAL CANULA AT 2 LITERS PER MINUTE. RESIDENT #607 WAS OBSERVED TO BE MOTIONLESS AND DID NOT RESPOND TO VERBAL STIMULI. ON 9/12/12 AT 9:40 AM RESIDENT #607 WAS PROVIDED MORNING CARE FROM CERTIFIED NURSE ASSISTANT (CNA) 'B.' RESIDENT #607 WAS GIVEN VERBAL COMMANDS AND TACTILE CUES FROM CNA 'B'; HOWEVER, RESIDENT #607 DID NOT RESPOND VERBALLY, PHYSICALLY NOR DID THE RESIDENT OPEN HER EYES. AT 10:30 AM, RESIDENT #607'S CLINICAL RECORD WAS REVIEWED AND REVEALED THE FOLLOWING: PER THE FACE SHEET, RESIDENT #607 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET (MDS), dated [DATE], REVEALED THAT RESIDENT #607 WAS ABLE TO VERBALIZE HER NEEDS AND UNDERSTAND OTHERS. RESIDENT #607 HAD "MODERATELY IMPAIRED" DECISION-MAKING SKILLS AND REQUIRED ONE PERSON PHYSICAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). RESIDENT #607 WAS ABLE TO FEED HERSELF AND PERFORM PERSONAL HYGIENE AND ORAL CARE UNDER THE SUPERVISION OF STAFF. THE RESIDENT WAS CONTINENT OF STOOL AND "OCCASIONALLY" INCONTINENT OF URINE. THE RESIDENT'S RECORDED WEIGHT AT THE TIME OF THE COMPLETION OF THE MDS WAS 80 POUNDS. REVIEW OF THE CARE AREA ASSESSMENT (CAA), REVEALED THERE WAS A CONCERN REGARDING RESIDENT #607'S "FUNCTIONAL NUTRITIONAL STATUS" AND THE GOAL WAS DOCUMENTED: "IMPROVEMENT". REVIEW OF THE CLINICAL RECORD REVEALED THAT THERE WAS NO NUTRITION CARE PLAN DEVELOPED, DESPITE THE RESIDENT'S ANOREXIA (LOSS OF APPETITE) AND RISK FOR [MEDICAL CONDITION]. THIS WAS CONFIRMED WITH THE FACILITY DIETITIAN ON 8/12/12 AT 1:30 P.M. REVIEW OF RESIDENT #607'S LABORATORY TEST DATED 7/11/12 REVEALED RESIDENT #607'S [MEDICATION NAME] (A PROTEIN MADE BY THE LIVER THAT INDICATES NUTRITIONAL STATUS) WAS 2.8 GRAMS PER DECILITER (G/dL)--WHICH WAS "LOW" (NORMAL REFERENCE RANGE WAS 3.6-5.1 G/dL). A LABORATORY TEST FOR [MEDICATION NAME] (A PROTEIN MADE BY THE LIVER THAT INDICATES A MORE RECENT CHANGE IN NUTRITIONAL STATUS), DATED 7/25/12, REVEALED A LEVEL OF 12 G/dL--"LOW". (NORMAL REFERENCE RANGE FOR [MEDICATION NAME] WAS 17-34 G/dL). ACCORDING TO LIPPINCOTT MANUAL OF NURSING PRACTICE, 2010, "IN CHRONIC [MEDICAL CONDITION], SERUM [MEDICATION NAME] LEVELS ARE TYPICALLY NORMAL OR HIGH". THE RESULTS OF THESE TESTS WERE NOT IN THE CLINICAL RECORD--THEY WERE "FAXED" to the facility on [DATE]. A FORM TITLED, "DIETARY ASSESSMENT & RAP REVIEW, NUTRITION, HYDRATION, AND TUBE FEEDING", DATED 7/08/12 REVEALED RESIDENT #607 WAS 4 FOOT 11 INCHES TALL AND WEIGHED 79.6 POUNDS. THE "USUAL" BODY WEIGHT WAS "BLANK". THE PORTIONS OF THE ASSESSMENT "MENTAL STATUS/BEHAVIOR" AND "ORAL/DENTAL CONCERNS" REVEALED THERE WERE NO ISSUES IDENTIFIED IN THESE AREAS THAT COULD INTERFERE WITH ORAL INTAKE. THE PORTIONS OF THE ASSESSMENT ADDRESSING "SKIN CONDITION" AND "DEHYDRATION RISK FACTORS" WAS INCOMPLETE. THE DIETITIAN WROTE, "BRUISES ON HANDS, EXCORIATED BUTTOCKS...ENCOURAGED RESIDENT TO DRINK FLUIDS WHEN I TALKED TO HER." THE PORTION OF THE ASSESSMENT ADDRESSING "MUSCULAR CONDITIONS" (ISSUES/CONDITIONS THAT MAY INTERFERE WITH ABILITY TO EAT), WAS "BLANK". THE RESIDENT WAS diagnosed with [REDACTED]. REVIEW OF THE CARE CONFERENCE "SIGN-IN SHEET" AND SUMMARY, DATED 7/25/12, REVEALED RESIDENT #607 LOST 3 POUNDS IN APPROXIMATELY THREE WEEKS AND WEIGHED 77 POUNDS. A RECOMMENDATION FOR THE USE OF "[MEDICATION NAME]" (AN APPETITE STIMULANT) WAS MADE BY THE DIETITIAN DURING THIS MEETING AND THE INTERDISCIPLINARY TEAM AND DAUGHTER AGREED WITH THE RECOMMENDATION. THERE WAS NO EVIDENCE THE RECOMMENDATION FOR "[MEDICATION NAME]" WAS GIVEN TO THE PHYSICIAN AND ACTED UPON. AN INITIAL PSYCHIATRIC DIAGNOSTIC EVALUATION, DATED 8/09/12, REVEALED RESIDENT #607 HAD SYMPTOMS OF "INCREASED ANXIETY" AND "POSSIBLE HALLUCINATIONS...PT (RESIDENT) HAS SIGNIFICANT LEUKOCYTOSIS (ELEVATED NUMBER OF WHITE BLOOD CELLS--CAN BE AN INDICATOR OF INFECTION, POTENTIAL INFECTION, [MEDICAL CONDITION]--LIPPINCOTT MANUAL OF NURSING PRACTICE, 2010). SHE IS LETHARGIC AND (UNABLE TO READ WORD) ORIENTED ON EXAM...WITH NO OVERT [MEDICAL CONDITION]." THE RESIDENT WAS diagnosed with [REDACTED]. THE RESIDENT WAS IDENTIFIED "AT RISK FOR [MEDICAL CONDITION]". REVIEW OF THE PHYSICIAN ORDER SHEETS FOR JULY, AUGUST, AND SEPTEMBER 2012 REVEALED THE FOLLOWING ORDERS: 1. 7/09/12: "PRE-[MEDICATION NAME]. WEEKLY WEIGHTS. CALORIE COUNT" (LABORATORY RESULTS FOR THIS TEST WERE "FAXED" 9/12/12 AND NOT INCLUDED IN THE ACTIVE CLINICAL RECORD). 2. 7/12/12: "MAGIC CUP THREE TIMES A DAY ON TRAY. CHOCOLATE ENSURE PLUS TWICE A DAY. [MEDICATION NAME] OATMEAL AT BREAKFAST. 30 CC'S PROMOD TWICE A DAY." 3. 7/19/12: "THREE DAY CALORIE COUNT" (THE CALORIE COUNT INFORMATION WAS NOT IN THE RECORD AND THERE WAS NO EVIDENCE RECORDED IN THE CLINICAL RECORD REGARDING FOLLOW-UP). 4. 7/23/12: "WEEKLY WEIGHTS TIMES FOUR WEEKS. PRE-[MEDICATION NAME]" 5. 7/24/12: an order for [REDACTED]. 6. 8/21/12: "MAGIC CUP THREE TIMES A DAY. ENSURE PLUS TWICE A DAY. [MEDICATION NAME] OATMEAL AT BREAKFAST. 30 CC'S PROMOD (A DIETARY SUPPLEMENT FOR PROTEIN) TWICE A DAY." 7. 9/10/12: "PRE-[MEDICATION NAME]. WEEKLY WEIGHT TIMES FOUR WEEKS. CALORIE COUNT." PER THE DIETARY NOTES, THE REGISTERED DIETICIAN (RD), DOCUMENTED THE FOLLOWING WEIGHTS: 7/12/12 - "WEIGHT 80 POUNDS (7/13/12) WEIGHT STABLE SINCE ADMIT." 7/19/12 - "WEEKLY WEIGHT: 77 #'S THIS WEEK. THIS IS A 3 % BW (BODY WEIGHT) LOSS TIMES ONE WEEK. PER CNA CHARTING SHE IS REFUSING MEALS -25% INTAKE." (NO INTERVENTIONS NOTED IN CLINICAL RECORD TO ADDRESS LOW FOOD INTAKE). 8/1/12 - "WEIGHT IS 76#'S THIS WEEK...ADDENDUM: 3-DAY CALORIE COUNT 7/20/12 - 1015 KCAL (KILOCALORIES), 7/21/12 249 KCAL AT BREAKFAST AND LUNCH. DINNER NOT RECORDED. 7/22/12 MEALS NOT RECORDED." THERE WAS NO EVIDENCE OF FOLLOW-UP OR ALTERNATIVE FOOD ITEMS OFFERED). 8/10/12 "WEIGHT 75.8#'S". WEEKLY WEIGHTS WERE NOT RECORDED IN THE ACTIVE CLINICAL RECORD. THE CLINICAL RECORD REVEALED THERE WERE NO DOCUMENTED DIETARY NOTES OR ASSESSMENTS COMPLETED FROM 8/10/12 THROUGH 9/11/12. THERE WAS NO DOCUMENTED EVIDENCE A PLAN OF CARE WAS DEVELOPED AND REVIEWED. REVIEW OF THE FOOD ACCEPTANCE RECORD FOR THE MONTH OF SEPTEMBER 2012 REVEALED THAT RESIDENT #607 WAS REFUSING MEALS, BUT WOULD OCCASIONALLY DRINK FLUIDS. OBSERVATION OF THE RESIDENT'S TRAY ON 9/12/12 AT 1:00 P.M. REVEALED NO FOOD INTAKE AND ONLY "SIPS" OF FLUIDS CONSUMED. THE DIETITIAN WAS INTERVIEWED AT THIS TIME AND WAS UNABLE TO EXPLAIN WHY SHE DID NOT FOLLOW-UP ON HER RECOMMENDATION FOR THE USE OF [MEDICATION NAME] TO STIMULATE RESIDENT #607'S APPETITE. ON 9/13/12 AT 11:15 AM, RESTORATIVE CNA 'R' AND CNA 'B' WERE OBSERVED TO TRANSFER RESIDENT #607 FROM THE BED TO THE WEIGHT CHAIR. RESIDENT #607'S RIB CAGE WAS VISIBLE THROUGH HER SKIN IN THE FRONT AND THE BACK. THE RESIDENT WAS ENCOURAGED TO HELP IN TRANSFERRING FROM THE BED TO THE CHAIR AND WHEN ASKED IF SHE WOULD BE ABLE TO HELP WITH THE TRANSFER, RESIDENT #607 SHOOK HER HEAD "NO." CNA 'R' LIFTED RESIDENT #607 UP (THE RESIDENT'S ARMS, LEGS AND HEAD WERE LIMP LIKE A RAG DOLL) AND PLACED HER ON THE CHAIR SCALE. RESIDENT #607 WAS ASKED TO "SIT UP"; HOWEVER, WAS UNABLE TO DO SO. CNA 'B' AND 'R' USED A PILLOW TO PREVENT RESIDENT #607'S HEAD FROM RESTING ON THE MACHINE. CNA 'R' OBTAINED A WEIGHT OF 71.2 POUNDS. THE RESIDENT HAD LOST AN ADDITIONAL 4.6 POUNDS FROM THE DOCUMENTED MONTHLY WEIGHT FOR "SEPTEMBER 2012" OF 75.8 POUNDS. ON 9/13/12 AT 1:45 PM, THE REGISTERED DIETICIAN WAS QUERIED REGARDING RESIDENT #607'S WEIGHT LOSS (8.8 POUNDS SINCE ADMISSION.) THE RD REPORTED SHE WAS UNAWARE OF THE RESIDENT'S WEIGHT LOSS OF 8.8 POUNDS. THE RD STATED THAT SHE WAS AWARE THAT RESIDENT #607 WAS admitted WITH ANOREXIA BUT WAS UNAWARE OF THE [MEDICATION NAME] LEVEL (THE [MEDICATION NAME] LEVEL THAT WAS REQUESTED ON 7/9/12 WAS NOT DRAWN UNTIL 7/25/12 AND WAS "FAXED" to the facility on [DATE]--THE INFORMATION WAS NOT PART OF THE CLINICAL RECORD.) THE DIETITIAN STATED, "I SAW THE ORDER BUT SOMETIMES THE LABS ARE NOT ALWAYS AVAILABLE FOR ME TO SEE." THE DIETITIAN WAS ASKED IF THERE WERE ANY CHANGES IN INTERVENTIONS SINCE SHE DOCUMENTED THAT THE RESIDENT WAS LOSING WEIGHT AND STATED, "I ADDED PROMOD (A PROTEIN SUPPLEMENT) 30 CC'S ON 8/21/12." (ACCORDING TO PHYSICIAN ORDERS, THE ORDER AND RECOMMENDATION BY THE DIETITIAN FOR THE USE OF 30 CC'S OF PROMOD ON 8/21/12 WAS THE SAME ORDER AS WRITTEN ON 7/12/12.) THE DIETITIAN WAS QUERIED REGARDING ANY ADDITIONAL INTERVENTIONS OR CHANGES TO ASSIST RESIDENT #607 TO IMPROVE IN HER NUTRITIONAL STATUS AS THE FACILITY DOCUMENTED CONTINUED WEIGHT LOSS AND THE REFUSAL OF MEALS. THE DIETITIAN REVIEWED THE CHART AND STATED THAT SHE DID NOT UPDATE OR TRY ANY NEW INTERVENTIONS FOR RESIDENT #607 AND THEN STATED, "I DO TALK TO HER TO FIND OUT WHAT SHE WANTS TO EAT." THE DIETITIAN FURTHER STATED, "I WAS TOLD THAT THE RESIDENT WAS STARTED ON [MEDICATION NAME] (AN APPETITE STIMULANT--THERE WAS NO PHYSICIAN'S ORDER FOR [MEDICATION NAME]). WHEN ASKED IF SHE REVIEWED MEDICATIONS PRESCRIBED FOR RESIDENTS AS PART OF HER ASSESSMENT, THE DIETITIAN PROVIDED NO VERBAL RESPONSE. THE DIRECTOR OF NURSING WAS INTERVIEWED ON 9/13/12 AT APPROXIMATELY 4:00 P.M. AND WAS UNABLE TO EXPLAIN WHY THE PHYSICIAN AND THE RESIDENT'S DAUGHTER WERE NOT PROVIDED INFORMATION REGARDING THE SIGNIFICANT WEIGHT LOSS NO WHY THE INTERDISCIPLINARY TEAM DID NOT MEET TO RE-EVALUATE RESIDENT #607. A REQUEST TO INTERVIEW THE PHYSICIAN WAS MADE AT THIS TIME AND THE DIRECTOR OF NURSING REPORTED SHE WOULD ARRANGE A MEETING TIME AND PLACE TO FACILITATE INTERVIEW WITH THE PHYSICIAN. THE PHYSICIAN WAS NOT MADE AVAILABLE DURING THE SURVEY. ON 9/14/12 AT 9:00 A.M., THE DIRECTOR OF NURSING PROVIDED physician progress notes [REDACTED]. THE physician progress notes [REDACTED]. LABS HAVE BEEN ORDERED INCLUDING A PRE-[MEDICATION NAME]. WEEKLY WEIGHTS ARE IN PLACE. CALORIE COUNT IS IN PLACE AS WELL. PATIENT DOES HAVE PROGRESSIVE DEMENTIA. PLAN: WE WILL ORDER LABS...LABS ARE STILL PENDING. WE WILL DISCUSS WITH FAMILY REGARDING EITHER A PEG (PERCUTANEOUS GASTROSTOMY TUBE) OR THE PATIENT WILL (BE) PLACED INTO HOSPICE..." THE physician progress notes [REDACTED]. WE WILL START THE PATIENT ON ANTIBIOTICS...ORDER BLOOD CULTURES...START IV (INTRAVENOUS FLUIDS--USED FOR HYDRATION)..." RESIDENT #607'S DAUGHTER WAS INTERVIEWED ON 9/12/12 AT 2:50 P.M. AND REPORTED SHE WAS NOT FULLY AWARE OF HER MOTHER'S CONDITION. RESIDENT #607'S DAUGHTER WAS UNAWARE OF THE LABORATORY TESTS ORDER AS WELL AS THE IV (FOR HYDRATION). THE RESIDENT'S DAUGHTER STATED SHE DID NOT WANT A FEEDING TUBE INSERTED IF HER MOTHER WAS NOT GOING TO RECOVER. THE DAUGHTER REPORTED IF HER MOTHER'S CONDITION WAS REVERSIBLE, SHE WANTED THE INSERTION OF THE FEEDING TUBE, STATING, "I DON'T WANT HER TO STARVE TO DEATH". ON 9/14/12 AT 1:00 PM, REVIEW OF THE FACILITY POLICY TITLED, "NUTRITION ASSESSMENT AND CARE PLAN", REVISED 3/10 DOCUMENTED, "ALL RESIDENTS ARE ASSESSED BY THE REGISTERED DIETITIAN, DIETARY TECH, OR CERTIFIED DIETARY MANAGER TO DETERMINE NUTRITIONAL NEEDS AND DEVELOP A CARE PLAN WHICH BEST MEETS THE INDIVIDUALS NUTRITIONAL NEED. PROCEDURE: ...CARE PLANS ARE COMPLETED BY DIETARY WITHIN 21 DAYS AFTER ADMISSION...ALL RESIDENT'S NUTRITIONAL NEEDS AND CARE PLANS ARE REVIEWED QUARTERLY. PROGRESS NOTES WILL REFLECT PROBLEMS, TREATMENT AND RESPONSE TO TREATMENT... IF MORE FREQUENT REVIEW OF RESIDENTS NUTRITIONAL STATUS IS NECESSARY IT WILL BE DOCUMENTED ON THE CONTINUED NUTRITIONAL ASSESSMENT FORM IN THE MEDICAL RECORD." ( )