Every finding on record at The Springs at Rochester Hills Rehab and Nursing C

This citation pertains to Intake Number(s): 3044078 and 3044417. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for one (R804) of four residents reviewed for abuse, resulting in psychosocial harm using the reasonable person concept when R805 laid in bed with R804, exposed his genitals, and touched R804's breast. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed there was an allegation of sexual abuse between R805 and R804 that occurred on [DATE]. A review of a complaint submitted to the SA revealed an allegation that R804 was sexually assaulted by an unknown male resident. On [DATE], an unannounced onsite investigation was conducted. On [DATE] at approximately 8:30 AM, R805 was observed lying in bed. R805 said hello in Spanish. Certified Nursing Assistant (CNA) 'E' was observed at R805's bedside. CNA 'E' explained she was assigned to provide 1:1 supervision for R805 but was not sure why. CNA 'E' said she thought it was because R805 wandered, but was not entirely sure.On [DATE] at 11:18 AM, R804 was observed lying in bed. R804 smiled when addressed, but then did not make contact or verbally respond to any questions. A review of R805's clinical record revealed R805 was admitted into the facility on [DATE] with diagnoses that included: Parkinson's Disease and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed no assessment of R805's cognitive status. The MDS noted R805 did not have any behaviors including wandering, and required partial/moderate assistance with transfers and walking. A review of R805's Wandering Risk Scale assessments revealed on [DATE] and [DATE], R805 was assessed to be at risk to wander. A review of a General Progress Note dated [DATE] at 8:30 AM, written by Licensed Practical Nurse (LPN) 'F', revealed, writer was at medication cart when nursing aid approached cart to report (R805) in another resident's bed upon writers' arrival in room writer witnessed (R805) in the resident's bed and under the covers together writer called out for another nurse assistance previous shift (LPN 'G') approached room both nurses pulled the covers back writer seen (R805) undressed from waist down other resident was still in gown with top half down and breast exposed brief was still on person. (R805) was turned to his left up close on resident genitals exposed resident was laying straight back resident's face had beefy red discolor on their right side and face was turned to their left while body remained straight .(R805) stated he didn't know what happen, and he doesn't remember when writer asked translator to ask resident why he took his brief off resident stated it was dirty. Resident then said he had a headache rested his head back down and didn't answer any more questions .A review of R804's clinical record revealed R804 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia. A review of a MDS assessment dated [DATE] revealed R804 had severely impaired cognition. A review of a General Progress Note dated [DATE] at 8:30 AM, written by LPN 'F', revealed, writer was at medication cart when nursing aid approached cart to report a resident (R804's) bed upon writers' arrival in room writer witnessed a male resident in the (R804's) bed under the covers writer called out for another nurse assistance previous shift nurse (LPN 'G') approached room both nurses pulled the covers back writer seen male resident undressed from waist down (R804) was still clothed with a gown on top half of gown was down and breast exposed brief was still on. male resident was turned to his left up close on (R804) male resident genitals was exposed (R804) was laying straight on her back face had beefy red discolor on right side and face was turned to left while body remained straight . resident was transferred via EMS (emergency medical services) to (hospital) for further evaluation .A review of a IDT (Interdisciplinary Team) Progress Note dated [DATE] in R804 and R805's clinical records revealed, The interdisciplinary team reviewed the investigation findings related to the resident-to-resident sexual contact event that occurred on [DATE]. Based on staff observations, resident assessments, interviews, and reviews, the investigation verified that inappropriate sexual contact occurred between the residents. Staff observed the male resident in bed with the female resident. The male resident with his brief removed and genitalia exposed, while the female's gown was displaced upward exposing her breasts. The male resident was observed with his hand on the female's right breast. The female resident was not observed touching the male resident and was noted to be facing away from him. A reddened area was identified on the female's right cheek during the immediate assessment. Due to the female resident's severe cognitive impairment, developmental delays, BIMS (Brief Interview for mental status) score of 3 (which indicated severely impaired cognition), and legal guardian status, she lacked the capacity to provide informed consent. The event was treated as an allegation of sexual abuse .Review of clinical records, behavioral documentation, prior events, and collateral information identified no prior resident-to-resident sexual incidents involving either resident. Both residents have documented cognitive impairment, which may have contributed to impaired judgment, impaired recognition of personal boundaries, and inappropriate resident-to-resident interactions. The exact circumstances leading to the event could not be fully determined .Further review of R805's clinical record revealed the following which indicated he had a history of wandering into other resident's rooms and going into their beds:A General Progress Note dated [DATE] noted, Res (resident) urinated in his how and garbage can on 2 different times today. also observed this morning sitting at the bed of another res. Res was assisted back to his own bed.A Mood/Behavior progress note dated [DATE] noted, Resident observed lying in another resident's bed wearing wet pants. Writer attempted to redirect resident to his own room for incontinence care with CNA assistance. Resident became agitated upon redirection and began yelling in Spanish. Resident then stood up from chair and continued yelling .It was documented in a General Progress Note on [DATE] that R805 was moved to a new room on the second floor from the first floor. There was no documentation as to why the room change was made. A review of the facility's investigation into the sexual abuse incident mentioned above, revealed the following:R804 was transferred to the hospital for further evaluation to include a forensic examination as requested by her legal guardian. A summary written about R805 noted, Review of admission records and collateral information received from the resident's prior care setting identified a history of wandering and searching behaviors related to his deceased spouse .R804 was unable to meaningfully participate in an interview due to severe cognitive impairment. It was noted that LPN 'F' was interviewed and said (R804) was lying on her back facing up, (R805) was to her right, lying on his left side. I got (LPN 'G') we went into the room, when the blanket was pulled down (R804's) gown was pulled up and her right breast was exposed. Her brief was in place and intact. (R805) had his right hand on (R804's) right breast. (R805's) gown was pulled up, his brief was pushed down to his ankle and his genitals were exposed .skin assessment was done for (R804). She had a red mark to the right side of her face .It was noted that LPN 'G' was interviewed and said, .(R805's) brief was on his left ankle, his gown was pulled up, exposing his genitals. (R804's) gown was pulled up, exposing her right breast. (R804) was lying on her back, (R805) was lying to the right of her on his left side facing her .It was noted that CNA 'C' was interviewed and said, .I went into (R804's) room, the door was closed, I opened the door and called for the nurse. (LPN 'F') came to the door and we entered the room; they were under covers. (LPN 'F') pulled the blanket down and (R805) had gown on; brief was on his ankle. (R804) was lying on her back, (R805) was lying on his left side on the right of her, facing her. (R804's) right breast was exposed .It was documented that .the allegation was verified based on direct staff observations .A review of hospital records for R804 revealed she received a Sexual Assault Nurse Examiner (SANE) exam. (A SANE exam is a specialized medial forensic examination to collect evidence related to sexual assault. The exam can be invasive in nature as it includes collecting bodily fluids, swabbing of the genital area, etc.)On [DATE] at 12:01 PM, an interview was conducted with CNA 'C'. When queried about what happened on [DATE] with R804 and R805, CNA 'C' reported she was reassigned to the second floor from the first floor. When she got to the unit, she checked on the residents in her set. R804's door was closed so she knocked and opened the door. When she opened the door, there was a man lying in bed with R804 and they were both underneath the blanket. CNA 'C' called for the nurse who came into the room. R804's right breast was out and R805's brief was all the way down and his genitals were exposed. CNA 'C' said R804 was just lying there on her back and R805 was lying on his side facing R804. CNA 'C' said two nurses took over from there. On [DATE] at 11:07 AM, an interview was conducted with LPN 'F' via the telephone. When queried about what happened on [DATE] with R804 and R805, LPN 'F' reported she was their assigned nurse that day. A CNA came to get her and said R805 was under the covers with R804 in her room. LPN 'F' explained she observed a beefy red cheek on R804's face, R805's brief was down to his ankle, and R804's brief was on, but her breast was exposed. According to LPN 'F', the CNA said R805 was touching R804's breast. LPN 'F' was not sure about any past behaviors of R805, sexual or wandering, but said other nurses had mentioned he was flirtatious. LPN 'F' said she heard from a CNA that R805 had went into another resident's room before to use the bathroom. On [DATE] at 1:48 PM, an interview was conducted with the Director of Nursing (DON). When queried about what was put in place prior to the sexual abuse by R805 toward R804 on [DATE], the DON reported R805 was moved upstairs from the first floor due to wandering but was not sure about other interventions that were put in place. At that time, the lack of care planned interventions for wandering, despite being assessed as at risk, and having documented incidents of being in other resident's beds in the past, was discussed with the DON. At that time, any evidence of interventions put into place prior to [DATE] was requested. No additional information was provided prior to the end of the survey. On [DATE] at 2:22 PM, an interview was conducted with the Administrator, who was the Abuse Coordinator for the facility. The Administrator reported she was unaware R805 had previously documented incidents of wandering into other residents' rooms and going into their beds and confirmed there should have been interventions in place. The Administrator reported the facility verified the incident of sexual abuse did occur based on the observations made by staff. A review of a facility policy titled, Abuse and Neglect, updated [DATE], revealed, in part, the following, .Instances of abuse of all residents, irrespective of any mental of physical condition, cause physical harm, pain or mental anguish .It includes .sexual abuse .Sexual is defined as non-consensual sexual contact of any type with a resident .Sexual abuse include, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area .This would include, but is not limited to, nudity, fondling .Prevention .This includes an analysis of .The assessment, care planning, and monitoring of residents .who have behaviors such as entering other residents' rooms .

This citation pertains to Intake Number(s): 3044078 and 3044417. Based on observation, interview, and record review, the facility failed to implement effective interventions for dementia related behaviors in a timely manner for one (R805) of one resident reviewed for dementia care, resulting in continued wandering behaviors and the resident climbing into bed with another resident, exposing his genitals, and touching the other resident's breast. Findings include:On [DATE] at approximately 8:30 AM, R805 was observed lying in bed with the privacy curtain pulled. R805 said hello in Spanish. Certified Nursing Assistant (CNA) 'E' was observed at R805's bedside. On [DATE] at 11:20 AM, R805 was observed lying in bed with the privacy curtain pulled. CNA 'E' was observed at R805's bedside. At that time, an interview was attempted with R805. R805 acknowledged he was able to understand English but did not speak it well. R805 answered yes and no to questions but was not able to give more detailed answers. On [DATE] at 11:25 AM, an interview was conducted with CNA 'E'. CNA 'E was asked why she was in R805's room with him. CNA 'E' reported she was assigned to be his 1:1 sitter. When asked why R805 required 1:1 supervision, CNA 'E' said she did not know. CNA 'E' said she thought it was because he wandered into other resident's rooms but was not positive. A review of R805's clinical record revealed R805 was admitted into the facility on [DATE] with diagnoses that included: Parkinson's Disease and dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed no assessment of R805's cognitive status. The MDS noted R805 did not have any behaviors including wandering and required partial/moderate assistance with transfers and walking. A review of R805's Wandering Risk Scale assessments revealed on [DATE] and [DATE], R805 was assessed to be at risk to wander. A review of a General Progress Note dated [DATE] at 8:30 AM, written by Licensed Practical Nurse (LPN) 'F', revealed, writer was at medication cart when nursing aid approached cart to report (R805) in another resident's bed upon writers' arrival in room writer witnessed (R805) in the resident's bed and under the covers together writer called out for another nurse assistance previous shift (LPN 'G') approached room both nurses pulled the covers back writer seen (R805) undressed from waist down other resident was still in gown with top half down and breast exposed brief was still on person. (R805) was runed to his left up close on resident genitals exposed resident was laying straight back resident's face had beefy red discolor on their right side and face was turned to their left while body remained straight .(R805) stated he didn't know what happen, and he doesn't remember when writer asked translator to ask resident why he took his brief off resident stated it was dirty. Resident then said he had a headache rested his head back down and didn't answer any more questions .Further review of R805's clinical record revealed the following which indicated he had a history of wandering into other resident's rooms and going into their beds:A General Progress Note dated [DATE] noted, Res (resident) urinated in his how and garbage can on 2 different times today. also observed this morning sitting at the bed of another res. Res was assisted back to his own bed.A Mood/Behavior progress note dated [DATE] noted, Resident observed lying in another resident's bed wearing wet pants. Writer attempted to redirect resident to his own room for incontinence care with CNA assistance. Resident became agitated upon redirection and began yelling in Spanish. Resident then stood up from chair and continued yelling .It was documented in a General Progress Note on [DATE] that R805 was moved to a new room on the second floor from the first floor. There was no documentation as to why the room change was made. A review of the facility's investigation into the incident documented in the [DATE] progress note revealed, .Review of admission records and collateral information received from the resident's prior care setting identified a history of wandering and searching behaviors related to his deceased spouse .A review of R805's care plans revealed there was no care plan to address R805's known wandering risk, as documented in the progress notes and assessments, until after he was found in bed with another resident on [DATE]. On [DATE] at 12:01 PM, an interview was conducted with CNA 'C' who was the CNA who found R805 in another resident's bed on [DATE]. CNA 'C' reported when she opened the door to the other resident's room, R805 was lying in bed with the other resident and they were both underneath the blanket. CNA 'C' further said R805's brief was down and his genitals were out and the other resident's breast was showing. When queried about any previously known behaviors that R805 had, CNA 'C' said she was not aware of any behaviors. On [DATE] at 11:07 AM, an interview was conducted with LPN 'F', the nurse assigned to R805 on [DATE]. LPN 'F' explained that R805 was found in another resident's bed with his genitals exposed and the other resident's breast was exposed. LPN 'F' said she was unaware of any wandering or sexual behaviors exhibited by R805 in the past but reported she heard from a nurse that R805 was flirtatious and heard from a CNA that R805 wandered into other resident's rooms before. On [DATE] at 1:48 PM, an interview was conducted with the Director of Nursing (DON). When queried about what interventions were put into place when R805 was assessed to be at risk for wandering, the DON reported R805 was placed on the second floor. The DON reported typically the Interdisciplinary Team (IDT) would try to figure out what was triggering the resident's wandering behaviors so that interventions could be put into the care plan and implemented. The DON reported she was aware R805 had wandered into other residents' rooms and got into bed with them in the past, but that it was not sexual, but did not offer a response as to why there were no interventions put into place until after the incident on [DATE]. When queried about the facility's protocol to monitor behaviors for residents with dementia, the DON reported there was a physician's order to monitor the specific behavior every shift, and it would be signed off on the Medication/Treatment Administration Record and also could be documented by the CNAs. The behaviors were reviewed by the IDT to determine if any additional interventions were needed. At that time, a review of R805's Physician's Orders (active and discontinued) revealed no orders for behavior monitoring until [DATE]. Further review of R805's clinical record revealed no documentation that provided evidence of the IDT monitoring R805's pattern of wandering to determine the triggers or patterns. The DON was given the opportunity to provide any additional information regarding interventions that were in place and/or behavior monitoring for R805 prior to [DATE]. No additional information was provided prior to the end of the survey. On [DATE] at 2:55 PM, an interview was conducted with the Director of Social Services (DSS). When queried about how residents with dementia who wander were monitored for their behaviors, the DSS said she did wellness checks and activities staff did 1:1 activities to keep occupied. The DSS reported she referred residents with behaviors to the contracted behavioral health agency. When queried about who determined what specific interventions were appropriate, the DSS said the IDT determined the interventions, and they were added to the care plan. In addition, weekly behavior management meetings were held for residents on psychotropic medications or those with behaviors and/or dementia. When queried about whether R805 was reviewed in behavior meetings prior to the [DATE] sexual incident, the DSS said she was on leave when he was admitted and was not sure what was done before she returned. Since she returned, she started wellness checks. A review of a facility policy titled, Behavioral Management, dated [DATE], revealed, .The interdisciplinary care team identified underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to changes in the resident's behavior .Identified behaviors will be documented and tracked in the medical record .Behaviors and interventions will be addressed in the care plan .

This citation pertains to Intake #2985803.Based on interview and record review, the facility failed to ensure a Preadmission Screening (PAS)/Annual Resident Review (ARR) Level II evaluation (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has a mental disorder and determines the appropriate setting for the individual and recommends any specialized services the individual needs) was completed and the recommendations incorporated into in the resident's assessments and plan of care for one (R802) of one resident reviewed for PASARR.Findings include: A review of a complaint submitted to the State Agency revealed an allegation that an PASARR Level II evaluation was not completed for R802 since 1/2025.A review of a document provided by the facility titled, OBRA Operations Manual 2017 revealed the following: .The Level I Process .All individual identified by a Level I Screen as possibly having a serious mental illness or intellectual disability/developmental disability or related condition must receive a Level II Evaluation and determination prior to admission to a nursing facility, unless they meet one of the following exemption criteria: coma, dementia or hospital exempted discharge. A DCH-3878 (Department of Community Mental Health) must be completed prior to admission identifying the exemption criteria claimed .The Level II Process .Persons who are identified on the Level I Screen by any 'YES' answer on the (Level I form) and who do not meet exemption criteria must be referred to the local (community mental health) for the possible need of a Level II Evaluation .(the local health and human services department) bases the determination of the need for Nursing Facility Services and/or Specialized Mental Health Services from the information in the Level II Evaluation .On 5/5/26 at approximately 11:45 AM, an interview was conducted with R802. R802 reported they needed to have a Level II evaluation completed in order to assist with facilitating discharge from a nursing home. R802 reported they have been unable to get copies of previous evaluations, and the last one was conducted in January of 2025 at a different facility. R802 reported a LEVEL II Evaluation had not been completed in the current facility. A review of R802's clinical record revealed R802 was admitted into the facility on 9/18/25 with diagnoses that included: schizoaffective disorder and delusional disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had moderately impaired cognition and was prescribed antipsychotic and antidepressant medications. A review of a PASARR Level I Screening form dated 7/30/25 (prior to R802's admission into the facility) revealed R802 had a diagnosis of a mental illness (schizoaffective, bipolar type), received treatment for mental illness, and routinely received one of more prescribed antipsychotic or antidepressant medications within the last 14 days. The instructions on the form noted, If any answer to items 1-6 (which included whether the resident had mental illness, received treatment for mental illness, and/or was prescribed antipsychotic or antidepressant medications) .is 'YES', send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. Further review of R802's clinical record revealed no DCH-3878 indicating an exemption or a Level II Evaluation.On 5/5/26 at 12:59 PM, an interview was conducted with the Administrator, as the Director of Social Services was unavailable for interview. When queried about the PASARR process in the facility, the Administrator reported a Level I screening was done immediately upon admission and a Level II Evaluation within 14 days. The Administrator reported all documents were uploaded into the electronic medical record (EMR). When queried about R802, the Administrator reported they would see if the Level II Evaluation was not yet scanned into the EMR. On 5/5/26 at approximately 1:49 PM, the Administrator followed up and reported the Level II Evaluation should have been obtained from the referring facility or the current facility should have followed the protocol and requested one to be completed.

This incident relates to Intake 2742599.Based on observation, interview, and record review, the facility failed to protect the residents right to be free from physical abuse when R106 punched R105 in the nose, which resulted in nasal fractures, pain, acute mental status changes, and feelings of fearfulness. Findings include: Review of a Facility-Reported Incident (FRI), dated 1/10/26, revealed R106 made contact with R105's face with a closed fist when R105 rolled over R106's toes with their wheelchair on 1/10/26 at approximately 7:03 p.m This resulted in R105's injury to R105's nose, an emergent hospital transfer, and R105 sustaining bilateral (both sides) nasal fractures. The report concluded that R105 had minimal injury and no psychosocial outcome. The incident was reported to the (County) Sheriff's Department, and residents' guardians and physician. Review of the Facility Investigation report, provided and written by the Nursing Home Administrator (NHA), revealed R105 was admitted to the facility on [DATE], with diagnoses including vascular dementia, generalized anxiety disorder, bipolar disorder (mood disorder), subarachnoid hemorrhage (brain bleed), muscle wasting and atrophy (wearing down of muscles), and malnutrition. R105 used a wheelchair for mobility. The BIMS (Brief Interview of Mental Status) showed a score of 6/15, which showed severe cognitive impairment. The report showed R106 was admitted to the facility on [DATE], with diagnoses including dementia, diabetic neuropathy, schizophrenia (a mental disorder which may cause psychosis, cognitive communication deficit, muscle weakness, and an adjustment disorder with anxiety. R106 was ambulatory without a device. The BIMS assessment showed a score of 6/15, which showed severe cognitive impairment. Review of R106's interview statement, in the investigation file, dated 1/12/26, completed with the Nursing Home Administrator (NHA) and Director of Nursing (DON), revealed R106 stated, She (R105) was rolling by, pulled on my pants. I knocked her in the face. (sic) Threw me out of control, off balance. I don't like being touched. It was noted R106 refused to sign the interview statement. On 2/23/26 at 12:30 p.m., R106 was observed walking on unit (first floor) by nurse's station. He was tall and thin, and dressed in a blue shirt and pants. R106 said hello to this surveyor. Review of the facility census showed R106 had been moved to the first floor after the resident-to-resident abuse incident, on 1/15/26, and R105 remained on the second floor. On 2/23/26 at approximately 12:35 p.m., Certified Nurse Aide (CNA) C said R106 was interviewable. On 2/23/26 at approximately 2:10 p.m., R106 was observed walking on the same unit and agreed to be interviewed in their room. On 2/23/26 at approximately 2:15 p.m., R106 was asked about any incident with another facility resident. R106 said, I punched her (R105) in the nose. (R105) ran into me in her wheelchair in the hall. I think she did it on purpose. Nothing else happened. I struck her with my fist.She (R105) made me feel angry.She called the police. They (law enforcement) did talk to me. R106 said they punched R105 because their foot hurt when she ran over it. R106 said they would leave R105 alone if he saw her again. R106 was alert and oriented to themselves and their surroundings and situation. R106 was sent out soon after the incident for psychiatric evaluation and returned to the facility. Review of R106's interview statement, in the investigation file, completed with the NHA and DON, revealed R106 stated, She (R105) was rolling by, pulled on my pants. I knocked her in the face. (sic) Threw me out of control, off balance. I don't like being touched. It was noted R106 refused to sign the statement. Review of the Accident and Incident report, dated 1/10/26 at 8:30 p.m., revealed R106 was walking down the hallway when it appeared R105 ran over R106's foot with their wheelchair. R105 screamed and hit R105 in the face with a closed fist, which resulted in R105 crying and screaming. R105 screamed, He (R106) hit me. R105 was sent to the hospital emergently after being cleaned up, neuro checks were started. R105 reportedly had increased anxiety and pain 10/10, with 10 being the worst. R106 was placed on 15-minute checks and the facility did not verify abuse occurred. The report showed R106 had no pain and was moved to another room on another floor. Review of Licensed Practical Nurse (LPN) Is handwritten witness statement, dated 1/10/26, revealed, I heard (R106) after say, 'No, I meant to do it. These people are always touching me and rubbing on me. I'm tired of it.' (R106) was upstairs (on the dementia/cognitive care unit) at the time. Review of Certified Nurse Aide (CNA) Ys handwritten written statement revealed, (R105) rolled towards (R106) in their wheelchair, and I think over (R106's) foot and (R106) came around the back from (R105), leaning against the wall of elevator and punched (R105) in her nose and proceeded to walk to his room. (R105's) nose started gushing blood. On 2/24/26 at 11:55 a.m., R105 was observed at the nurse's station, well-dressed and smaller statured, in a manual wheelchair. No bruising was observed. R105 agreed to be interviewed in their room. On 2/25/26 at 12:00 p.m., R105 was asked how they were doing and if they had any concerns. R105 stated, One man (R106).We had a war and I thought he was my friend. He was real nice before. I wondered what was in his pocket. I liked the color blue. and said she reached for (R106's) pocket when he hit her. R105 said, .We had quite a boxing match.I tried to pull something out of his pocket. R105 said she was injured and pointed to her face. R105 said she had hemorrhages and started crying. R105 said R106 just giggled about the incident and it made her feel terrible, as he went in for her nose and face. R105 said, How does it look now? and said she had bruising and tried to cover it up with make-up at the time. R105 said she had pain in their ears when it happened and still had ear pain sometimes and said it made her feel horrible. R105 stated, My head was spinning. My head hurts still. When asked if she felt safe, R105 said, No. I told my girlfriend I didn't feel safe here, and said she wanted to go home. R106 said they felt better now that R106 was not there (on their floor). R105 was able to tell time, and said, It's ten after 12 (which was accurate). and knew the year. R106 was oriented to themselves, time, and place, as they knew the address number and city, although at times their speech was tangential during the interview. On 2/24/26 at approximately 12:40 p.m., it was reported to the Director of Nursing (DON) R105 expressed not feeling safe in the facility, and R105 said they were still having some pain in their head and ears after the incident. On 2/24/26 at 2:00 p.m., CNA U was asked what happened during the incident between R106 and R105 on 1/10/26. CNA U confirmed they were working when the incident occurred. CNA U observed R106 hit R105 in the nose when R105 was trying to turn around from the elevator and described R105 accidently ran over R106's foot, and R106 turned around and said 'ouch'. Then said R106 hit R105 with a closed fist; it was one punch, and R105's nose started bleeding and she was crying. Then one of the nurses intervened and applied pressure to stop the bleeding and called the ambulance. CNA U said this was the second time R106 hit somebody, so they believed it was intentional, as this happened with another female resident. Review of R106's progress notes revealed another resident-to-resident incident between themselves and an unnamed female resident which occurred on 9/20/25 at 17:30 (5:30 p.m.). The progress note revealed, Writer witnessed resident assault a female resident with a closed fist.Police contacted. 15-minute checks conducted for 48 hours by nurse supervisor . Review of R106's nursing progress note dated 1/10/26 at 21:24 (9:24 p.m.) revealed, At approximately 1915 (7:15 p.m.), writer was informed by another nurse that resident (R105) had been physically assaulted by another resident (R106) and was punched in the nose with a closed fist. The assaulted resident (R105) did not lose consciousness during the attack; however, resident (R105) is a poor historian as baseline mental status is pleasantly confused, (R105) presented with active nasal bleeding. (R105) allowed writer to assist with hygiene, which including cleaning blood from face, hands and changing of undershirt and sweater but resident (R105) appeared visibly anxious and refused vital signs. Resident left facility via stretcher accompanied by ambulance personnel and was transported to (Name of) hospital. Police were notified.(R105) stable at time of transfer. Review of R105's progress note, dated 1/13/26 at 10:56 a.m., showed R105 fell in her room due to agitation, and could not recall what occurred clearly. Review of R105's pain log, under vitals, revealed R105's pain was 10/10 after the incident at 20:12 (8:12 p.m.) and 20:09 (8:09 p.m.), requiring two additional doses of Tylenol (as needed dosing). Review of R105's Care Plan, accessed 2/25/26, showed no updates for R105, to protect them or address their psychosocial concerns after the incident. Review of R105's physician note, dated 1/12/2026, revealed, Progress note.Full Scope of treatment. admitted to hospice. The patient (R105) was recently hospitalized for a short time and returned from the emergency room the same day. She is currently experiencing what appears to be another episode of delusions. On January 10, 2026, the patient accidentally rolled over another residents' foot while in her wheelchair. That resident (R106) screamed and hit the patient in the nose with a closed fist, causing bleeding. Following the incident, the patient was taken to the hospital where she underwent a CT scan of the maxillary (nose sinus area). The patient currently has a small bruise on the left side of the bridge of her nose. There is not more bleeding noted at this time. However, the patient is currently refusing care and is agitated, having conversations with herself. She is currently on hospital care and has multiple medications including trazadone, melatonin, Depakote, carbamazepine, Ability, morphine, lorazepam, and haloperidol among others.Diagnosis and Assessment: Nose fracture. R105's physician note further revealed: .Assessment and Plan: (R105) is a patient with bipolar disorder and dementia presenting with delusional thoughts about bruises, room cleanliness and people taking her belongings, following a recent hospitalization for nasal fracture sustained form being stuck by another resident. 1. Acute psychotic episode with delusions. Assessment: (R105) is experiencing another episode of delusions, presenting with paranoid thoughts about bruises,.about room cleanliness, maintenance issues, fears of being locked in her room, and beliefs that people are taking her clothes. This presents an acute exacerbation of her underlying psychiatric condition in the setting of recent hospitalization and trauma. Patient is currently refusing care and agitated, having conversations with herself, indicating active psychosis requiring immediate attention. Plan: Continue current psychiatric medications.Discuss with nursing supervisor regarding current episode and care management.Recent nasal bone fractures.Small bruise remains visible on the left side of the bridge of her nose, but bleeding has resolved. Plan. Monitor healing process. Continue acetaminophen (OTC Tylenol pain medication) and morphine for pain management. May need ENT (specialist consult) if patient started complaining of symptoms or recurrent bleeding.Multiple chronic conditions. Assessment.Patient has multiple comorbidities. She is currently on hospice care, indicating advanced illness with focus on comfort measures. Review of a police report from the (Name of County) Sheriff's Department, dated 1/10/26 at 19:07 (7:07 p.m.), revealed the facility called 911, and the dispatched offense was 1313 Assault Battery/Simple, and the verified (conclusion) offense was 1313 Assault/Battery/Simple.with an Exceptional Clearance date in red, stating, Victim refused to cooperate. Further review of the report revealed the Officer was unable to interview R105 due to her mental status when the incident occurred so they called R105's guardian. The Officer interviewed R106, who confirmed he punched R105 one time with his right fist when she grabbed onto his pant leg. The report verified the incident was witnessed by a facility nurse, who confirmed R105 was struck by R106 in the face with his right fist after the incident across from the elevator. The report further revealed on 1/22/26 law enforcement was able to reach R105's guardian, who declined to press charges, so the case was closed due to lack of cooperation from the victim/guardian. The Police report verified an assault occurred by R106 towards R105. Review of the concerns related to the resident-to-resident physical abuse and psychosocial outcome on 2/25/26 was reviewed with the NHA and DON during the survey and at survey exit, and with Regional Nurse Consultant, Registered Nurse (RN) A. RN A confirmed the facility had addressed the concerns in their Quality Assurance and Performance Improvement (QAPI) review on 2/24/26 and had begun to implement prevention measure for other resident-to-resident incidents. RN confirmed the facility had relocated R106 to another floor in the facility after the incident occurred, which was observed during the survey. The NHA and DON had no additional comment related to the findings of abuse. Review of the policy, Abuse and Neglect, updated 6/18/25, revealed, Policy: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse,.neglect, or mistreatment.The facility follows federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations.Definitions of Abuse, Neglect, Mistreatment, and Abuse Coordinator. Abuse: Abuse defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse.Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Types of Abuse and Examples: Physical: Physical abuse includes but is not limited to infliction of injury that occur other than by accidental means. Example: hitting, slapping, kicking, squeezing, pinching, punching, poking, twisting, roughly handling.Any person may potentially harm a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employees, family members, guardian, and other visitors.If abuse is suspected, the facility will 1. Take immediate steps to assure the protection of the resident(s). This may include separation from the alleged abuse and/or provision of medical care.9. The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

This citation relates to Intakes 2730741, 2706499, and 2706385.Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent four resident-to-resident altercations for R109 and R108, R104 and R117, R103 and R110, and R103 and R111 of four incidents reviewed. Findings include:R109 and R108:Review of a Facility-Reported Incident (FRI), received on 1/02/26 at 4:28 p.m., to the State Agency, revealed on 1/02/26 at approximately 3:50 p.m., Licensed Practical Nurse (LPN) V heard R109 say, Get the f*ck out of my room, b*tch, and upon reaching the doorway, R108 reported R109 had been swinging at them. Then LPN V observed R109 kicked R108 on his back, who was on the floor in R109's room. The residents were separated. R109 had a scratch on his neck and R108 had a cut on their left upper arm. The report alleged a physical resident-to-resident interaction with no psychosocial outcomes or significant injuries.Further review of the FRI report revealed R109 was admitted to the facility on [DATE], with diagnoses including mild dementia, psychotic disturbance, mood disturbance, schizoaffective disorder (mood disorder with possible psychotic features), anxiety, traumatic brain injury, and intellectual disabilities. R109 had a score of 8/15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment.Further review of the FRI report revealed R108 was admitted to the facility on [DATE], with diagnoses including stroke, bipolar (mood) disorder, schizophrenia (disorder which may cause psychosis), PTSD (Post-Traumatic Stress Disorder) and anxiety, with a BIMS score of 12/15, which showed mild cognitive impairment. R108 reportedly refused a full assessment and said they had nothing wrong with them. Both residents had a history of aggression towards other residents and during care. R108's interview showed he went to talk to R109 about a car and R109 swung at them. When asked if they were kicked, R108 said, I don't know. When R109 was asked about the incident, he stated, I was sleeping when he (R108) came in here and attacked me again, when I was sleeping. He fell on top of me; I hit my head. He (R108) slammed me to the ground and punched my forehead (this part of R109's reporting was not witnessed). R108 was placed on 15 -minute checks to not go back to R109's room. A stop sign was placed on R109's door. The residents/guardians declined the police to be contacted. The facility concluded that a resident-to-resident incident occurred between R109 and R108 however it could not be concluded what happened before staff observed R109 kick R108, and they did not substantiate abuse or neglect. The report further revealed that R109's Traumatic Brain Injury (TBI) contributed to lack of impulse control or understanding consequences and said R108's dementia caused him to not be able to be act intentionally or purposely. It was noted R108's BIMS score was 12/15, which showed only moderate cognitive impairment, and the report showed mild dementia.On 2/23/26 at 3:35 p.m., R109 was observed in their room, dressing and laying on their bed. R109 sat up on the edge of their bed and agreed to be interviewed. There was a Velcro stop sign observed on their room door. On 2/23/26 at 3:37 p.m., when asked if they had any concerns or incidents with other residents, R109 said, I don't want to talk about that, and walked out of their room. No further interview was attempted. On 2/24/26 at 10:34 a.m., R108 was in their room, dressed and seated on their bed, with no bruising or skin concerns observed. R108 was asked if they could be interviewed. R108 declined via gesture as they were listening to a radio program. On 2/25/26 at 9:32 a.m., R108 was in their bed, and when asked how they were doing or if they had any concerns, R108 gave a thumbs up, indicating they were doing fine. When asked if they could be interviewed, they said, No. On 2/25/26 at approximately 9:40 a.m., R108's nursing staff were asked how they communicated. It was confirmed that R108 could talk when they wanted to speak and could communicate their basic needs. On 2/25/26 at 3:57 p.m., Licensed Practical Nurse (LPN) V was asked about the resident-to-resident incident between R109 and R108 in a phone interview. LPN V confirmed they were working and witnessed the incident occurred. LPN V stated they heard R109 tell R108 to get out of their room and saw R108 on the floor of their room. LPN V stated themselves and a nurse aide were trying to help R108 get off the floor when they saw R109 kicking R108 in the back and attempted to kick them more. R109 kicked R108 twice on their left side on their left shoulder or back. LPN V said R109 and R108 had prior altercations and R109 did not want R108 in their room. LPN V said R108 came into R109's room to talk to R109 about a car. After being kicked, R108 had back pain and a small cut to their arm, and R108 had scratches on their neck. LPN V said R109 said they got in a fight before they got there. LPN V reported R108 asked for pain medication, which was provided for back pain, and R109 did not complain of any pain. When asked if the incident was intentional, LPN V said, Yes, (R109) was adamant he wanted (R108) out of his room.(R109) said, 'Get him out of this room; (R108) is not supposed to be here.' Review of R109 and R108's resident-to-resident investigation report revealed LPN V witnessed the incident, as described in their witness statement. The residents were moved to different floors after the incident, and no other incident occurred. Review of a psychiatry visit dated 1/06/26 showed R109 was being seen for follow up related to behaviors. Further review revealed another resident-to-resident incident occurred on 7/10/26, when R109 hit another resident who was sent to the emergency room and returned on 7/11/25 with medication adjustments. Review of R108's Interdisciplinary team note revealed, .Based on the findings, review of the clinical record, and interview with the staff, a decisive conclusion was made that this resident (R108) was struck by other resident (R109).The facility is unable to clearly extract events lead to the occurrence but physical contact was witness (sic) between the residents involved.15 minute checks were completed with no deviation from baseline.Care plan will be updated. Review of R108's nursing progress note, dated 1/06/26, showed Room move completed. Guardian made aware. No other concerns or issues. Review of R108's provider notes, dated 1/05/26, showed R108 had no increased pain or injuries after the incident. R104 and R117 Review of a FRI received on 2/25/26 (during the survey) revealed, .Incident Detail:At approximately 5:00 pm on 2/17/26, Resident (R117) came into the hallway from her room which she was sharing with resident (R104) at the time, loudly saying, She hit me. Staff responded and kept the residents separated. Skin assessments and pain assessments were completed. No injuries were noted. Administrator, Director of Nursing (DON), Physicians, and legal guardians were notified. The report further revealed R104 denied hitting R117 when they got their bathrobe back, and said physical contact was not verified.On 2/24/26 at 12:50 p.m. R104 was observed in their room and agreed to be interviewed at their door. R104 was thin in stature, and had long hair, which appeared unwashed, and was wearing a gown with a covering. On 2/24/26 at 12:52 p.m., R104 was asked about any concerns or incidents, and denied any concerns or incidents with facility residents. R104 was oriented to themselves and their surroundings. On 2/24/25 at 2:15 p.m., the Nursing Home Administrator (NHA) reported they had just submitted a 5-day investigation into a recent incident a few days prior between R104 and R117 when they were roommates. The NHA described R117 said R104 hit them with their housecoat, when R104 said R117 had their clothes and denied hitting R117. The NHA said there was no outcome/injury, and abuse was unsubstantiated. On 2/25/26 at approximately 8:45 a.m., R117 was observed on the unit walking with a cup of coffee in their hands. R117 was wearing a pink shirt, and a headband. R117 was oriented to themselves, place, situation and time, as they could read a clock. They were unavailable for an interview but said to come back when staff were not with their roommate. On 2/25/26 at 9:19 a.m., R117 was asked if they had any concerns. R117 said, (R104) hit me. R117 said, One of the girls here gave me (R104)'s pajamas on accident. as R104 was in their joint room at the time. R117 explained, (R104) hit me with the bathrobe. She was not wearing it and it was not hard. (R104) was carrying the bathrobe across her chest. It didn't hurt. R117 said they had no bruises, and staff checked. R104 was asked if they felt safe. R117 responded, I feel safe in this (current) room but not in the other room (prior with R104). That was the first time I got switched into her (R104's) room. I am ok now. I am not scared anymore. I feel safe here. I thought they were mine (the pajamas) and I put them on. We (residents) have to be nicer and they (residents) can't hit people. She did it on purpose. Everything is ok now. R117 denied any other incidents with R104. On 2/25/26 at approximately 4:15 p.m., LPN J confirmed during a phone interview they were on shift when the incident occurred. LPN H said they had to switch R117 to R104's room per management directive, although most were aware R104 did not like having roommates and had some aggressive behaviors. LPN J reported R104 wanted their door closed and R117 liked their door opened. LPN J said they and staff had told administration they had concerns and this would not be a good fit, as R104 was aggressive and R117 was nice, and administration had agreed to switch them back (moving R117 out) in the morning. When they were roommates that afternoon, LPN J said R104 got mad at R117 and struck them. R117 came out of the room and said, (R104) hit me in the face with her hand. LPN J said R104 was wearing their bathrobe, so they did not believe or recall R117 being struck with the bathrobe, as R117 did not report that. Per LPN J, R117 was crying and very upset, and said they wanted their room changed. LPN J said there were no bruises on R117. LPN J said R117 was oriented to themselves, place and person. LPN J said they believed the incident occurred as R104 had hit the staff before, and the unit manager moved R117 out of R104's room right after the incident, to prevent any recurrence. Review of LPN's witness statement at the time of the incident corroborated the occurrence and description of the incident. Review of R117's progress notes revealed an incident occurred on 2/17/26 at 16:45 (4:45 p.m.) when R117 came out their room, appearing distressed, stating, (R104) hit me. She hit me. Nursing responded and followed the resident to her room where the resident pointed at her roommate and stated, She hit me. Staff separated the resident immediately.Resident (R117) stated to the staff, She thought I took her clothes.(Staff) was the one that brought them to me, so I gave them back to her, and she hit me with the bath robe. Immediate intervention: Room move for the resident. R103 and R110 Another third FRI was received by the State Agency on 12/19/26 which described a resident-to-resident altercation between R103 and R110 on 12/19/25 at 11:20 a.m Review of the FRI revealed R110 was observed in R103's room. R103 was observed to have a hold of R110's forearm and made contact towards R110 with his other hand. The facility concluded that the resident-to-resident interaction occurred resulting in no injury and no negative psychosocial outcome. It was described the Unit manager, LPN H, heard resident R103 yelling out, from his room. Upon reaching the doorway to the room, LPN H observed R110's feet in a laying position on the foot of the bed, however the privacy curtain was restricting the full view; the only portion of R103 that could be seen from his wheelchair striking something. Upon reaching the residents beyond the curtain, it was observed that R103 had a hold of R110's right wrist with his left hand. Staff immediately intervened and separated the residents. Both residents were assessed for injury; no visible injuries or psychosocial concerns were noted at the time of the assessments. The report showed physical contact occurred from R103 towards R110. Both R103 and R110 had marked cognitive impairment per the report. Review of the Electronical Medical Record (EMR) showed R103 had been discharged from the facility. On 2/24/26 at 1:27 p.m., R110 was observed walking ad lib in the facility hallway. R110 made poor eye contact and could not answer any questions. R110 was orientated to their name only and had no bruising or injuries noted. On 2/24/26 at approximately 1:45 p.m., R110's CNA, CNA L confirmed they were working when the resident-to-resident incident occurred between R103 and R110 and had cared for both residents regularly. CNA L clarified R110 was not interviewable. CNA L said R110 had a behavior of climbing into other resident's beds, and said it was impossible to stop her, so they would redirect her when this was discovered. R103 said staff intervened, R110 had no bruising, and R103 was not injured, and R110 did not recall the incident. CNA L said R103 did not like other resident's coming into his room and would yell at other residents when this occurred. CNA L confirmed the incident occurred as described per their understanding and neither resident was injured. CNA L denied R110 was abused and had no signs of being abuse. R103 and R111A fourth FRI received by the State Agency revealed a resident-to-resident physical incident occurred on 12/18/26 at 10:48 p.m., between R103 and R111. The FRI described R103 was moving about the hallway around mealtime, exclaiming that R111 stole his items, Staff intervened and separated residents, R103 (sic- went) into the dining-room, R111 was still in the hallway, R103 then re-emerged and continued his claim that R111 is a thief and approached R111 who then reacted with physical contact. Staff were unsure who made physical contact first, but the encounter was mutual, resulting in contact made to R103's left side of the face and R111's right side of the face. The report confirmed R111 and R103 hit each other and had no injuries. Both residents had marked cognitive impairment per the reports and were immediately separated. The report revealed LPN V was present and verified the physical incident occurred. On 2/25/26, concerns regarding adequate supervision and the higher number resident-to-resident incidences were shared at survey exit with the NHA, DON, and Regional Nurse Consultant, Registered Nurse A. RN A indicated the facility had addressed the concerns in their Quality Assurance Improvement Process (QAPI) during the survey. RN A described they had begun to make proactive changes in programming, supervision and care planning on their second floor, related to the care of residents with cognitive impairment, dementia, and geriatric psychiatric concerns. The NHA and DON had no additional comment. Review of the policy, Administration: Staffing, adopted 07/11/2018, revealed, Our facility provides adequate staffing to meet needed care and services for our resident population. Procedures: 1. Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are adequately staffed to ensure that resident needs are met. 2. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

This citation relates to Intake #2736914. Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment with consistent availability of bath linens and laundry for residents (R102, R105, R112, R114 and R118) to ensure resident cleanliness and ability to complete personal bathing and hygiene, with the potential to affect the facility residents who used facility bath linens. Findings include:An anonymous complaint was received by the State Agency on 2/06/26, which alleged there were not enough linens to maintain the care needs of the facility residents. On 2/23/26 at approximately 11:30 a.m., Certified Nurse Aide (CNA) C, with CNA W and CNA P present, was asked about providing residents' linens. CNA C reported they were short almost all of the time. CNA C stated, Sometimes there is no linen at the start of our shift. We have brought this to administration's attention. I have cut bath blankets and I have used a pillowcase (to clean the residents) CNA C stated the towels and washcloths were short. CNA P and CNA W concurred the facility was short on linens for bathing residents and providing personal hygiene, such as brief changes, which delayed care and showers for residents. On 2/23/26 at approximately 1:15 p.m., R112 was asked about their care. R112 responded, I don't get towels or washcloths; they (facility staff) have never offered them.I would like towels and washcloths and water. R112 explained that their family member brought in hygiene and bathing wipes, which they used to clean themselves, and they would like using water to clean themselves once in a while. On 2/23/26 at approximately 2:15 p.m., R113 was observed resting in their bed in their room with covers pulled partly over their head. Review of R113's nursing progress notes on 2/04/26 at 21:30 (8:30 p.m.) revealed R113's family member requested towels and washcloths to bathe R113. The note revealed, .Due to lack of supplies on the unit, writer went to 2N (a unit on another floor) and obtained three towels and three washcloths and delivered them to the shower room. Review of R113's nursing progress note on 2/04/26 at 21:39 (8:39 p.m.) revealed R113's family members became upset and stated they removed (R113)'s bed sheet from resident bed because she believes the bed linens are dirty and belonged to the previous resident occupying the bed who she believes had Covid-19 (viral infection). The note revealed the attending nurse denied the concern and showed R113's family members were escorted out of the facility after becoming escalated and threatening to call the government on the facility. On 2/23/26 at approximately 2:25 p.m., CNA F was asked about bathing linens. CNA F responded, The linen do be short and I don't know the system. I know the lady (laundry aide) washes and it is usually done in the morning when we first come in (the aides) and nobody stay and washes at night.We do have wipes. CNA F reported they struggled to find gloves in their size. During the interview, a male resident approached CNA F and asked for an electric razor. CNA F told them they didn't have one and said the resident had asked for the electric razor earlier in their shift. CNA F explained the male resident preferred to shave themselves, however CNA F had found two electric razors with no plugs. CNA F said the resident had not owned their own electric razor. When asked how the resident would be shaved, CNA F reported they would shave them with a regular razor later and clarified the resident could have shaved themselves if they had an electric razor. On 2/23/26 at 2:40 p.m., R114 was asked about their care. R114 reported they had concerns and had never been offered a way to express their concerns. R114 stated, .The towels are short and you can't take a shower and I need to take a shower twice a week. There are times I have to fight for a shower. Observations on the units of the clean utility linen supply closets on 2/23/26 revealed no washcloths and only a few towels. There were four clean linen rooms total. There were no observations of washcloths or towels in residents' rooms during resident interviews during the day. On 2/23/26 at approximately 4:42 p.m., the Housekeeping Supervisor, Staff M was asked about the shortages of washcloths, towels, and linens reported by staff and residents, and observed. Staff M indicated one laundry staff had vacated their position about a week prior, and another laundry staff broke their arm and could not work. Staff M said they had linens. Staff M acknowledged it was the laundry department's job to put clean linens in the clean utility room supply closets on the first and second floors. Staff M said they wondered if staff or residents were keeping extra supplies in residents' rooms. On 2/23/26 at approximately 5:00 p.m., the Housekeeping Supervisor, Staff M was asked if there was another storage areas for facility linens. On 2/23/26 at 5:08 p.m., another storage room on the first floor was observed with Staff M, which showed only a few sheets, gowns, and bed linens, and no towels and washcloths. On 2/23/26 at 5:15 p.m., Surveyor toured the laundry room with Staff M, who reported the towels and washcloths were being washed, and showed Surveyor clean storage bins, with washed clothing. Surveyor observed running washers which appeared to be mainly laundering sheets. It was observed there were no clean towels or washcloths in the large clean laundry bins. Surveyor asked if there was any other area in the facility which had clean washcloths and towels. On 2/23/26 at approximately 5:20 p.m., Staff M showed Surveyor a room down the hall on a closed unit which was under construction, which would not have been accessible to floor staff. The unit was dirty from construction residue, and an unlabeled room door lead to a room with many cardboard boxes which were unopened. Staff M hurriedly opened a couple boxes, which revealed washcloths and towels which were packaged and not in circulation in the facility. Staff M asked if they needed to prove to Surveyor if the rest of the boxes had washcloths and towels, and began opening two other boxes, which showed additional stacks of new additional washcloths and towels. Three packages of washcloths were observed, with 60 washcloths in each pack, per Staff M, and 8 packs of towels, which had a dozen in each pack. The room was stacked with several more boxes of washcloths and towels which they showed Surveyor. When asked why these were not in circulation Staff M had no comment and said soon after reported the facility administrator was aware. On 2/23/26 at approximately 5:25 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware of the concerns related to limited wash cloths and towels observed in the facility, and the boxes of new washcloths and towels not in circulation. The NHA and DON accompanied Surveyor into the construction area of the building and observed the boxes of new washcloths and towels. The NHA and DON both said they were unaware these new washcloths and towels were in this room, and had only newly learned of the concerns, and planned to follow up. On 2/24/26 at 9:48 a.m., the NHA followed up regarding the shortages of linen, and the observation of new linens in the construction wing of the facility. The NHA said Staff M told them this was emergency stock and said they had laundry staff pull what was needed for residents' care after finding the extra linens. The NHA said they felt like the staff had been delivering them to residents' rooms. Surveyor shared this was not reported by staff or residents or observed. The NHA clarified it was important to have emergency supplies on hand in the event their water went out and they could not do laundry and said they could boil water to clean washcloths and towels in an emergency. On 2/24/26 at approximately 10:48 a.m., R118 reported they were missing dresses and pants, and said, I am always missing my pants. R118 was fully alert and oriented. R118's room was observed soon after with the NHA and Staff M, with R118's permission. A few dresses were located but no pants were found. On 2/24/26 at approximately 11:15 a.m., R102 reported there were times the aides would come in their room and told them they were completely out of washcloths and towels and said they could not change them until they found some. R102 explained then the aides had to do a scavenger hunt, which bothered them, as they had to wait to be cleaned up. R102 was asked if the aides brought washcloths, towels, or linens to their room in the mornings, and said they never brought any. R102 was alert and oriented to themselves, their surroundings, situation, and time. On 2/25/26 at approximately 10:30 a.m., R105's family member (FM) R asked to speak with Surveyor when observed on R105's hall. FM R stated, .(R105) has no laundry; his sister brought him a blanket (which was missing from laundry) and he has no blanket on his bed (observed) and he has no clothes' in his room and his clothes and grey blanket disappeared. The laundry doesn't come back since May (2026) when he got here. I fill drawers (with clothing) and say 60 to 70% of the time when they visited 1 to 3 times a week R105 had no clothing. R105 said, There have never been washcloths or towels in his room. They never bring that stuff. I bring my own washrags.There is nothing and I have checked everywhere. There has never been (any) washcloths or towels in his room since the first day he was here and I have never seen any.Most of the time he does not have a blanket. FM R said there were no clothes in his room when they arrived today around 9:00 a.m., and said there was one damp shirt and pants that was not his and smelled of urine so they let staff know it needed to be laundered. FM R said to look in R105's drawers and closet. An observation was made of R105's room with his permission, which showed no clothing in any of their drawers or both closets, as they were in a private room. R105 was observed in their wheelchair during the interview and was wearing a t-shirt and sweatpants. On 2/25/26 at approximately 11:40 a.m., R105's aide, CNA L was asked about R107's missing clothing in his room and about caring for R107. CNA L acknowledged there were no clothes in R107's room, and said FM R was upset and said they smelled or urine and threw them on the floor of R107's room in a pile so they had to go to laundry on 2/24/26. CNA L acknowledged there had been a shortage on washcloths, towels, and linens since they started their job at the facility three months prior. CNA L said they had to figure out patient care, and had to use wipes and the draw sheets, however denied residents were missing care or showers. On 2/25/26 at 1:24 p.m., the laundry aide, Staff T, was asked about the shortages of linens and possible delays in laundering residents' clothing. Staff T reported there were shortages of linens on the units and said it was mainly because of the two people we are down with (not working). Staff T said they leave at 2:00 p.m., and explained there were some CNAs who tried to help them out in laundry. Staff T stated they were washing for all three shifts and had to make sure they had linen and clothes to put on the residents. Staff T clarified there were times they were short and they did not have linen. Staff T explained when they arrived at 6:00 a.m. they started the process of washing, drying, and folding laundry. Staff T was asked about an emergency supply and said they knew of one but did not know where it was. When asked about R105, Staff T said they went through a lot of clothes (due to incontinence). When asked about R118, Staff T reported R118 always got their clothing washed. Staff T said the problem was not supply as much as not having enough staff in laundry to get the clothes up to the floors. Observations of the clean utility storage supply rooms on the first and second floors during the survey on 2/24/26 and 2/25/26 (after the concern was brought to the NHA) showed the supply rooms were stacked with ample washcloths and towels, with no additional shortages observed or reported, after the concerns were brought forward. The facility was asked via email on 2/24/26 if they had a policy or process on laundering linens. The NHA responded they had no such policy or process, and provided an environmental services policy upon request, in lieu of no laundry policy. An email response was received on 2/24/26 at 11:40 a.m., which revealed, We do not have a Linen policy per say. We typically have 4 full-time staff members in laundry. We currently have 3 on staff. We have CNAs and housekeeping who stay over to help. Last week we lost 2 to personal injuries outside of the facility, so we are down to 1 current full-time laundry staff member working. According to (Staff M), We pass linen as soon as it is available throughout the day. Laundry staff come in at 6am and remove dirty items from the soiled utility rooms, fold what is in the dryers from the night prior and pass linen as soon as it is done, typically 7am. They move over what is in the washer to the dryer and start more linen. When it is dried and folded it is passed again. There is at least 1 staff member assigned to laundry at all times from 6a-10p. Signed electronically by the NHA. On 2/05/26 at 4:52 p.m., a call was returned to FM R, who was asked to clarify what happened to R105's clothing earlier. FM R reported R105 had one shirt and a pair of pants in their drawer which they believed smelled of urine, so they requested the two clothing items to be sent to laundry, and the staff cleaned R105's drawers. FM R clarified R105 had no clothes in their room when they arrived earlier on this date at about 9:00 a.m and none arrived when they were present until around 5:00 p.m. Review of the policy, Physical Environment, Environmental Services, adopted 9/08/21, revealed, To provide guidelines for those in Environmental Services to foster appropriate infection control. The policy did not include any guidance respective to laundering linens or resident's clothing. No additional policy was provided by survey exit.

This citation relates to Intake 2736914. Based on observation, interview, and record review, the facility failed to ensure the availability and consistent provision of evening snacks. Findings include: On 2/23/26 at approximately 1:15 p.m., R112 was observed lying in their hospital bed. On 2/23/26 at approximately 1:17 p.m., R112 reported their family member brought them snacks, as they had never been provided or offered a snack at the facility. R112 stated, I would like to at least be offered and see if there is something I like. R112 reported they were restricted to staying in their bed in their room at that time. R112 was alert and oriented to themselves, their surroundings, situation and time.On 2/23/26 at approximately 2:40 p.m., R114 was observed seated in their manual wheelchair in the facility dining room. On 2/23/26 at approximately 2:45 p.m., R114 said they were missing snacks at times, especially in the evenings, which bothered them. R114 stated, If you are not at the desk when they pass them out, you do not get a snack. It is peanut butter and jelly (sandwiches), pudding, and sometimes chips. You have to run to that desk to get it. R114 said there were days they did not get a snack and wanted a snack daily. R114 was oriented to themselves, their surroundings, situation, and time.Review of the medical record revealed R114 was their own responsible party. On 2/24/26 at 3:30 p.m., the Dietary Manager, Staff N, was asked about snack provision and availability for the residents. Staff N reported they had a variety of snacks including chips, cookies, Jello, pudding, sandwiches, and rice crispy treats. Staff N stated they placed the snacks on a tray in the evening, which was taken to the unit. Staff N indicated they were aware of residents stealing snacks and hoarding them in their rooms, and said the nurses were aware. Staff N said they believed it was possible the snacks were being taken by staff, as they disappeared quickly. Staff N said they could have the nurses lock the snacks in the med room to ensure the residents received them and were not hoarding them in their rooms. On 2/24/26 at approximately 5:00 p.m., the Director of Nursing (DON) shared they understood the concern and would be making improvements in their snack process including assigning a CNA (Certified Nurse Aide) to pass the HS (nighttime) snacks and put them in the med room in a sealed container. The DON said the Dietary Manager was going to check that container at least three times a week and ensure they were checking the dates (such as for the sandwiches). The DON said they would review the updated process in their resident council and food committee meetings. On 2/25/26 at approximately 10:50 a.m., Family Member (FM) R was asked if R107 received snacks when requested. FM R indicated they were not aware of R107 receiving snacks, as they seemed hungry during their visits, so they had asked for double food portions for R107, which were often not received. During the interview, R107 was observed quickly propelling themselves in their manual wheelchair in and out of their room. FM R said R107 was not verbal, however could respond to yes and no questions accurately. R107 shook their head no when asked about receiving snacks. R107 showed they were hungry at night by pointing to the surveyor's stomach and then to their stomach and grimaced, appearing distressed. FM R said R107 did this when they were hungry, which they did often. When FM R was asked if they had filed a grievance or concern form, FM R indicated this had not been offered and said they would like to file a concern form. The Nursing Home Administer (NHA) was notified of their request after the interview. On 2/24/26 at approximately 12:30 p.m., the NHA and Director of Nursing (DON) arrived outside R107's room and said they had spoken to FM R who denied concerns to them with snacks. Both said R107 received enough food and indicated they would follow up with FM R with a concern form. On 2/25/26 at approximately 8:20 a.m., DM N was asked where the snacks were kept. DM N said the snacks were kept in their office. DM N agreed to show surveyor their office. On 2/25/26 at approximately 8:25 a.m., Staff N's office was observed with [NAME] O present. There was adequate evidence of chips and dry snacks being available.On 2/25/26 at approximately 8:30 a.m., the concerns were reviewed with both related to residents reporting missing their snacks and snacks not being offered. Both agreed the snack provision and availability process should be improved to ensure all residents were being offered a snack and understood the concern. On 2/25/26 at approximately 6:00 p.m., the concerns were reviewed with the NHA and DON related to residents' reporting not receiving snacks. There was no additional comment. Review of the policy, Dietary Services. Bed Time (HS) Snack, adopted 7/11/2018, revealed, Policy: It is the policy of the facility that all residents be offered a midnight snack, to the extent medically possible. Purpose: To ensure resident's appetite is satisfied before bedtime.Procedure: 1. Residents on regular diets are offered a snack before bedtime each evening.3. Bedtime (H.S.) snacks must be documented, indicating the H.S. snack was offered.

This citation relates to Intake 2736914Based on observation, interview, and record review, the facility failed to provide ensure residents' activities of daily living (adl care) were completed timely for five Residents (R102, R107, R112, R115, and R116) of six residents reviewed for adl care provision. Findings include: An anonymous complaint was received on 2/06/26 by the State Agency, which alleged short staffing, residents were sitting in wet or soiled briefs for extended periods, including R102, and staff were sleeping on the night shift, neglecting resident's basic care needs. On 2/23/26 at approximately 11:35 a.m., Certified Nurse Aide (CNA) C, CNA W and CNA P were asked about staffing and resident care. The CNAs collectively reported they were unable to give residents the care they needed when the facility was short staffed, especially when there were two aides instead of three aides scheduled in their areas. They said with two aides they struggled to feed all the residents, which caused the food to be cold. They expressed the biggest concern was on the midnight shift, as some residents were supposed to be gotten up for the day by the night shift aides. They collectively said it was difficult when they had 15 to 16 residents a piece (to provide care in the daytime) and said the second floor had nearly every resident who required a check and change (every two hours) at night, and said residents were getting left wet. All confirmed they worked on both floors, and said the aides were scheduled and worked eight-hour shifts, along with the nurse. All said they were responsible for showers as well and had many residents who used lifts. All said the residents upstairs were up nearly all night, as many did not sleep and had behaviors, so they needed at least 3 aides on those shifts. The aides said there were 38 residents on the first floor on this date, as a couple residents were in the hospital, and said that each floor (1st and second floor) had about 40 residents each, with an average census of 80 residents.Review of a list provided by Unit Manager D showed 22 residents used a lift. Review of staff schedules, provided by the Nursing Home Administrator (NHA), from 2/01/26 through 2/23/26, revealed there were two aides on a floor on the following dates on the midnight shift: 2/01/26, 2/06/26, 2/09/26 (second floor), 2/11/26, 2/12/26 (second floor), 2/15/26, 2/17/26, 2/22/26, and 2/23/26. The census upon entry was 83 residents. On 2/23/26 at approximately 1:15 p.m., R112 reported when they turned their call light on to be changed, sometimes they waited 1-2 hours for assistance to change their brief. This made them feel frustrated, as they were dependent for assistance and bedbound. R112 was alert and oriented to themselves, place, time, and situation. On 2/23/26 at approximately 3:45 p.m., two interviewable residents, R115 and R116, asked to meet with Surveyor regarding care concerns. Both were observed dressed and propelled their manual wheelchairs to their room for the interview. On 2/23/26 at approximately 3:48 p.m., R115 said sometimes they needed help with transfers and toileting as they were wearing an orthopedic boot on their right foot which was casted. R115 reported they sometimes waited an hour or longer, which was upsetting to them. R116 reported they were waiting the same amount of time. R115 said, It is usually waiting in bed, and I am waiting a good hour sometimes or longer; sometimes it is for ice water, sometimes for bathroom. Sometimes for meds. R115 said they felt angry and anxious. R115 added they sometimes had to wait over an hour for Xanax (for anxiety) and added, It happened yesterday. Yesterday evening, I waited about an hour and a half. This one (time) was for picking up my dinner tray and for ice. R115 said they went to the Administrator about their concerns. R116 said they had similar wait times when they needed water or medications, and they felt upset and anxious when this happened. Both residents were alert and oriented to themselves, situation, place, and time. An observation was done during the interview of R115's and R116's call light, which visually activated (lit up) in the hallway when R115 pressed their call light. On 2/24/26 at approximately 11:15 a.m., R102 was observed in their room, in a bariatric bed reading a book. R102 agreed to be interviewed, and explained they were in bed frequently and were dependent upon staff for care. R102 stated, It takes two hours for the call light to be answered. They (staff) shut the light off and tell you they are coming back. Certain aides tell you they are busy. I got told I go to the bathroom (need to be changed) too much. I am on Lasix (a water pill which can increase urination) and some say, 'You didn't pee enough to call it wet,' and I say, 'I am wet and I need to be changed. R102 clarified, They (staff) are doing a terrible job of answering call lights, more in the afternoons. I am realistic. When it gets to be an hour, I get upset. During mealtimes there are times when you don't ask for anything. R102 was asked about the complaint allegation about being left wet several hours. R102 stated, I had a midnight aide and she pulled out 11 wipes and she did wipe me, but my butt (bottom) wasn't clean. R102 had to wait to be changed until the morning, and said she had hard, caked-on stool by the morning. R112 said it made her feel awful to wait so long. On 2/25/26 at approximately 10:40 a.m., R107's Family Member (FM) R reported when they visited, they found R107 soaked this morning when they arrived and found them soaked wet often during their visits. R107 was present during the interview and made gestures pointing to their brief and nodded rapidly, appearing frustrated. FM R confirmed this was upsetting to R107, and to them when they found them soaked. Surveyor asked R107 yes/no questions and for R107 to identify ten objects in the room, which they did accurately by pointing. It appeared R107 had the ability to convey some basic information and needs, which FM R confirmed. Concerns regarding residents adl care not being completed timely and staffing concerns were shared with the NHA, the DON, and Regional Nurse Consultant, Registered Nurse (RN) A at exit. There was no additional comment regarding the concerns. Review of the policy, Administration: Staffing, adopted 07/11/2018, revealed, Our facility provides adequate staffing to meet needed care and services for our resident population. Procedures: 1. Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Other support services (e.g., dietary, activities/recreational, social, therapy, environmental, etc.) are adequately staffed to ensure that resident needs are met. 2. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

This citation relates to Intake 2733234 Based on observation, interview, and record review, the facility failed to provide consistent meaningful person-centered activities for two Residents (R101 and R114) of three residents reviewed for activities. Findings include: A complaint was received to the State Agency on 2/03/26, which alleged activity concerns. On 2/23/26 at 1:29 p.m., R101 was observed in their room, seated in their wheelchair. A current monthly activity calendar was observed posted in their room. On 2/23/26 at 1:30 p.m., R101 reported the Activity Director posted the monthly activity calendars but was not following the calendar. R101 said they were missing activities, especially on the weekends, such as BINGO, and brain games. R101 added the activity staff never did room visits. R101 also felt the music activities did not represent their preferences. R101 reported they were usually not being taken on outings when the residents went into the community. R101 clarified this was upsetting to them. R101 wheeled over to their activity calendar and showed Surveyor most of the weekend activities were not occurring, such as when they tried to attend Brain Games this past Saturday and they waited, and no one came (to the day/activity room). R101 said they were bored on the weekends and would attend activities on the weekends if they were consistently offered. R101 explained they were not notified when an activity was cancelled or a time was changed, which caused them to feel frustrated and upset. On 2/23/26 at approximately 2:00 p.m., the Nursing Home Administrator (NHA) was asked about R101's concerns with missing activities. The NHA confirmed some activities were getting missed currently because of low staffing. The NHA explained they had hired a part-time staff who they needed to let go and another new hire stopped coming to work so they were currently hiring, onboarding and training new staff. The NHA explained their COVID outbreak impacted their activity program as well, and said they cancelled one of the community store outings due to the outbreak. An observation of the first-floor activity calendar for February 2026 in R101's room revealed the activity Brain Games was scheduled on Saturday, 2/21/26 at 3:00 p.m The calendar did not appear to show any scheduled community outings. On 2/23/26 at 2:30 p.m., the first-floor activity calendar was observed posted in the day (dining) room. The calendar showed BINGO was scheduled on this date at 2:30 p.m. On 2/23/26 at 2:35 p.m., the first-floor day (dining/activity) room was observed (where group activities were held) and showed no BINGO activity. It was noted that R114 was seated in their wheelchair in the dining room at a table, with a few other residents present and no staff. On 2/23/26 at beginning at 2:40 p.m., R114 was interviewed in the first-floor day room. R114 said they were waiting for BINGO to start and had been there a few minutes. R114 said the activity staff were always late for activities, and said the activities did not start on time, which was frustrating to them. R114 said, Everything is late. The BINGO is supposed to start at 2:30 p.m., and at a quarter til (2:45 p.m.), they (activity staff) might stroll in. R114 said they were missing activities, and clarified there were no activities on Sundays and some Saturdays. Now we play BINGO on Mondays only. R114 said they used to play BINGO three times a week. R114 clarified everyone (residents) liked BINGO and felt they should at least have BINGO regularly at a minimum. R114 was alert and oriented to themselves, time, place, and situation, and could tell time accurately during the interview. Review of the first-floor activity calendar showed a full day of scheduled activities on Sundays, and BINGO was only noted on Mondays, although a BINGO pass was noted on two of four Saturdays. On 2/23/26 at 3:10 p.m., R114 was observed leaving the first-floor day room, saying they had waited long enough (40 minutes). At least three other residents had left the dining room. On 2/23/26 at 2:35 p.m. through 3:15p.m. (40 minutes) it was observed no activity staff or BINGO activity was observed in first floor day room. On 2/23/26 at 3:27 p.m., BINGO was observed to have just started in the first-floor day room, with the first BINGO number called by an activity aide at that time. There were eight residents present, with five residents playing BINGO, including R114, who returned. On 2/23/26 at approximately 3:43 p.m., the Activity Director, Staff B was asked why there was no BINGO today per the activity calendar in the first-floor dining room at 2:30 p.m Staff B was made aware R114 was waiting for BINGO for at least 40 minutes, which frustrated them. Staff B acknowledged BINGO had started late. Staff B explained the facility was hiring more activity staff and said it was just themselves and one other full time activity staff on this date, who were covering activities on both floors (the first and second floor). Staff B said the activity was running late upstairs, and explained they were bouncing between floors and doing some charting and said, That's my fault. Staff B said there was a no call, no show today (an activity aide called off), and said it took longer for the staff to clean the activity room upstairs before they could start their activity earlier upstairs (second floor), which subsequently made them late for the first-floor activity, BINGO. Staff B was asked how many activity staff were in the building, and they said it was themselves and a new activity staff member recently hired. Staff B understood the concern related to R114 waiting for BINGO, feeling frustrated, and leaving. It was shared R114 was not aware BINGO was running late, as Surveyor was with R114 during the duration of their waiting, which Staff B acknowledged. Staff B said the calendar showed subject to change but understood the residents' perception and the concern may have been counting on activities at scheduled times, unless notified prior. On 2/24/26 at 10:00 a.m., the activity calendar showed a light exercise activity was scheduled to start on the second floor at 10:00 a.m. On 2/24/26 at 10:21 a.m , the second-floor day (dining/activity) room was observed. There was no activity or residents in the dining room (they were in the hallway) as the dining room was being thoroughly cleaned by multiple housekeeping staff. A few minutes later, an activity was observed to begin. On 2/25/26 at 9:35 a.m., the Activity Director, Staff B was interviewed in full about activity concerns reported by R101 and R114. Staff B said they had COVID during the past few months and said this caused some shifts in the activities offered. Staff B explained this affected the whole first floor so there were no group activities for an extended period. Staff B acknowledged there were some late and missed activities for both residents and said they (facility) were hiring more staff. Staff B said the activities calendar noted the activities were subject to change when Surveyor shared both R101 and R114's self-reported they were not made aware when activities were moved or cancelled. Surveyor noted there were no activities documented in the EMR (electronic medical record) for both residents. Staff B said they used their own logging of activities in a separate system. It was shared that the Nursing Home Administrator (NHA) earlier told Surveyor their expectation would have been the activity staff would transfer their documentation into the EMR. Staff C explained activities were getting missed more on the first floor (verses the second floor) as residents were more independent, which included R101 and R114. Staff C clarified they spent more time completing activities on the second floor with the (primary) dementia or cognitively impaired residents who had some behaviors. During the interview, Surveyor viewed R101's and R114's February 2026 activity documentation logs with Staff C. The logs showed for the past month (look-back period) they each participated in activities about 64% and 56% days (2/01 through 2/23/26) offered, respectively. It was noted there were similar dates when both had no activities, showing activities may not have been offered on those days. The logs also showed there were no refusals documented. The logs also showed no activities were documented on Sundays, other than two dates of four when residents received their coffee and a newsletter. Staff C understood the concerns and said they would start documenting refusals. Staff C explained they have additional staff incoming. Further review of the activity calendar with Staff C revealed there were activities scheduled on the same times on both floors simultaneously. Surveyor noted when both or all activity staff were observed in activities, as occurred during the survey, it would not be possible to have both scheduled activities covered or ongoing on both floors at the same time. Staff C planned to address this as well. Staff C acknowledged they could use more training with dementia residents and was pursuing additional training to maximize activity engagement for the residents especially with behaviors related to cognitive deficits on the second floor. The NHA was made aware of these concerns during the survey and acknowledged more staff were incoming related to activity delays and or missed activities. The NHA noted the calendar concerns and activities being subject to change noted on the calendar. Surveyor shared the residents self-reported counting on activities at scheduled times unless otherwise informed. Review of an email received from the Director of Nursing (DON) on 2/25/26 at 10:40 a.m. revealed, Covid outbreak started on 1/26/26 last positive was on 2/1/2026. This showed the facility COVID outbreak lasted one week, per this email.Review of the policy, Activities: Resident's choice, adopted 8/01/2019, revealed, It is the policy of this facility that residents shall have the right to participate or not participate in leisure, recreation and social involvement of their choosing. PROCEDURES: Residents will be invited and encouraged to assist in the planning and development of the recreation programming.Residents will be informed of activities of preference and interest and programs through:Posted calendarPosted announcementsIndividual communicationIndividual care planResidents will be invited to attend activities and will be provided the opportunity to participate in structured and individual programs.Preferences for residents who have Dementia will be determined through communication with the resident, family, friends and care givers.Assistance will be provided for residents who wish to participate but are not able to get to activities on their own. Residents who prefer not to participate in structured programs will be offered alternatives and necessary support/resources for meaningful individual pursuit of leisure interest.

This citation pertains to Complaint #2578523. Based on observation, interview, and record review, the facility failed to assess, monitor, and document a change in condition in a timely manner for two (R27 and R92) of four residents reviewed for change in condition, resulting in a delay in treating a Urinary Tract Infection (UTI) leading to septic shock and admission into the Intensive Care Unit (ICU) at the hospital. Findings include: R27 On 12/2/25 at 9:40 AM, R27 was observed lying in bed, in a low position. R27 was sleeping with the blanket pulled up over her face. On 12/2/25 at 12:45 AM, an interview was conducted with R27's family member who reported R27 fell in the dining room a couple weeks ago and was sent to the hospital. R27's family member reported the resident was very lethargic earlier in the day and was in the dining room unsupervised by staff. R27's family member further explained R27 was diagnosed with septic shock due to a UTI and is now receiving hospice (end of life) services. A review of R27's Physician's Orders revealed the following orders: 10/16/25 (discontinued on 10/19/25) - UA (Urinalysis) one time only for MSC (mental status change) and increased fatigue for 3 days 10/22/25 (discontinued on 10/24/25) - UA C&S (Culture and Sensitivity) to be obtained. every shift for UTI R/O (rule out) for 3 Days .Please contact the daughter and the MD if the UA cannot be obtained. Novolog (short acting insulin) 100 Unit/ML (milliliter) Inject as sliding scale .401-1000 = 6 units call [physician, subcutaneously before meals for hyperglycemia (high blood sugar) A review of R27's progress notes revealed the following: A General Progress Note dated 10/16/25 that noted, .Resident refused to take meds or eat any food .woken up for a brief change but was combative, unable to collect urine specimen due to resident current situation and her combative self. Endorsed to next shift . On 10/22/25 it was documented R27's blood pressure (BP) was 97/5 [sic] and her BP medication was held due to the low BP reading. A General Progress Note dated 10/22/25 noted, Residents brief was soiled with urine. Attempted to still obtain urine specimen. Was able to obtain small amount of urine but not enough to send out for urinalysis .Will attempt to obtain urine specimen later . An eMAR (electronic Medication Administration Record note dated 10/23/25 at 8:30 AM noted, .contact the daughter and the MD if the UA cannot be obtained .Unable to retrieve specimen .Will notify all parties . A General Progress Note dated 10/23/25 (entered as a late entry) noted, Writer spoke with RP (responsible party) regarding inability to obtain urine for UA as per physician's order. Education provided regarding obtaining urine via straight cath (catheter), daughter declined to allow staff to obtain urine via straight cath . It was documented on 10/24/25 that the urine specimen was unable to be obtained and the order was discontinued to obtain the UA. A review of R27's Medication Administration Record (MAR) for October 2025 revealed R27's blood sugar was 481 on 10/28/25 at 5:00 PM which required six units of Novolog (short acting insulin), 434 on 10/31/25 at 7:00 AM and was administered 6 units of insulin (the progress note documented R27 was given 8 units of Novolog per physician's orders), and 466 on 10/31/25 at 11:00 AM and was administered 6 units of insulin (the progress note for this date/time noted 12 units of Novolog were given per the physician's orders). On 11/6/25 at 3:37 PM, it was documented in a General Progress Note that Staff alerted Nurse pt (patient) observed on the floor in the dining room at (2:20 PM). Pt VS (vital signs) 80/56 (low blood pressure) .BS (blood sugar) 516 (abnormal high). Staff assisted pt to w/c (wheelchair) and back to bed. Writer administered 6 units per sliding scale (according to the physician's orders, R27 received her 5 units of sliding scale Novolog at 11:00 AM and would not have been due for another dose until 5:00 PM) .MD notified send pt out to hospital for observation . A review of R27's vital sign summary revealed R27's vital signs were not consistently documented throughout the period of her change in condition (once a UTI was suspected and a UA was ordered). There was no documentation of any additional monitoring for signs and symptoms of a UTI when R27 was not cooperative with providing a urine sample. There was no evidence that R27 was evaluated by a medical provider to address the change in condition between 10/16/25 when the UA was initially ordered and 11/6/25 when R27 was sent to the hospital after a fall and having abnormal vitals and blood sugar. On 12/4/25 at 1:08 PM, an interview was conducted with the Director of Nursing (DON). When queried about R27 and how she was monitored for signs and symptoms of a UTI and/or any other change in condition when she refused to provide a urine sample, the DON reported the resident's vital signs would be monitored every shift as well as monitoring whether there were any other signs and symptoms of a UTI. The DON further reported any contact made to the physician should be documented in the medical record along with any new recommendations. When queried about where the vital signs were documented, R27 said they would be in the vitals summary in the electronic medical record. When queried about whether R27 should have been evaluated by a physician since she refused to give a urine sample and a UTI could not be confirmed that way, the DON reported R27's family member wanted her to have a UA but would look into whether she was seen by a physician. On 12/4/25 at approximately 2:00 PM, the DON followed up and reported R27 was seen by a psychologist on 10/16/25, a Rehabilitation Physician on 10/29/25 (for therapy needs), and Psychiatrist on 10/29/25. However, R27's change in condition and possible UTI were not addressed with those medical providers. A review of R27's hospital records revealed the following: A Discharge summary dated [DATE] documented, .admission Information .presenting to the emergency department (ED) via EMS (emergency medical services) from her nursing home after an unwitnessed fall .According to the patient's daughter .the patient has been noted to be lethargic since this morning .At the nursing home, initial vital signs revealed hypotension (low BP) with systolic blood pressure in the 80s and a markedly elevated blood glucose level on the glucometer .WBC (White Blood Count) 15.8 (abnormal high) .UA was positive for protein, leukocyte esterase, red cells, white blood cells, WBC clumps, bacteria (indicative of an infection) .In the ED patient was given 3 L (liters) LR (lactated ringer's) bolus (electrolytes), Rocephin (antibiotic) 2 g (gram) IV (intravenous), started on insulin drip .admitted to ICU for closer monitoring and further management .Hospital Course .Significant Findings: Septic shock likely due to acute complicated UTI .High anion gap metabolic acidosis due to critical lactic acidosis and DKA (diabetic ketoacidosis) .likely due to UTI . Further review of R27's clinical record revealed R27 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease, Type 2 diabetes mellitus. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R27 had severely impaired cognition. A complaint was submitted to the State Agency on 8/1/25 with the allegations of facility did not give the first day of antibiotics as ordered and R92 was not assessed for a change in condition timely. On 12/3/25 an onsite investigation was completed for the allegations. A review of the medical record revealed that R92 was admitted to the facility on [DATE] with the admitting diagnosis of Local infection of the skin and acute hematogenous osteomyelitis. A Brief Interview for Mental Status (BIMs) score 00 which indicated sever cognitive impairment. A further review of the record revealed that R92 received a prescription on 7/8/25 for Meropenem 500mg IV every eight hours for eleven days. For a total of thirty-three doses. On 7/16/25 starting at 4 PM according to the medication administration record (MAR) it showed that a dependent resident self-administered an IV antibiotic. From 7/16/25-7/22/25 the MAR revealed eighteen self-administered IV meropenem medications. On 12/3/25 at 12:07 PM, Nurse U was interviewed via phone. Nurse U reported that R92 was a resident on the first floor, she was receiving IV antibiotics, missed several doses and became unresponsive. R92 had a pulse and vitals so we sent them to the hospital. Nurse U further reported, they went to the administrator about the change in condition and started an investigation, that is when it was discovered that R92 missed 18 doses of meropenem IV antibiotics. The doctor was called to let them know that R92 had missed several doses of antibiotic therapy and the doctor ordered them to receive a new IV line, obtain x-rays of the affected area and start the antibiotics for three additional days. The daughter was called as well to inform them that R92 needed a new IV line and that medications had been missed. The day R92 was sent out to the hospital, Nurse U reported that they went to the administrator to let them know the findings. Nurse U , reported that the administrator told them to tell the family that R92 was dehydrated. Nurse U reported the facility started doing a soft file on the incident, educating the staff on change in conditions for missed medications, transcribing medication orders correctly, and documentation located in a brown folder in their (administrator) office but they were terminated so they were unsure if the file was still available. A review of the record revealed that R92 was sent out to the hospital on 7/28/25 at 11:50 AM, with a progress note that reads, EMS notified -- Rochester Hills Fire Department accompanied resident via stretcher. A further review of the recorded revealed there was not any vital signs, assessments, notification to family or physician about the transfer. On 12/3/35 at 12:00 PM, a call was made, voice mail left and text message sent to Nurse 'V the nurse who put in the progress note the day of transfer, with no reply or call back. No additional information was submitted at the exit of survey.

Based on observation, interview, and record review the facility failed to ensure a homelike environment during dining for four (R7, R47, R64, and R72) of nine residents reviewed for dining. Findings include: On 12/2/25 at 12:28 PM, an observation was made of the lunch meal in the second floor dining room. On 12/2/25 at 12:39 PM, R47's meal was served on a tray, instead of placing the plate on the table. A television remote control was observed on the tray. On 12/2/25 at approximately 12:40 PM, R64's meal was served on a tray. R7 was not served at the same time and was observed grabbing R64's meal tray and pulling it toward herself. Then R72, who was also seated at the same table and not yet served a tray, pulled R64's tray toward himself. On 12/2/25 at approximately 12:45 PM, R7 was moved to another table and was served her meal on a tray. On 12/2/25 at approximately 12:50 PM, R72 was served his meal on a tray. On 12/3/25 at 2:33PM, an interview was conducted with Regional Registered Dietician (RD) 'O'. When queried about whether residents' meals should be taken off trays when served, RN 'O' reported the meal trays should be removed from the table to provide a homelike dining experience. A review of R7's clinical record revealed R7 was admitted into the facility on 1/10/19. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had severely impaired cognition. A review of R47's clinical record revealed R47 was admitted into the facility on [DATE]. A review of a MDS assessment dated [DATE] revealed R47 had severely impaired cognition. A review of R64's clinical record revealed R64 was admitted into the facility on 1/2/24. A review of a MDS assessment dated [DATE] revealed R64 had severely impaired cognition. A review of R72's clinical record revealed R72 was admitted into the facility on 7/23/25. A review of a MDS assessment dated [DATE] revealed R72 had severely impaired cognition.

This citation pertains to complaint 2578523.Based on interview and record review the facility failed to ensure one (92) of one resident was free from significant medication error when 18 doses of Intravenous (IV) antibiotics were ,missed and not given as the prescriber's ordered. Findings include:A complaint was submitted to the State Agency on 8/1/25 with the allegations of facility did not give the first day of antibiotics as ordered and R92 was not assessed for a change in condition timely.On 12/3/25 an onsite investigation was completed for the allegations.A review of the medical record revealed that R92 was admitted to the facility on [DATE] with the admitting diagnosis of Local infection of the skin and acute hematogenous osteomyelitis. AR92 had a Brief Interview for Mental Status (BIMs) score 00, indicating severe cognitive impairment.A further review of the record revealed that R92 received a prescription on 7/8/25 for Meropenem 500mg IV every eight hours for eleven days. For a total of thirty-three doses. On 7/16/25 starting at 4 PM according to the medication administration record (MAR) it showed that a dependent resident self-administered an IV antibiotic. From 7/16/25-7/22/25 the MAR revealed eighteen self-administered IV meropenem medications.On 12/3/25 at 12:07 PM, Nurse U was interviewed via phone. Nurse U reported that R6 was a resident on the first floor, she was receiving IV antibiotics, missed several doses and became unresponsive. R92 had a pulse and vitals so was sent them to the hospital. Nurse U further reported, they went to the administrator about the change in condition and started an investigation, that is when it was discovered that R92 missed 18 doses of meropenem IV antibiotics. The doctor was called to let them know that R6 had missed several doses of antibiotic therapy and the doctor ordered them to receive a new IV line, obtain x-rays of the affected area and start the antibiotics for 3 additional days. The daughter was called as well to inform them that R92 needed a new IV line and that medications had been missed. The day R92 was sent out to the hospital, Nurse U reported that they went to the Administrator to let them know the findings. Nurse U , reported that the administrator told them to tell the family that R92 was dehydrated. Nurse U reported the facility started doing a soft file on the incident, educating the staff on change in conditions for missed medications, transcribing medication orders correctly, and documentation which was in a brown folder in the Administrator's office.On 12/3/25 at 12:40 PM, a phone interview was conducted with the Administrator in relation to the allegations for R92 that was submitted to the state agency. The Administrator reported that they did not know about the incident and was not informed about anything. On 12/3/25 at 1PM, the Director of Nursing(DON) was interviewed about the incident where they informed surveyor that they were not a part of the facility at that time and presented the soft file on the incident.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included staff education and audits. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. There was no addition information provided at the exit of the survey.

Based on observation, interview, and record review, the facility failed to maintain sufficient dietary support personnel to meet the needs of the residents in the second floor dining room for five (R7, R23, R26, R64, and R72) of 10 residents reviewed for the dining task. Findings include:On 12/2/25 at 12:28 PM, an observation of the lunch meal was conducted in the second-floor dining room. The following was observed: At 12:39 PM, the cart containing the resident's meals arrived and staff began serving the food. At approximately 12:40 PM, R64's meal was served on a tray. R7 sat to the left of R64 and R72 sat across from R64. R7 and R72 were not served their food at that time. R7 was observed grabbing the tray from R64 and attempted to pull it toward herself. R64 pulled the tray back and began putting food into a cup of juice and stirring it with a knife. There were no staff members seated at the table with the residents. At approximately 12:45 PM, R7 pulled R64's tray in front of herself. At that time, R72 pulled the tray in front of himself and drank the juice with the mixed-up food in it. R7 pulled the tray back in front of herself. At that time, Certified Nursing Assistant (CNA) 'K' walked over to R7 and tried to give the tray back to R64 (it should be noted that no staff observed all of the residents touching R64's food and R72 drinking the juice mixed with food). R7 would not let go of the tray and became agitated when CNA 'K' tried to remove it from her, then eventually moved R7 to another table. At that time, R64's tray was removed after the Director of Nursing (DON) was alerted that other residents had made contact with his food. At approximately 12:49 PM, R72 was served his meal on a tray. A cup of juice was observed with plastic wrap on top of it and a nutritional shake was unopened on the tray. R72 asked the surveyor to help open the shake. At that time, Licensed Practical Nurse (LPN) 'E' sat down and began assisting R72. At 12:51 PM, R64 was served another meal which included a whole pork chop. No set up assistance was provided at that time. LPN 'E' was assisting R72 at 12:53 PM, then washed his hands and began assisting R64 at 12:54pm. However, when LPN 'E switched to assist R64, R72 spilled the nutritional shake and ate his food with a knife instead of the fork. Between 12:42 PM and 1:20 PM, R26 was observed with a plate of food placed in front of her. R26 was observed to pick at the grains of rice with her hands, but never successfully getting anything into her mouth. No staff stopped to encourage or assist R26 during that time frame and no food was consumed. Between 12:51 PM and 1:13 PM, R23 was observed with a plate of food placed in front of her. R23 remained asleep throughout that time. No staff were observed to attempt to wake R23 to encourage her to eat, until 1:13 PM, when CNA 'P' asked to take her tray away. CNA 'P' then fed R23 a few bites of food and then walked away. On 12/4/25 at 9:59 AM, an interview was conducted with Unit Manager, LPN 'B'. When queried about how staffing was determined to ensure residents received the appropriate assistance to meet their needs during meals, LPN 'B' reported she was unsure about the staffing decisions for the dining room on the second floor and would look into it. On 12/4/25 at 10:12 AM, an interview was conducted with the Director of Nursing (DON). When queried about how staffing was determined to ensure residents received the appropriate assistance to meet their needs during meals, the DON said it was based on the facility's policy, but she was not sure how it was determined and would look into it. The DON confirmed the second floor was mostly resident with cognitive impairment or who needed more assistance. A review of R7's clinical record revealed R7 was admitted into the facility on 1/10/19 and readmitted on [DATE] with diagnoses that included: dementia. A review of R7's care plans revealed R7 could be aggressive with other staff and residents and required set up assistance for meals. A review of R23's clinical record revealed R23 was admitted into the facility on 5/14/20 and readmitted on [DATE] with diagnoses that included: dementia. A review of R23's care plans revealed R23 required set up and supervision assistance by one staff member for eating. A review of R26's clinical record revealed R26 was admitted into the facility on 5/16/24 with diagnoses that included: Alzheimer's Disease. A review of R26's care plans revealed R26 required partial/moderate assistance from one staff member for eating.A review of R64's clinical record revealed R64 was admitted into the facility on 1/2/24 with diagnoses that included: dementia. A review of R64's care plans revealed R64 requires supervision/touching assistance from one staff member for eating. A review of R72's clinical record revealed R72 was admitted into the facility on 7/23/25 with diagnoses that included: dementia. A review of R72's care plans revealed R72 required set up or clean up assistance by one staff member for eating.

Based on observation, interview and record review, the facility failed to provide nail care and eating assistance for three dependent residents (R3, R23 and R26) of three residents reviewed for activities of daily living (ADL's). Findings include: On 12/2/25 starting at approximately 12:35 p.m., the following observations were made during the lunch meal in the second-floor dining room: At approximately 12:42 p.m., R26 was observed in dining room attempting to each the lunch meal by themself without any assistance. R26 was observed to be having a hard time getting any food off of their plate. At that time, a review of R26's Meal ticket (an informational paper that states the residents assistive deices, diet order and assistance level) was conducted which indicated R26 required assistance from staff with meals. At approximately 12:51 p.m., R23 was observed in the dining room, attempting to eat the lunch meal. R23 was observed sitting in their chair. R23 was observed to be silently staring, and their food was not touched. No assistance was observed being provided to R23 to help them eat the lunch meal. At approximately 12:56 p.m., R26 was still observed attempting to eat the lunch meal. R26's plate was observed to contain almost all of their food. R23 was observed to not have any staff assisting them. At approximately 1:05 p.m., R23 and R26 were both observed at their tables without having consumed any food. No assistance was observed to have been provided from staff with eating. At approximately 1:13 p.m., Certified Nursing Assistant P (CNA P) was observed to enter the dining room and ask to take R23's and R26's full meals away from them. At approximately 1:14 p.m., CNA P was observed to attempt to assist R23 with feeding by standing up over them and trying to encourage R23 to take a bite of food and then after a few bites, left R23's presence. At that time, CNA P was queried if R23 needed assistance from staff with eating and they indicated that they normally did not. At approximately 1:20 p.m., R26 was still observed attempting to eat the lunch meal. R26's plate was observed to contain almost all of their food and did not appear successful in eating the lunch meal without any assistance. At approximately 1:21 p.m., CNA P was queried if R26 needed assistance from staff with eating and they indicated that they sometimes did require help with eating. On 12/3/25 at approximately 8:19 a.m., R26 was observed lying in bed awake. R26 expressed feeling hungry and said she had not received breakfast yet. R26 was asked if she had any concerns about the care in the facility and R26 stated, They don't pay any attention to us. When queried about the lunch observation on 12/2/25 when R26 was observed having difficulty feeding herself and did not consume her meal or receive assistance from staff, R26 reported she needed help eating at times and stated, They don't pay attention to us. R26 again expressed that she was very hungry and wanted to know when she would receive breakfast. On 12/3/25 at approximately 2:33 p.m., during a conversation with Registered Dietician O (RD O), RD O was queried regarding the lack of assistance being provided to both R23 and R26 during the lunch meal observation on 12/2/25 and they reported that staff should being providing assistance to residents who were having difficulty eating the meal on their own. On 12/3/25 a review of R23's comprehensive plan of care was conducted and revealed the following: Focus-I have nutritional problem or potential nutritional problem r/t (related to) h/o (history of) dementia, dysphagia, anxiety DO (disorder), diabetes and major depressive DO provide finger foods-Hospice patient. Date Initiated: 09/18/2024 .Interventions-Offer meal setup and feeding assistance as resident allows. Date Initiated: 09/18/2024 On 12/3/25 a review of R26's comprehensive plan of care was conducted and revealed the following: Focus-I have an ADL self-care performance deficit related to Alzheimer's Disease, Adjustment disorder with mixed Anxiety and depressed mood, Psychotic disorderwith hallucinations, muscle weakness, Difficulty in walking, generalized muscle weakness, and psychoactive drug use Date Initiated: 08/14/2023 .Interventions-EATING: 1 person partial/moderate assist Date Initiated: 05/25/2024 . On 12/4/25 at 9:59 a.m., an interview was conducted with second floor Unit Manager, Licensed Practical Nurse (LPN) 'B'. When queried about what should be done if a resident was having difficulty eating or they had not touched their food, LPN 'B' reported the expectation was that staff would physically assist or attempt to encourage the resident to eat. On 12/4/25 a facility document titled Feeding the Dependent Resident was reviewed and revealed the following: POLICY: It is the policy of this facility to ensure adequate nutrition for residents who are unable to feed themselves Sit at eye level of the resident. This allows social interaction and better observation if any swallowing difficulty arises . On 12/2/25 at approximately 9:30 AM, R3 was observed lying in bed. The resident had disheveled hair and dirty long fingernails on both hands. The resident was alert and able to answer questions asked. R3 was asked about the dirty long nails and stated that they had not been cut in a while and could not remember the last time they had a shower. R3 also alleged their roommate bit them and tried to kiss them. They indicated the bite was on their left arm near their elbow. The allegation was reported to facility staff. A review of R3's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Bipolar disease, paranoid schizophrenia, PTSD (post-traumatic stress disorder) and chronic pain. A review of the Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderate cognitive impairment). A review of R3's ADL Kardex and Tasks for the past 30 days showed no documentation that pertained to nail care. The last noted shower provided was on 11/27/25. Continued review of R3's record was a General Progress Note dated 12/4/25: . During survey resident reported that he had been bitten by (name redacted) roommate. Area.is on the top of left forearm.the top of the left forearm appears as a skin abnormality.resident has 2 small open areas to the left wrist.The resident.was scratching both areas.Writer asked if the writer could see his nails, nails are over the base of the finger. Redness was noted under the residents' nails as well and dry brown in color was grit under the nails as well .it was reported that resident refused nail care. The DON was asked to provide documentation pertaining to nail care. The DON reported that it is not in the electronic record but would attempt to locate paper skin observations. The documents were reviewed and noted a section titled: Nails Filed and Needs Clipping. Documents provided for November dated: 11/3/25, 11/10/25, 11/13/25, 11/20/25 and 11/27/25 did not indicate R3's nails were either filed or needed clipping.

Based on interview and record review, the facility failed to ensure accurate advance directive information was in place for one (R33) of four residents reviewed for advance directives. Findings include: Review of the clinical record revealed R33 was admitted into the facility on [DATE] with diagnoses that included: major depressive disorder, vision loss and chronic kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R33 scored had severely impaired cognition. Review of the facility's electronic medical record [emar] revealed at the top of the screen next to Advance Directive R33 was listed as Full Code.Review of a document titled, Advance Directive for R33 revealed an 'X' was marked in the box labeled Do Not Resuscitate (DNR) MUST HAVE ORDER ON FILE OR INITIATE DNR PAPERWORK, it was signed by R33, dated 12/27/24, signed by two witnesses on 12/27/24, and signed by a physician on 12/27/25. Then next page of the document was titled, DO-NOT-RESUSCITATE ORDER signed by the physician on 12/27/25 and signed by two witnesses on 12/27/25.Review of R33's comprehensive care plan revealed a Focus initiated 12/27/24 that read, Resident has established Advance Directive of DNR. I have a POA [Power of Attorney] that assists in making decisions.Review of R33's physician orders revealed an order for Full Code created by Unit Manager [UM] B on 4/25/25.Review of a document to determine competency for R33 revealed an 'X' was marked in the box labeled Incompetent. The form was signed by a second physician on 6/2/25.On 12/3/25 at 1:46 PM, Social Worker [SW] H was interviewed and asked about R33's emar listing R33 as full code when there was DNR paperwork signed by R33. SW H explained she had been hired recently and was currently doing an audit on Advance Directives on all the residents.On 12/3/25 at 1:54 PM, Licensed Practical Nurse [LPN] F, who was R33's assigned nurse, was asked what R33's code status was. LPN F explained it was full code. LPN F was asked how she knew what the code status was. LPN F explained it was at the top of the emar, and also on the Face Sheet.On 12/4/25 at 9:51 AM, UM B was interviewed and asked why R33's code status had been changed on 4/25/25 to full code when there was a signed DNR order. UM B explained she had been instructed by the former Director of Nursing (DON) to make R33 a full code by default while competency was being determined. UM B was asked why there was no advance directive signed by the POA after 6/2/25 when R33 was deemed incompetent. UM B had no explanation.On 12/4/25 at 11:35 AM, the DON was interviewed and asked what was the procedure for determining resident code status. The DON explained they had separate forms if the resident could sign themself, if there was a POA, or if there was a guardian. all the forms had to be signed by the doctor and witnesses. Review of a facility policy titled, Advance Directives updated 3/22/21 read in part, .Review of Advance Directives: 1. Advance Directive information should be reviewed during quarterly care planning sessions. 2. The staff shall review treatment options wit the resident or legal representative to determine if the wishes remain the same or if changes are desired.

This citation pertains to Incident #2569672 and Complaint #2677444.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R5) of six residents reviewed for abuse and neglect, resulting in the resident being confined to bed and their room, not receiving any oral hygiene, and not being changed out of a hospital gown. Findings include:On 12/2/25 at 9:44 AM, R5 was observed asleep in bed. Signage was hung throughout the room and noted the following, Bra on always, Hospital gown on always, No wheelchair or gerichair, No oral care. The signage was signed by R5's responsible party. R5 was observed lying on her back in bed, wearing a hospital gown.On 12/2/25 at 2:35 PM, R5 was observed lying on her back in bed. R5 was awake and did not respond via eye contact or verbally when addressed. R5 was observed in a hospital gown.On 12/3/25 at 8:45 AM, R5 was observed lying on her back in bed wearing a hospital gown.On 12/3/25 at 10:44 AM, R5 was weighed using a mechanical lift by Certified Nursing Assistant (CNA) 'K' and CNA 'M'. Second floor Unit Manager, Licensed Practical Nurse (LPN) 'B' informed R5 that she was going to be weighed. R5 was more alert than the previous observations and stated, I hope so. During the observation, the mechanical lift sling was too big for the resident and she began to slip out and required a smaller size.On 12/3/25 at 10:55 AM, an interview was conducted with LPN 'B' regarding the size of the mechanical lift sling. LPN 'B' reported the mechanical lift was used only to weigh R5 because they do not get her out of bed per family's request. LPN 'B' further reported in the past when they got R5 out of bed and put her in the dining room, she enjoyed it and appeared comfortable.On 12/3/25 at 11:09 AM, an interview was conducted with CNA 'K'. CNA 'K' reported she began working in the facility approximately three weeks ago and has not gotten R5 out of bed.On 12/3/25 at 4:15 PM, an observation of R5's left hand was conducted with LPN 'B' and the Director of Nursing (DON). LPN 'A' reported after the earlier observation at 11:09 AM, R5 tried to swing her legs to the side of the bed and said she wanted to get out of bed to watch television. LPN 'B' reported they did not get her out of bed because the resident representative (family member) did not want her out of bed. At that time, LPN 'B' and the DON were interviewed about what had been done to ensure R5 received care to meet her physical and emotional needs, such as getting out of bed, getting dressed, and receiving oral hygiene. The DON reported they educated the family member. On 12/4/25 at 10:43 AM, an observation of R5's skin was conducted with the DON and LPN 'F'. R5's bra was not clean in appearance and was greenish in color underneath the armpit area.A review of R5's clinical record revealed R5 was admitted into the facility on 3/18/16 with diagnoses that included: [NAME]-Pick Disease Type C (a rare genetic disorder that causes abnormal accumulation of lipids within cells, leading to progressive organ damage and neurological impairment), dysphagia (difficulty swallowing), dementia, and aphasia (difficulty speaking). R5 received all nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube inserted in the stomach to deliver nutrition) and did not consume any food or fluids by mouth. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R5 had severely impaired cognition and was dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs) including oral hygiene and upper and lower body dressing.Further review of R5's progress notes revealed R5 had a fall from bed on 6/9/25 and the Interdisciplinary Team (IDT) met and implemented the following intervention Resident to be offered to get up in geri chair daily.A review of a General Progress Note dated 6/9/25 revealed, Writer made contact with (DPOA). Writer attempted to inform RP (responsible party) about intervention that was placed for resident regarding recent fall. RP began to yell at writer stating we are to remove the airloss mattress (a mattress that redistributes air to relieve pressure and to assist in prevention of skin breakdown and pressure ulcers) from resident's bed and we are not to get resident up to any sort of chair. Writer again attempted to educate RP the rationale for intervention RP continued to yell at writer and talk about when her son was at the facility.A review of a General Progress Note dated 6/9/25 revealed, Writer into see resident. As writer entered room, lab was in drawing ordered labs. Resident was awake and responsive to conversation. Writer asked resident if she would like to get up to geri chair. Resident responded with 'yes'. After lab draw was completed CNA completed care and resident was transferred into geri chair and take into dining room. Writer into speak with resident. Resident was asked if she was comfortable, she responded with a smile and stated 'yes'. Resident was then asked did she like that she was up to a chair, again responded with a smile and a 'yes'.A review of a General Progress Note dated 6/9/25 revealed, Resident's [sic] switched out from airloss to regular mattress per RP request.A review of a General Progress Note dated 7/22/25 revealed, This author spoke with the guardian in regards to resident being up in geri-chair. Guardian is requesting resident not to be up in chair. Guardian was educated that resident has the right to get up in chair everyday to prevent wounds.A review of a General Progress Note written by the DON on 10/10/25 revealed, DPOA (Durable Power of Attorney - A document that designates a person to make decisions for the resident when they were no longer able to) does not want oral care performed on this resident, DPOA states that she is afraid she is going to aspirate on water from the sponges. Education provided on oral care and the process of use of the sponges. DPOA does not want the oral care provided at all. Resident DPOA does not want the resident dressed in clothing, DPOA only wants the resident in a gown and a bra. Resident DPOA does not want the partials removed from the mouth of the resident and care perform on the partial dentures. Writer acknowledged understanding and did educate the DPOA on oral care risk vs (versus) benefit. DPOA stated she does not care she does not want it done along with the partials dentures, she does not want them removed either.A review of a General Progress Note dated 10/20/25 revealed, .resident's DPOA does not want the resident up in Geri chair, does not want the resident dressed for the day.A review of R5's care plans revealed the following:A care plan initiated on 10/10/25 that noted, Residents (DPOA) does not [sic] the resident dressed, she only wants the resident in gown. DPOA does want bra on 24 hours a day.DO NOT DRESS THIS RESIDENT IN CLOTHING GOWN ONLY and BRA ONLY, DO NOT REMOVE BRA AT NIGHT. REMOVE AND REPLACE WHEN GOWN IS CHANGED - per DPOA. An intervention initiated on 1/1/24 noted, TRANSFERS: Dependent x 2 person assist.(family requests resident to stay in bed). An intervention revised on 10/2/25 noted, Resident uses a manual wheelchair for locomotion (mother requests resident not get up in w/c - wheelchair).A care plan initiated on 1/23/25 and revised on 10/10/25 revealed, Resident requires tube feeding.Resident DPOA does not want any oral care performed.also does not want care performed on partial dentures. An intervention initiated on 10/10/25 noted, DO NOT PERFORM ORAL CARE ON THIS RESIDENT - per DPOA.DO not remove and perform care on the residents partial dentures. PER DPOA.A care plan that noted R5 was at risk for falls was initiated on 9/27/23 and revised on 10/2/25 and included an intervention to get R5 up to geri chair daily (initiated on 6/9/25).On 12/4/25 at 8:45 AM, an interview was conducted with the DON. When queried about what could happen if partial dentures were not ever removed from someone's mouth and their oral hygiene was not tended to, the DON reported it could result in an infection. When queried about what the facility had done to address the basic care needs R5's DPOA has asked the facility not to provide, the DON reported she talked to the DPOA and the Administrator about it and they educated the DPOA about the risks. The DON reported R5's DPOA gets mad and yells if they did oral care or removed the partial dentures. The DON reported it was the same reaction if the facility got R5 out of bed. When queried about what the facility's protocol was if a resident's representative (decision maker) was not making decisions in the best interest of the resident, the DON asked if it would be the same if a resident wanted to leave the building, but the DPOA said they could not. When queried about the difference between basic care that was necessary for the resident to meet their highest practicable physical and mental well-being and a choice (such as leaving the building unsupervised) that could be unsafe for a resident, the DON did not offer a response. When queried about whether any investigation was done into the neglectful practices requested by the DPOA, the DON reported she spoke with the Administrator. On 12/4/25 at 9:10 AM, an interview was conducted with the Administrator/Abuse Coordinator via the telephone. When queried about the facility's process when a resident's legal representative did not make decisions in the best interest of the resident that could potentially cause harm, the Administrator reported it would depend on the situation, but an investigation would be conducted to determine how that allegation was formed.When queried about R5's basic care needs being neglected per the DPOA's request (oral care, getting out of bed, leaving the room, getting dressed), the Administrator reported he was not aware of an issue, but stated, We would have to put a stop to that because we have to base the care on doctor's orders and a team approach. The Administrator reported the facility was responsible for keeping residents at their highest practical level of functioning. The Administrator further reported required care in the facility was not directed based on the desires of the DPOA. When queried about whether he was aware that R5 had a care plans implemented since 1/1/24 to not get R5 out of bed, since 10/2/25 to not get R5 up in a wheelchair, since 10/10/25 to not perform oral care , to not remove partial dentures, and to not dress R5 in clothing other than a gown and to keep a bra on 24 hours a day, the Administrator reported he was not aware but confirmed he was familiar with the resident.A review of a facility policy titled, Abuse and Neglect, revised on 6/17/19, revealed, in part, the following, It is the policy of this facility to provide professional care and services in an environment that is free from any type of.neglect.Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional.

This citation pertains to Incident #2569672 and Complaint #2677444. Based on observation, interview, and record review, the facility failed to report incidents of neglect to the Abuse Coordinator and the State Agency for one (R5) of six resident reviewed for abuse and neglect. Findings include:On 12/2/25 at 9:44 AM, R5 was observed asleep in bed. Signage was hung throughout the room and noted the following, Bra on always, Hospital gown on always, No wheelchair or gerichair, No oral care. The signage was signed by R5's responsible party. R5 was observed lying on her back in bed, wearing a hospital gown.On 12/2/25 at 2:35 PM, R5 was observed lying on her back in bed. R5 was awake and did not respond via eye contact or verbally when addressed. R5 was observed in a hospital gown.On 12/3/25 at 8:45 AM, R5 was observed lying on her back in bed wearing a hospital gown.On 12/3/25 at 10:44 AM, R5 was weighed using a mechanical lift by Certified Nursing Assistant (CNA) 'K' and CNA 'M'. Second floor Unit Manager, Licensed Practical Nurse (LPN) 'B' informed R5 that she was going to be weighed. R5 was more alert than the previous observations and stated, I hope so. During the observation, the mechanical lift sling was too big for the resident and she began to slip out and required a smaller size.On 12/3/25 at 10:55 AM, an interview was conducted with LPN 'A' regarding the size of the mechanical lift sling. LPN 'B' reported the mechanical lift was used only to weigh R5 because they do not get her out of bed per family's request. LPN 'B' further reported in the past when they got R5 out of bed and put her in the dining room, she enjoyed it and appeared comfortable.On 12/3/25 at 4:15 PM, an observation of R5's left hand was conducted with LPN 'B' and the Director of Nursing (DON). LPN 'A' reported after the earlier observation at 11:09 AM, R5 tried to swing her legs to the side of the bed and said she wanted to get out of bed to watch television. LPN 'B' reported they did not get her out of bed because the resident representative (family member) did not want her out of bed. At that time, LPN 'B' and the DON were interviewed about what had been done to ensure R5 received care to meet her physical and emotional needs, such as getting out of bed, getting dressed, and receiving oral hygiene. The DON reported they educated the family member and updated the care plan to reflect the DPOA's wishes. On 12/4/25 at 10:43 AM, an observation of R5's skin was conducted with the DON and LPN 'F'. R5's bra was not clean in appearance and was greenish in color underneath the armpit area.A review of R5's clinical record revealed R5 was admitted into the facility on 3/18/16 with diagnoses that included: [NAME]-Pick Disease Type C (a rare genetic disorder that causes abnormal accumulation of lipids within cells, leading to progressive organ damage and neurological impairment), dysphagia (difficulty swallowing), dementia, and aphasia (difficulty speaking). R5 received all nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube inserted in the stomach to deliver nutrition) and did not consume any food or fluids by mouth. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R5 had severely impaired cognition and was dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs) including oral hygiene and upper and lower body dressing.A review of a General Progress Note dated 6/9/25 revealed, Writer made contact with (DPOA). Writer attempted to inform RP (responsible party) about intervention that was placed for resident regarding recent fall. RP began to yell at writer stating we are to remove the airloss mattress (a mattress that redistributes air to relieve pressure and to assist in prevention of skin breakdown and pressure ulcers) from resident's bed and we are not to get resident up to any sort of chair. Writer again attempted to educate RP the rational for intervention RP continued to yell at writer and talk about when her son was at the facility.A review of a General Progress Note dated 6/9/25 revealed, Writer into see resident. As writer entered room, lab was in drawing ordered labs. Resident was awake and responsive to conversation. Writer asked resident if she would like to get up to geri chair. Resident responded with 'yes'. After lab draw was completed CNA completed care and resident was transferred into geri chair and take into dining room. Writer into speak with resident. Resident was asked if she was comfortable, she responded with a smile and stated 'yes'. Resident was then asked did she like that she was up to a chair, again responded with a smile and a 'yes'.A review of a General Progress Note dated 6/9/25 revealed, Resident's [sic] switched out from airloss to regular mattress per RP request.A review of a General Progress Note dated 7/22/25 revealed, This author spoke with the guardian in regards to resident being up in geri-chair. Guardian is requesting resident not to be up in chair. Guardian was educated that resident has the right to get up in chair everyday to prevent wounds.A review of a General Progress Note written by the DON on 10/10/25 revealed, DPOA (Durable Power of Attorney - A document that designates a person to make decisions for the resident when they were no longer able to) does not want oral care performed on this resident, DPOA states that she is afraid she is going to aspirate on water from the sponges. Education provided on oral care and the process of use of the sponges. DPOA does not want the oral care provided at all. Resident DPOA does not want the resident dressed in clothing, DPOA only wants the resident in a gown and a bra. Resident DPOA does not want the partials removed from the mouth of the resident and care perform on the partial dentures. Writer acknowledged understanding and did educate the DPOA on oral care risk vs (versus) benefit. DPOA stated she does not care she does not want it done along with the partials dentures, she does not want them removed either.A review of a General Progress Note dated 10/20/25 revealed, .resident's DPOA does not want the resident up in Geri chair, does not want the resident dressed for the day.A review of R5's care plans revealed the facility implemented the requests to withhold oral care, removing the partial denture, getting the resident out of bed and the room, and dressing the resident in clothing per the DPOA's request. On 12/4/25 at 8:45 AM, an interview was conducted with the DON. When queried about what could happen if partial dentures were not ever removed from someone's mouth and their oral hygiene was not tended to, the DON reported it could result in an infection. When queried about what the facility had done to address the basic care needs R5's DPOA has asked the facility not to provide, the DON reported she talked to the DPOA and the Administrator about it and they educated the DPOA about the risks. The DON reported R5's DPOA gets mad and yells if they did oral care or removed the partial dentures. The DON reported it was the same reaction if the facility got R5 out of bed. When queried about what the facility's protocol was if a resident's representative (decision maker) was not making decisions in the best interest of the resident, the DON asked if it would be the same if a resident wanted to leave the building, but the DPOA said they could not. When queried about the difference between basic care that was necessary for the resident to meet their highest practicable physical and mental well-being and a choice (such as leaving the building unsupervised) that could be unsafe for a resident, the DON did not offer a response. When queried about whether any investigation was done into the neglectful practices requested by the DPOA, the DON reported she spoke with the Administrator. On 12/4/25 at 9:10 AM, an interview was conducted with the Administrator/Abuse Coordinator via the telephone. When queried about the facility's process when a resident's legal representative did not make decisions in the best interest of the resident that could potentially cause harm, the Administrator reported it would depend on the situation, but an investigation would be conducted to determine how that allegation was formed. When queried about R5's basic care needs being neglected per the DPOA's request (oral care, getting out of bed, leaving the room, getting dressed), the Administrator reported he was not aware of an issue, but stated, We would have to put a stop to that because we have to base the care on doctor's orders and a team approach. The Administrator reported the facility was responsible for keeping residents at their highest practical level of functioning. The Administrator further reported required care in the facility was not directed based on the desires of the DPOA. When queried about whether he was aware that R5 had a care plans implemented since 1/1/24 to not get R5 out of bed, since 10/2/25 to not get R5 up in a wheelchair, since 10/10/25 to not perform oral care , to not remove partial dentures, and to not dress R5 in clothing other than a gown and to keep a bra on 24 hours a day, the Administrator reported he was not aware but confirmed he was familiar with the resident. The Administrator confirmed he did not report the neglect of R5 to the State Agency or conduct an investigation because it was not brought to his attention in that way. A review of a facility policy titled, Abuse and Neglect, revised on 6/17/19, revealed, in part, the following, .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional.All allegations and/or suspicions of abuse must be reported to the Administrator immediately .All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received .

Based on interview and record review the facility failed to ensure PASSAR (Preadmission Screening/Annual Resident Review) documentation and OBRA Level II exemption criteria were completed appropriately for two residents (R3 and R20) of three residents reviewed for PASSAR/OBRA (Omnibus Budget Reconciliation Act) assessments. Findings include:R3A review of R3's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Bipolar disease, paranoid schizophrenia, PTSD (post-traumatic stress disorder) and chronic pain. Continued review of R3's clinical record noted a document dated November 6, 2024 that read, .completed an OBRA Level II Evaluation on the above named individual (R3).Determination.Specialized Mental Health Services.Individual's physical, mental and psychosocial needs can be met in a nursing facility.If the above named individual remains in the nursing facility a Level II Evaluation is needed by November 5, 2025. *It should be noted that the Level II Evaluation that needed to be completed by 11/5/25 was not done. R20A review of R20's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: undifferentiated schizophrenia, bipolar disorder and adjustment disorder. Continued review of R20's clinical record noted a document dated September 11, 2024 that read, .completed an OBRA Level II Evaluation on the above named individual (R3).Determination.Specialized Mental Health Services.Individual's physical, mental and psychosocial needs can be met in a nursing facility.If the above named individual remains in the nursing facility a Level II Evaluation is needed by September 10, 2025. *It should be noted that the Level II Evaluation that needed to be completed by 9/10/25 was not done. 12/03/2025 at approximately 1:40 PM, Social Worker (SW) H was interviewed and asked about OBRA Level II evaluations that had not been completed. SW H reported that they were fairly new to the facility and determined that prior to their employment several residents, including R3 and R20 had not received Level II evaluations as needed. SW H reported that they were completing audits on the residents and hoped the Level II's would be addressed.

Based on observation, interview and record review, the facility failed to ensure professional standards for Nursing were practiced including performing accurate assessments and maintaining an accurate treatment record for two residents (R5 and R64) of two residents reviewed for Professional Standards. Findings include: On 12/2/25 at 9:44 AM, R5 was observed lying in bed sleeping. A tube feeding pole was observed tucked behind the privacy curtain, but no tube feeding formula was hung or infusing. On 12/2/25 at approximately 12:20 PM, an observation of R5 was made. When spoken to R5 did not respond or make eye contact. No tube feeding was hung in the room at that time. A review of R5's Physician's Orders revealed an active order for .Jevity 1.5 via pump per PEG (Percutaneous Endoscopic Gastrostomy - a tube surgically inserted into the stomach to deliver nutrition) at 65 ml/hr (milliliters per hour) x 18 hours (up at 6pm) or until total volume of 1170 mL is reached daily . On 12/3/25 at 8:13 AM, R5 was observed in bed with no tube feeding hung in the room. On 12/3/25 at 8:30 AM, a review of R5's Medication Administration Record (MAR) for December 2025 revealed Licensed Practical Nurse (LPN) 'E' signed off that 325 ml of tube feeding was administered on 12/3/25 day shift. However, it should be noted that there was no tube feeding hung during the observation at 8:13 AM and if the tube feeding was hung according to the physician's orders at 6:00 PM, the tube feeding would not have been taken down until 12:00 PM to equal 18 hours of feeding. On 12/3/25 at 8:45 AM, an interview was conducted with LPN 'E'. When queried about R5's tube feeding and why there was nothing hung and infusing, LPN 'E' said there was nothing hanging when he arrived on the day shift and stated, The night nurse must not have hung the second bottle. When queried about why he signed off that 325 ml was administered if there was nothing hung, LPN 'E' stated, That is the amount she will get today. When queried about whether it was protocol to sign out administration of something that was not yet done, LPN 'E' stated, I don't know. I don't want to say the wrong thing. At that time, LPN 'E' then obtained a bottle of tube feeding formula, hung it up, but did not start it. The bottle of Jevity contained 1000 ml of formula when full. On 12/3/25 at 9:00 AM, an interview was conducted with Unit Manager, LPN 'B'. When queried about when the nurses documented administration of medication or treatments, including tube feeding, LPN 'B' reported they would document on the MAR after it was administered. On 12/3/25 at 10:55 AM, Certified Nursing Assistant (CNA) 'K' and CNA 'M' were observed weighing R5 using a mechanical, battery powered lift that utilized a cloth sling placed underneath the resident, hooked to the lift, which then was operated to lift the resident up into the air. At that time, CNA 'K' and CNA 'M' placed an extra-large (XL) underneath R5, hooked the sling to the mechanical lift, and began lifting R5 off the bed. As they lifted R5, R5's lower body started slipping out of the end of the sling. Unit Manager, Licensed Practical Nurse (LPN) 'B' and LPN 'E' were present in the room during the transfer. LPN 'B' instructed CNA 'K' and CNA 'M' to readjust the position of the sling. When R5 was lifted a second time, the sling began to slip overtop her head. At that time, CNA 'K' and LPN 'B' went to find a different size sling. On 12/3/25 at approximately 11:05 AM, an interview was conducted with LPN 'B'. When queried about how the CNAs knew what sling size to use, LPN 'B' reported it was based off of the assessment. LPN 'B' reported R5's responsible party did not want her to get out of bed, so the mechanical lift was only used once a month to weigh the resident. A review of a Resident Lift Assessment for R5 dated 12/3/25 at 9:46 AM (prior to the above observation) completed by the Director of Nursing (DON) revealed the sling size for R5 was XL - Xtra Large. A review of the previous Resident Lift Assessment for R5 dated 11/29/25 revealed the sling size was L - Large. A review of a Resident Lift Assessment for R5 dated 12/3/25 at 11:25 PM completed by LPN 'B' revealed the sling size for R5 was changed to L - Large. On 12/3/25 at 11:37 AM, an interview was conducted with the DON. When queried about how she assessed R5 for the correct sling size on that day, the DON stated, We talked about it. The DON further explained that she did not physically assess R5 and LPN 'B' said R5 was an XL so that was what she documented on the assessment. On 12/3/25 at 12:33 PM, an interview was conducted with LPN 'B'. When queried about the assessment completed on 12/3/25 prior to weighing R5, LPN 'B' reported they did an assessment because we knew you wanted her weight. When queried about how R5 was assessed for the sling size, as the size was incorrect and too big which caused the resident to start to slip out of the sling, LPN 'B' stated, We held the sling over here. LPN 'B further said a large sling was not available, so they just measured it on her by holding it over her. LPN 'B' stated, I'm glad I was in there to stop them (when R5 started falling out of the sling). A review of R5's clinical record revealed R5 was admitted into the facility on 3/18/16 with diagnoses that included: [NAME]-Pick Disease Type C (a rare genetic disorder that causes abnormal accumulation of lipids within cells, leading to progressive organ damage and neurological impairment), dysphagia (difficulty swallowing), dementia, and aphasia (difficulty speaking). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R5 had severely impaired cognition and was dependent on staff for transfers. R64 On 12/2/25 at approximately 10:55 a.m., R64 was observed in the second-floor dining room. R64's left forearm was observed to have a foam dressing that had an application date of 11/30/25 with Nurse T's initials on it, indicating who administered the dressing. On 12/2/25 at approximately 12:34 p.m., R64 was observed in the dining room, sitting at a table and was still observed to have the dressing on their left forearm that was dated 11/30/25. On 12/2/25 the medical record for R64 was reviewed and revealed the following: R64 was initially admitted on [DATE] and had diagnoses including Dementia and Hypokalemia. A review of R64's MDS (minimum data set) with an ARD (assessment reference date) of 10/7/25 revealed R64 needed assistance from facility staff with most of their activities of daily living. R64's BIMS score (brief interview for mental status) was zero indicating severely impaired cognition. A Physician's order dated 11/20/25 revealed the following: Cleanse L (left) elbow skin tear with wound cleanser. Pat dry. Apply thin layer TAO (triple antibiotic ointment) and cover with boarder foam dressing. A review of R64's December 2025 Treatment Administration Record (TAR) revealed documentation by Nurse S that they had changed R64's dressing on 12/1/25. On 12/3/25 at approximately 2:04 p.m., during a conversation with Unit Manger B (UM B), UM B was informed of the multiple observations of R64's forearm dressing on 12/2/25 with the date of 11/30/25 and Nurse T's initials on it. R64's December 2025 TAR was reviewed with UM B and they were shown that Nurse S had documented they had administered the treatment on 12/1/25 when it was dated 11/30/25 by Nurse T. UM B indicated that Nurse S should not have documented the treatment as being completed when it was not and that Nurses should only document in the TAR if they actually performed the treatment. A document from the American Nurses Association titled Principles for Nursing Documentation revealed the following: Overview of Nursing Documentation-Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Nurses practice across settings at position levels from the bedside to the administrative office; .Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care .

This citation pertains to Intake 2662526.Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R12, R49 and R23) of three residents reviewed for dignity. Findings include: On 12/2/25 at 10:55 AM, R12 was observed sleeping in a geriatric (geri) chair holding a baby doll. On 12/2/25 at 12:56 AM, Unit Manager [UM] C was observed to enter R12's room, go behind the geri chair R12 was reclining in and turn the chair around and pull R12 in the chair backwards out of the room. UM C then proceeded to pull R12 backwards down the hall to the dining room and continue to pull R12 backwards to a table on the far side of the room to a table. On 12/2/25 at 1:00 PM, UM C was interviewed and asked if she usually pulled residents backwards in geri chairs. UM C explained she always pulled the chairs as it was easier to pull the chair than to push. Review of the clinical record revealed R12 was admitted into the facility on 3/3/25 and readmitted on [DATE] with diagnoses that included: Alzheimer's disease, anxiety disorder and peripheral vascular disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R12 had severely impaired cognition. On 12/3/25 at 3:50 PM, the Director of Nursing (DON) was asked if it was appropriate to pull residents backwards in a geri chair. The DON explained residents should always be pushed in the chair facing forwards, not backwards. On 12/2/25 starting at approximately 12:35 p.m., the following observations were made during the lunch meal in the second-floor dining room: At approximately 1:08 p.m., Unit Manager B (UM B) was observed standing over R49 for an extended period of time while they were seated at the table attempting to help feed them. AT approximately 1:14 p.m., Certified Nursing Assistant P (CNA P) was observed entering the dining room. CNA P was then observed to stand over R23 and start to provide feeding assistance to them. On 12/3/25 at approximately 2:33 p.m., during a conversation with Registered Dietician O (RD O), RD O was queried regarding the provision of providing a dignified dining experience and the multiple observations of staff members standing over seated residents in the dining room providing feeding assistance to them. RD O indicated that staff who are providing feeding assistance should be seated next to them and engaging the residents in order to provide an optimal dining experience and treat them in a dignified manner. On 12/5/25 a facility document titled Feeding the Dependent Resident was reviewed and revealed the following: POLICY: It is the policy of this facility to ensure adequate nutrition for residents who are unable to feed themselves Sit at eye level of the resident. This allows social interaction and better observation if any swallowing difficulty arises . On 12/5/25 a second facility document titled Resident Rights was reviewed and revealed the following: POLICY: It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. 1. The Resident has the right: To be treated with consideration, respect, and full recognition of his or her dignity and individuality .

This citation pertains to intake 263088. Based on observation, interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident for three (R801, R802, and R803) of three residents reviewed for abuse, resulting in R801 punching R802 in the face twice breaking R802's jaw and R802 pushing R803 to the floor, then kicking R803 and trying to run R803 over in their wheelchair. Findings include:Review of the facility reported documentation submitted to the State Agency on 9/21/25 included an incident summary of a resident to resident physical altercation which read, On 9/20/25 at approximately 5:50pm Nurse was at medication cart in the hallway. She heard a commotion and when she turned around she observed [R801] make contact with [R802] in the face with a closed hand.Staff completed a skin and pain assessment on [R802] with notation of slight redness, res (resident) did not resent with any pain. It should be noted that the information submitted as above did not accurately represent the extent of the events that were documented on witness statements and included in the electronic medical record (EMR).R801 & R802On 10/7/25 at 9:00 AM, the Administrator was requested to provide facility documentation of the resident to resident altercation that occurred between R801 and R802 on 9/20/25.On 10/7/25 at 9:54 AM, R801 was observed walking independently in the hallway near the elevator and upon approach agreed to go to their room to talk. When asked if they could recall any incident in which they punched another resident in the face, R801 reported Yes, she pushed right into me when I was going by. I was moving past her wheelchair and she grabbed me. No, she didn't grab me, kinda pushed against me and I hit her back. When asked what happened after that, R801 stated, Called the police on me.Review of the clinical record for R801 revealed the resident was initially admitted into the facility on 5/1/18 with diagnoses that included: unspecified dementia, unspecified severity, with other behavioral disturbance, undifferentiated schizophrenia, cognitive communication deficit, dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, and adjustment disorder with anxiety.According to the Minimum Data Set (MDS) assessment dated [DATE], R801 had no communication concerns, had severely impaired cognition (scored three out of 15 on the Brief Interview for Mental Status/BIMS exam), had disorganized thinking which fluctuated, had no hallucinations/delusions, behaviors, and was independent with ambulation without an assistive device.Review of the most recent BIMS exam dated 9/23/25, R801 had scored a 9/15 which indicated moderate cognitive impairment.Further review of R801's documentation included a progress note created on 9/21/25 at 2:29 AM for 9/20/25 at 5:30 PM by Nurse 'B' that read, Writer witnessed resident assault a female resident with a closed fist.On 10/7/25 at 10:00 AM, R802 was observed lying in bed. R802 was asked if her jaw hurt. R802 explained, while touching her jaw on the right side, her jaw used to hurt a lot, but it was not as bad now. R802 was asked if she knew what happened to her jaw. R802 explained she thought she broke it falling.Review of the clinical record revealed R802 was admitted into the facility on 5/7/25 and readmitted [DATE] with diagnoses that included: major depressive disorder, anxiety disorder and fracture of coronoid process of right mandible. According to a Brief Interview for Mental Status (BIMS) exam dated 9/23/25, R802 scored 8/15 indicating moderately impaired cognition.Review of R802's Comprehensive Care Plan revealed an additional Focus that read, Resident is/has potential to be physically aggressive with residents in facility created 10/6/25.Review of R802's progress notes revealed multiple entries from nursing staff since May 2025 that documented R802 had a history of combative/aggressive/intrusive behaviors which included: being more agitated, aggressive, frustrated with other residents, including swatting motions for another resident to get out of their personal space, going into and out of other resident rooms, rummaging through roommate's belongings, and being combative and verbally aggressive with staff.An Event note dated 9/20/25 at 5:27 PM read in part, Writer witnessed (female) resident assaulted by (male) resident with a closed fist. Police contacted. Resident is complaining of facial pain 9/10 with signs of erythema [redness]. Ordered for x-ray.A General Progress note dated 9/21/25 at 12:24 AM read in part, Resident transferred to [hospital]. for follow up care and diagnostic testing (x-ray) related to injury/assault. Resident reports pain right side of face.Further review of the facility's investigation file included: .The investigation ascertained that physical contact did occur between the two residents, but the facility is unable to clearly extract the events leading up to [R801] striking [R802] - it does appear contact from both parties occurred, initiated by [R802]. The reaction appears to be a situational event, related to the resident's cognitive impairments.[R802] did sustain a non-displaced mandible fracture.A written statement from Nurse 'B' dated 9/20/25 at 7:30 PM read: At/around 5:27 pm writer [Nurse 'B'] witnessed pt (patient) [R801] strike female pt [R802] in the face with a closed fist. [R801] struck resident twice on right side of face (cheek) standing over [R802] while she was seated in wheelchair. Staff separated residents to prevent further injury/assault. Writer observed mild signs of erythema on female victim right cheek. Female pt [R802] complained of pain - stated pain level 9/10. Police contacted, physician, legal guardian and on call nurse supervisor notified of incident. Resident [R801] went into his room after altercation.Female resident transported to local hospital vice EMS (Emergency Medical Services) @ [left blank, no time included]A written statement from Certified Nursing Assistant (CNA 'A') dated 9/20/25 with no time identified read: 9-20-25 At about 5:27 pm [R801] was walking in the hallway, then [R802], grabbed him by the shirt and said hey you have my glasses, then he shrugged aways [sic] and he said leave me alone, then she grabbed him again and punch him then he turned around and hit her back.A written statement from CNA 'C' dated 9/20/25 with no time identified read: [R801]was walking up the hallway and [R802] hit him then he hit her in her head and face and now she has a bruise on her right eye.A written statement from the Director of Nursing (DON) dated 9/22/25 with no time identified read: Upon interview with the staff [CNA 'D'] she stated that Pt. [R802] was in the hallway wheeling self and her hand slipped off the wheel when [R801] was walking by and hit [R801]. [R801] then proceeded to hit [R802] in the face x 2.A psychiatric evaluation completed by the facility's contracted Psych Nurse Practitioner (NP 'Q') dated 9/23/25 at 3:24 PM documented, in part: .was seen and examined to follow up resident-to-resident altercation. Patient hit another resident in the face. He said that she pushed him first. He acknowledged that he cannot do this and cannot hit other people. He said his mood is okay, denies anxiety, denies hallucinations, no delusions expressed, no problems with appetite or sleep, no other behaviors noted.Mental Status Evaluation.ORIENTATION - The patient is oriented to person and grossly to place, There is no inconsistency or variability in orientation.JUDGMENT - Judgment is marginal, Patient acknowledged that hitting another resident was inappropriate behavior. INSIGHT - Insight is marginal, Patient understands he cannot hit other people. R802 & R803On 10/7/25 at 10:10 AM, during an interview with Nurse 'L' regarding another resident to resident incident that involved R802, R803 was observed walking in the hallway without any assistive devices and approached the nursing desk. The resident's balance was slightly wobbly, but they reached out and began opening a binder that was on the nursing desk. R803 did not respond verbally upon approach and proceeded to grab the binder. Nurse 'L' and another staff were able to redirect the resident away from the area. Nurse 'L' reported they were not R803's nurse but was familiar with the resident. Nurse 'L' was asked if they could recall any incidents with R802 and R803 and reported they heard something recently when they came back to work, but had never witnessed anything themself.Review of the clinical record revealed R803 was initially admitted into the facility on 5/14/20 and readmitted on [DATE] with diagnoses that included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized anxiety disorder, age-related osteoporosis without current pathological fracture, mood disorder due to known physiological condition with manic features, dysthymic disorder, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, aphasia, senile degeneration of brain, not elsewhere classified, unspecified abnormalities of gait and mobility, delusional disorders, and major depressive disorder recurrent, moderate.According to the MDS assessment dated [DATE], R803 had severely impaired cognition (scored 00/15 on BIMS exam), exhibited no mood or behavior concerns, and received hospice services.On 10/7/25 at 11:24 AM, the Administrator was requested to provide facility documentation of any resident to resident altercations that occurred with R803.Review of the documentation submitted to the State Agency on 10/5/25 included a resident to resident physical altercation on 10/5/25 at approximately 4:30 PM which documented, in part .Risk Manager [Administrator's Name] was made aware that resident [R802] may have pushed resident [R803] subsequently causing her to fall to the floor.a bruise and swelling were noticed to right eye . It should be noted that the information submitted as above did not accurately represent the extent of the events that were documented on witness statements and included in the electronic medical record (EMR).Review of the documentation provided by the facility included:A handwritten witness statement by Nurse 'E' dated 10/5/25 (no time) documented, in part: To whom it may concern, At approximately 3:20 pm Nurse observed resident on floor after hearing a big boom during medication pass. Writer turned around to see what it was and that's when writer observed [R802] kicking [R803] and running into her with her wheelchair. Writer yelled to the other Nurse for Assistance to separate residents.A typed witness statement by Nurse 'T' (undated and no time identified) documented, in part: I am writing this statement letter to provide details of the incident I witnessed between [R802] and [R803].On October 5, 2025, at approximately 3:20 PM, I was standing at my med cart preparing medication for a resident, I heard a loud bump as I begin to look around, I hear my floor nurse at the end of the hall yelling my name, I look on to see [R803] on the floor, against the wall, and [R803] kicking her multiple times, while rolling her wheel chair into her.Review of R803's progress notes included:An entry on 10/5/25 at 6:29 PM by the Director of Nursing (DON) read: Resident had witnessed fall at the nurses station in the hallway during res (resident) to res. Resident [R802] pushed resident causing resident to fall and hit the right side of the head and right side of face near eyebrow. Resident fell to the floor. Resident [R802] began to attempt to kick and run into her while resident was attempting to stand back up.An entry on 10/5/25 at 6:07 PM by the DON read: Reported to writer that resident [R802] pushed resident, causing resident to hit the wall with the back of the head / right side of the face causing the resident to fall to the floor. As resident was trying to get back up resident [R802] began to attempt to kick and run into the resident via wheelchair, stating resident was talking to her husband.MD (Medical Doctor) made aware the resident hit the right side of the face / head during fall r/t (related to) incident. Hospice made aware and Daughter made aware. MD wanted resident sent to ER (Emergency Room) for eval and treatment regarding hitting head / facial area. DPOA (Durable Power of Attorney) declined to have resident sent and wanted hospice to eval and treat if necessary to send to ER for eval. Resident had slight redness to the right side of face near eye brow at time of incident but no swelling/ bruising/ redness at this time.Phone interviews with staff regarding incidents between R801 and R802 and R802 and R803:On 10/7/25 at 12:24 PM, a phone interview was conducted with Nurse 'B'. When asked to recall the events on 9/26/25 between R801 and R802, Nurse 'B' reported, Was doing my med pass and had my back turned and when I turned around I saw a CNA (Certified Nursing Assistant) on northwest (hall) closer to where the window was and saw him [R801] punch her [R802] in her face. The female patient was in her wheelchair and the male was over her. I separated them, contacted the DON, called 911, took pics and gave report number. I did my nursing note and head to toe assessment. Later on [R802] was sent to the hospital via EMS (Emergency Medical Services) and stated she had a fractured jaw.When asked if they could recall how [R802's] demeanor was, Nurse 'B' reported, She was visibly upset and said he hit me, he hit me. She just kept holding her face and said my face hurt. Nurse 'B' reported they did a head to toe assessment looking for any other bruising and got to tail end of it and she said 9/10 pain in her face. [R802] laid down and continued to complain of pain, think it was about 12 when she was transported to the hospital.When asked who they notified about the incident, Nurse 'B' reported, Between 5:27 PM when incident happened, Oakland county (police) came out did their report, contacted DON, on call nursing, pt continued to complain of pain and that's when 911 was called a second time and she was sent to hospital.When asked if they were aware of any other incidents between R801 and R802, Nurse 'B' stated, I have noticed she [R802] gets into it with a lot of patients. If others get too close, will throw water, grab pitcher of water.[R802] more so independent and more so gets into it with other residents. She has good and bad days.Nurse 'B' further reported, What kind of bothered me is I overheard other staff saying yeah that's what she get she's always doing that. When asked if they had every reported that to the facility, Nurse 'B' reported, I didn't, I was just upset. I think the staff that made that comment no longer works at that facility.When asked if they received any training about who to report to, and what the facility's expectations were for reporting abuse allegations, Nurse 'B' reported they did not receive any additional training. They reported they worked at the facility On and off and recalled they were in contact with the DON as the DON was very concerned about the incident between R801 and R802.When asked to confirm if there were any other incidents observed between R801 and R802 after the incident on 9/20/25, Nurse 'B' reported after this incident they were working on the unit and [R802] tried to have conversation with [R801] and {R802] was getting aggressive and Nurse 'B' had to tell her to calm down. Nurse 'B' further reported {R802] was trying to touch [R801] and he's getting upset and when {R802] reached out to touch the patient [R801] Nurse 'B' redirected [R802] to her room and [R801] calmed down.Nurse 'B' then reported [R803] was trying to push [R802] down the hallway (via wheelchair) and [R802] threw water on [R803] and seen her [R802] hit her [R803] a few times.When asked if that was reported to anyone, Nurse 'B' stated Honestly not. They further reported they were not sure if they came up to the unit to talk with staff and but they were not assigned to work that floor when they saw that.When asked if they could identify when they thought that resident to resident incident had occurred, Nurse 'B' reported they would review their schedule in their phone and they could tell the exact date from that. Nurse 'B' then reported it was within the last 2 weeks and reported, It was Friday 26th, the afternoon shift. That's when the incident between [R803] and [R802] happened. She [R802] got mad and I saw her hit [R803] on the arm. She [R802] kept hitting her. I said to [R802] you have to understand because [R803] just doesn't understand.When asked to confirm if they were assigned to that unit with R802 and R803, Nurse 'B' reported on that day (9/26/25) they worked on the first floor. Nurse 'B' further reported, I came upstairs and that's when I saw the interaction between the two residents. When asked if they could recall the time it occurred, Nurse 'B' stated, I wanna say it was probably after dinner, because I had just took my lunch break. I remember it was still light outside.On 10/7/25 at 1:20 PM, a phone interview was conducted with Nurse 'E'. When asked to recall their events of the incident between R802 and R803, Nurse 'E' reported, [R802] was my resident and the resident that got hit [R803] was not my resident. Was in middle of med pass and turned and looked and when seen resident {R803] on the ground, [R802] was thinking another resident was her husband and [R802] knocked her on the floor.[R802] been having a mental status change, this is new for her. When asked if they were aware of any other incidents between R802 and R803, Nurse 'E' reported, Believe it was probably just one. Heard about a resident to resident with [R802] sometimes she can be aggressive with other residents. I don't know. I think I can recall hearing something of hers from another nurse on another shift, or her past history. Just happened the other day. Don't want to speak on something I overheard.On 10/7/25 at 1:27 PM, a phone interview was conducted with Nurse 'T'. When asked to recall their events of the incident between R802 and R803, Nurse 'T' reported, I was assigned to [R803]. I was down the hall at the med cart and the other nurse I heard her yell out for me cause I heard a bump. She yelled out [Nurse 'T's' name] and I looked down and [R803] had both hands on the floor and her head was on the wall a bit. [R802] was kicking at her. It wasn't hard, only so much she can do in her wheelchair. I'm not sure how she got on the floor but ran down to separate them.When asked if they were familiar with R802 and R803's behaviors and if they were aware of any other instances between the two residents, Nurse 'T' reported they were not.Nurse 'T' further reported the hospice nurse came onsite to evaluate the resident and there was a small area in her eyebrow.On 10/7/25 at 2:40 PM, an interview was conducted with the Administrator (who also was the facility's Abuse Coordinator) and the Director of Nursing (DON). When asked to explain the details of the incidents between R801 and R802, the Administrator deferred to the documentation provided in their investigation file and what was reported to the State Agency.When asked about how it was determined the facility was not able to substantiate actual abuse had occurred between R801 and R802, the Administrator deferred to the documentation in their investigation file and State Agency portal and offered no further details. When asked about the discrepancies within the witness statements of what was actually witnessed and what was included in the investigation, they acknowledged the discrepancies but were not able to provide any additional explanation.According to the facility's policy titled, Abuse and Neglect dated 6/28/2025: .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Physical abuse includes but not limited to infliction of injury that occur other than by accidental means. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, roughly handling.

Based on observation, interview and record review the facility failed to timely identify and address the weight loss for one R25 of five residents reviewed for nutrition, resulting in the delay of an identified significant weight loss of -11.67% within six months and the delay of nutritional interventions implemented. Findings include: On 8/26/27 at 9:48 AM, R25 was observed laying down in their bed with their head slightly elevated sleeping with milk in their hand. R25's breakfast tray was observed uneaten in front of them. R25 was easily awaken with verbal stimuli. Once awake R25 did not respond to any questions, however continued to sip their milk. There was no staff observed in the room. On 8/26/27 at 9:48 AM, R25 was observed laying down in their bed with their head slightly elevated sleeping with milk in their hand. R25's breakfast tray was observed uneaten in front of them. R25 was easily awaken with verbal stimuli. Once awake R25 did not respond to any questions, however continued to sip their milk. A record review revealed R25 weighed 132 lbs (pounds) on 2/1/24, which was compared to the 8/4/24 weight of 116.6 lbs. This indicated a severe weight loss of -11.67% within 6 months. On 7/13/24 R25 weighed 122 lbs, compared to the 2/1/24 weight of 132 lbs, this indicated a -11.08 weight loss within five months. Further review of R25's weights revealed a gradual weight loss from April to August 2024, that was not timely identified. The facility staff failed to implement interventions to prevent further weight loss until 8/22/24. Review of the care plans revealed no additional nutritional interventions implemented and documented since 2023, prior to August 2024. Further review of the nutrition care plan documented an intervention to Provide assistance with meals as needed. Review of the facility policy titled Nutrition Monitoring & Management Program dated 8/1/24, documented in part . It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight . unless the resident's clinical condition demonstrates that this is not possible . Assessing the resident's nutritional status and the factors that put the resident at risk . Analyzing the assessment information to identify medical conditions . Monitoring and evaluating the resident's response or lack of response to the interventions . Revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches . Weight Loss . 10% in six (6) months, as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss, should be addressed in the care plan . Ongoing interventions are evaluated and modified as needed . Any resident that various from the previous reporting period . Will be evaluated by the Interdisciplinary Team . Once weight . loss is identified . Any resident meeting the criteria for weight loss and any at risk will be weighed weekly . R25 had not been weighed weekly and did not have orders to be weighed weekly at the time of the survey. On 8/27/24 at 1:02 PM, Registered Dietician (RD) C who was identified as the corporate dietician was interviewed and asked about the delayed identification of R25's weight loss and the delayed interventions implemented to prevent further weight loss. RD C stated they had started coming to the facility at the beginning of the month when the corporation they worked for took over the facility. RD C stated they could not answer for the previous Dietician, however implemented interventions once they identified the weight loss in August 2024. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of facility acquired pressure ulcers for two (R58 and R22) of two residents reviewed for pressure ulcers and failed to implement treatments in a timely manner (R58 and R22) and according to physicians orders (R58 and R22), ensure assessments of wounds were accurate (R58 and R22), and ensure oversight by a medical provider after the development of a pressure ulcer (R58), resulting in R58 developing a stage II pressure ulcer (partial-thickness skin loss with exposed dermis) that developed into a Stage IV pressure ulcer (Full-thickness skin loss) with acute osteomyelitis (bone infection) and R22 developing an unstageable pressure ulcer (Obscured full-thickness skin and tissue loss). Findings include: Resident #58 (R58) On 8/26/24 at 10:34 AM, R58 was observed positioned on his back in bed with his neck tilted to the right side with a tracheostomy tube (a tube inserted into the windpipe to provide breathing assistance) and a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to directly provide nutrition). When spoken to, R58 did not make eye contact and did not verbally respond to questions. On 8/26/24 at approximately 1:15 AM and 4:00 PM, R58 remained positioned on his back with his neck tilted to the right side. On 8/27/24 at 8:02 AM, 9:40 AM, and 10:32 AM, R58 was positioned on his back with his neck tilted to the right side. At 10:32 AM, Certified Nursing Assistant (CNA) 'H' entered R58's room to provide care. When CNA 'H' exited R58's room, he reported he cleaned R58 up and repositioned him. Upon observation at 11:01 AM, R58 remained positioned on his back the same as previous observations. On 8/27/24 at 4:43 PM and 8/28/24 at 8:04 AM, R58 was observed positioned on his back with his neck tilted to the right side. During all of the above observations, it appeared there were pillows underneath R58's knees and heel protectors on his feet, but no positioning devices were observed to off load pressure from the buttocks. A review of R58's clinical record revealed R58 was admitted into the facility on [DATE], and readmitted on [DATE] with diagnoses that included: diffuse traumatic brain injury with loss of consciousness, acute respiratory failure with hypoxia, type 2 diabetes, and seizures. A review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed R58 had severely impaired cognition, was dependent on staff for transfers, toileting hygiene, bed mobility, and did not walk. The MDS assessment indicated R58 did not have any pressure ulcers at the time of the assessment. A review of a History and Physical from a hospital admitted d 7/20/24 (the day R58 was transferred to the hospital from the facility) revealed, .CT (Computed Tomography) abdomen pelvis showed gluteal region decubitis ulcers to the left of the midline with an open wound and multiple gas locules extending deep to the coccyx (tailbone) with concern for osteomyelitis . A review of an Infectious Disease progress note dated 7/22/24 revealed, Impression and Plan .Septic shock secondary stage 4 sacral decubitis infection complicated with Proteus bacteremia . A review of Clinical Discharge Instructions from the hospital provided to the facility dated 7/23/24 revealed, .Discharge Diagnosis: Acute osteomyelitis .Sepsis .Plan of Care .Wound Care by nursing Start dt(date)/tm(time): 7/22/24 .DAILY - Irrigate sacral buttock wound with Dakins solution in a 10 ml (milliliter) syringe til clear. Then soak a 4x4 gauze in Dakins solution and wring it out, open it up and pack it into the wound undermining space. Cover with dry 4x4s, ABD (abdominal pad), secure with tape . Further review of R58's clinical record revealed the following: A review of a Nursing Admission Evaluation dated 6/11/24 revealed no documentation of any skin impairments to R58's sacrum or buttocks. A review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed R58 was at high risk for pressure ulcers based on a score of 11 (High Risk is between 10 and 12). A Skin assessment dated [DATE] revealed new abnormal skin areas to the left buttock and treatment was initiated. It was documented that wound care nurse aware. Stating that its MASD (moisture associated skin damage). There was no documentation of a full assessment of the wound on 7/2/24. A review of a Nurses' Note dated 7/3/24 revealed, .informed of Left buttock skin changes . A review of a Skin & Wound Evaluation dated 7/4/24 (two days after new abnormal skin areas to R58's left buttock were identified on the skin assessment) revealed R58 had a Stage 2 pressure ulcer to the right ischial tuberosity that was in-house acquired as of 7/3/24. It was documented that the pressure ulcer was staged by the in-house nurse and measured 7.7 centimeters (cm) in length by 3.8 cm in width with a depth of 0.1 cm. It was documented the wound was healable and that the medical practitioner (Physician 'K') was notified. It should be noted that the skin assessment dated [DATE] and the nurses' note dated 7/3/24 documented a skin impairment to R58's left side, not the right side. A review of R58's Physicians Orders and Treatment Administration Record (TAR) for July 2024 revealed an order to apply triad (a hydrophilic wound dressing) to the left ischium and to cover with bordered foam every night shift beginning on 7/4/24 and it was discontinued on 7/16/24. (It should be noted that it was documented on the Skin & Wound Evaluation that R58 had a Stage 2 pressure ulcer to the right ischial tuberosity.) A review of a Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] revealed R58 was assessed as very high risk for developing pressure ulcers, as evidenced by a score of six (a score of nine or below indicated very high risk). A review of a Nurses' Note dated 7/9/24 revealed, Resident seen by wound care r/t (related to) stage 2 on right ischium (hip bone). Upon most recent assessment wound was smaller, but wound bed contained slough and was slightly deeper and has now been changed to stage 3 (Full-thickness skin loss). Tx (treatment) changed to medihoney and calcium alginate with bordered foam dressing. A review of a Skin & Wound assessment dated [DATE] revealed R58 had a Stage 3 pressure ulcer to the right ischial tuberosity that was identified on 7/3/24 and measured 6.6 cm by 4.0 cm. It was documented depth was not applicable and 40 percent of the wound by filled with slough (a non-viable yellow, tan, grey, green or brown tissue that is usually moist and can be soft, stringy and mucinous in texture). It was documented the treatment was changed to medihoney and calcium alginate with bordered foam dressing. The assessment noted the practitioner was notified, but did not document the name of the provider. A review of R58's Physicians Orders and TAR for July 2024 revealed no change in treatment order until 7/16/24, seven days after it was documented the pressure ulcer worsened from a Stage 2 to a Stage 3 and there was to be a change in treatment. There was no order for treatment to the right ischium which was the location that was documented on the Skin & Wound assessment. The treatment implemented on 7/4/24 for the stage 2 pressure ulcer remained in place until 7/15/24. On 7/10/24 and 7/15/24, the physician ordered treatment was not administered as evidenced by no nurses' signature on the TAR. The treatment was changed on 7/16/24 to Honey gel followed by calcium .to left ischium .cover with bordered foam dressing . and was discontinued on 7/21/24 after R58 was transferred to the hospital. A review of a Skin & Wound Evaluation dated 7/18/24 revealed R58 had an unstageable pressure ulcer to the left ischial tuberosity that was in-house acquired since 7/3/24. The wound was staged by in-house nursing and measured 6.0 cm by 4.5 cm. The wound was 90 percent filled with slough and therefore the depth of the wound was unable to be determined. It was documented the wound was healable and the treatment was not changed at that time. It was documented Physician 'K' was notified. A review of a second Skin & Wound Evaluation dated 7/18/24 revealed R58 had a Stage 2 pressure ulcer to the right ischial tuberosity that was in-house acquired that measured 0.7 cm x 0.4 cm. Treatment included zinc barrier cream and bordered gauze dressing which, according to physicians orders, was ordered on 7/18/24 and discontinued on 7/20/24. A Skin & Wound Evaluation dated 7/25/24 noted the pressure ulcer to the right ischial tuberosity was resolved on that date. A review of R58's TAR for July 2024 revealed an order to check placement of right ischial dressing started on 7/6/24 and discontinued on 7/15/24 and an order to check the placement of left ischial dressing started on 7/16/24 and discontinued on 7/21/24. Further review of R58's progress notes revealed R58 was transferred to the hospital on 7/20/24. A review of a Nursing Admission Evaluation dated 7/23/24 (upon readmission from the hospital) revealed R58 had a pressure ulcer to the coccyx. A review of a Skin & Wound Evaluation dated 7/25/24 revealed R58 had a Stage 4 pressure ulcer to the left ischial tuberosity, present since 7/3/24 (it should be noted that it was previously assessed to be on the right side) that measured 5.6 cm x 3.8 cm with 3.8 cm of undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface). It was noted the would was 80 percent filled with slough with heavy exudate (drainage). There was no documentation of treatment and it was noted that the practitioner was notified. Further review of R58's Physician's Orders and TAR for July 2024 revealed no treatment order was put in place for R58 until 7/25/24, two days after he was readmitted into the facility with a diagnosis of acute osteomyelitis. On 7/25/24, the treatment ordered was Cleanse with wound cleanser. Pat dry. Apply Honey Gel as directed to left ischium and pack wound with calcium alginate. Skin barrier wipe to peri wound. Cover with bordered foam dressing. Every night shift for wound care. This order remained in place until it was discontinued on 8/12/24. The treatment was not done on 7/28/24, 7/29/24, and 7/31/24. It should be noted that this was not the same order documented in the hospital discharge instructions/plan of care that noted, Irrigate sacral buttock wound with Dakins solution in a 10 ml syringe til clear. Then soak a 4x4 gauze in Dakins solution and wring it out, open it up and pack it into the wound undermining space. Cover with dry 4x4s, ABD, secure with tape. A review of all progress notes for R58 revealed R58 was seen by a physician 'I'on 6/20/24 for a competency evaluation and on 6/26/24 for a History and Physical. There was no documentation in the electronic medical record that indicated R58 was evaluated by a medical practitioner after 6/26/24 and not after the development of a pressure ulcer that continued to worsen from a Stage 2 to a Stage 3/Unstageable and then a Stage 4 pressure ulcer on the day R58 arrived at the hospital. The next time R58 was evaluated by a medical provider was on 8/13/24 when he was seen by the wound physician. On 8/27/24 at 3:01 PM, an observation of R58's pressure ulcer was made with Licensed Practical Nurse (LPN) 'L' who was the Wound Care Coordinator for the facility. The wound was observed to be on the left buttock area, approximately nickel sized, packed with gauze with an undetermined depth. On 8/28/24 at 8:54 AM, an interview was conducted with the Director of Nursing (DON). When queried about whether residents with pressure ulcers received evaluations by a medical provider, the DON reported the facility had an issue with some of the physicians seeing residents in a timely manner. When queried about whether the facility contracted with a wound provider, the DON reported the facility hired a wound physician on 8/1/24 and he started seeing residents on 8/13/24. The DON explained that Licensed Practical Nurse (LPN) 'L' was the Wound Care Coordinator for the facility. On 8/28/24 at 9:20 AM, an interview was conducted with LPN 'L' who reported she was wound care certified. When queried about her role, LPN 'L' reported she rounded with the wound care provider weekly, but if there was no wound care provider, she would still assess the wounds. When queried about the facility's protocol when a new skin impairment was identified, LPN 'L' explained the nurse wrote it on the wound care log or told LPN 'L' in person and the nurse would start a treatment. LPN 'L' further explained that when she was at the facility she would assess the wound and ensure the proper treatment was in place. When queried about any new interventions that were put in place for R58 after he developed a pressure ulcer to the left ischium, LPN 'L' reported she would look into it. At that time, it was requested that LPN 'L' provide information about what interventions were put into place on 7/2/24 when R58 was first identified to have skin impairment to the left buttock, on 7/4/24 when it worsened to a Stage 2, on 7/11/24 when it worsened to a stage 3, and on 7/18/24 when it was identified as an unstageable pressure ulcer. LPN 'L' reported she would look into it. When queried about the confusion about what side of R58's body the worsening pressure ulcer was, LPN 'L' reported it was her mistake and the existing pressure ulcer present on the left ischium was also the first one that developed on 7/4/24 and she did not document the correct side in her assessment. When queried about how R58 should be repositioned due to his lack of mobility and tracheostomy status, LPN 'L' said it was hard to reposition him on his side due to the trach, but he should be repositioned with devices to off load pressure. When queried about how residents were monitored to ensure interventions were implemented according to the residents' plan of care, LPN 'L' reported nurses were responsible to monitor the CNAs and LPN 'L' will make observations as well. When queried about whether R58 was evaluated by a medical provider related to the pressure ulcer, LPN 'L' reported he was seen for the first time in the past couple weeks because the facility did not have a wound provider. LPN 'L' was not sure if R58's wounds were evaluated by an attending physician in the absence of a wound provider. LPN 'L' reported she notified the attending physician by writing it in a log if a new wound has developed or it worsened and that it was also discussed during the daily interdisciplinary team meetings. On 8/28/24 at 11:25 AM, the DON and LPN 'L' reported they did not see any additional interventions implemented for R58 after the development of the pressure ulcer to the left ischium. They also confirmed there was no documented evaluation by a medical provider until 8/13/24 which was after R58 developed a stage 2 that worsened to a stage 4 with osteomyelitis. When queried about the treatments not being implemented timely after each worsening stage of the wound, no explanation was given. Resident #22 (R22) On 8/26/24 at 12:04 PM, an interview was conducted with R22's family member who revealed a concern that the facility was keeping R22 up in the wheelchair for too long which resulted in a healed pressure ulcer reopening. R22's family member reported there were physicians orders to keep her out of the chair but staff are inconsistent with following the orders. On 8/27/24 at 8:01 AM, R22 was observed seated in a geriatric chair (reclined chair) in her room. At 9:39 AM, 10:34 AM, 12:57 PM, and 1:30 PM, R22 remained seated in the chair for a total of five and a half hours. A review of R22's clinical record revealed R22 was admitted on [DATE] with dementia and type 2 diabetes and signed onto hospice on 4/27/24. A review of R22's MDS assessment dated [DATE] revealed R22 had severely impaired cognition, was dependent for transfers, required substantial/maximal assistance for bed mobility, was incontinent of urine and stool, and had no unhealed pressure ulcers. A review of R22's Physicians Orders revealed an active order started on 8/22/24 that read, Resident to be assisted to bed between meals every shift for wound prevention. A review R22's TAR for August 2024 revealed the order was not carried out on on all shifts on 8/23/24, 8/24/24, and 8/25/24; and it was not done on 8/27/24 during the day shift. A review of a Skin Observation Tool dated 8/17/24 revealed no documentation of a skin alteration to R22's sacrum or coccyx. A review of a Skin Observation Tool dated 8/23/24 revealed R22 had a new alteration in skin integrity which was documented as a small wound to the coccyx. Prior to that date there were no new skin alterations documented on the weekly skin observation tools. A review of a Skin & Wound Evaluation dated 8/20/24 revealed R22 had a new unstageable pressure ulcer to the sacrum that was 14 days old and measured 5.55 cm by 3.24 cm with 100 percent slough tissue. A review of R22's progress notes revealed no documentation of a wound to the sacrum prior to 8/26/24 when the following was documented, Resident seen by wound care r/t .unstageable pressure injury to the sacrum .Medihoney and calcium alginate with bordered foam dressing ordered to sacrum . A review of R22's Physician's Orders and August 2024 TAR revealed an order with a start date of 8/20/24 (It should be noted that the assessment done on 8/20/24 noted the pressure ulcer had been present for 14 days) for Honey gel to wound bed followed by calcium alginate and cover with bordered foam dressing every night shift and PRN (as needed) . A review of the August 2024 TAR revealed the treatment was not administered on 8/20/24, 8/21/24, and 8/23/24. Prior to 8/20/24, there was an order to apply zinc barrier cream every shift to the coccyx and sacrum that was started on 6/13/24 after R22 had a stage 2 pressure ulcer to the same area that was resolved. This order was discontinued on 8/27/24 but remained in place in addition to the treatment implemented on 8/20/24 through 8/27/24, which would have instructed nurses to administer two separate treatments to the area. On 8/28/24 at 9:59 AM, an observation of R22's pressure ulcer to the coccyx was conducted with LPN 'L'. Upon observation, there was no dressing on R22's coccyx wound. A half dollar sized unstageable pressure ulcer covered with yellow slough was observed. LPN 'L' reported the wound should have had a dressing applied. There were no loose dressings observed in R22's chair or bed. On 8/28/24 at 11:20 AM, an interview was conducted with the DON and LPN 'L'. When queried about when R22's sacral pressure ulcer was first identified, LPN 'L' reported she first assessed it on 8/20/24. LPN 'L' did not have an explanation as to why it was documented the wound was present for 14 days. When queried about the skin assessment dated [DATE] that did not identify any skin alterations to R22's coccyx/sacrum and whether LPN 'L' assessed it prior to becoming an unstageable pressure ulcer, LPN 'L' reported when she assessed the wound, it was already an unstageable pressure ulcer. Both the DON and LPN 'L' reported any changes in residents' skin should be immediately identified and reported to the DON and LPN 'L'. LPN 'L' reported on 8/20/24 she put an order in place for R22 to be laid down in between meals and the expectation was that the order was followed. A review of a facility policy titled, Skin Monitoring and Management - Pressure Ulcer, adopted 7/11/18, revealed, in part, the following, . A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation, or discoloration or other unusual findings must be documented in the resident's clinical record .A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each wound, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to .describing the location of the wound .describing the progress with healing, and any barriers to healing which may exist .Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order .All wound or skin treatments should be documented in the resident's clinical record at the time they are administered .In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: .Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition .Reposition the resident .Use pressure relieving/reducing and redistributing devices .If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative nurse's note documenting the notification .Re-evaluate existing treatment regimen in connection with the resident's clinical presentation .if any wound .is worsening .

Based on observation, interview and record review the facility failed to provide safe, appropriate monitoring/supervision/interventions for a resident that had a physician order for NPO (non-per-oral/nothing by mouth) from being fed by family member(s), resulting in an Immediate Jeopardy for one (R53) out of six residents reviewed for accidents. R53 was sent to the hospital on at least two occasions (7/10/23 and 7/12/23) for a decrease in oxygen saturation after being fed by family member(s) and the likelihood of possible aspiration, choking and/or other negative consequences. This deficient practice placed all residents with a NPO order at high risk for further safety concerns, significant harm, injury and/or death. Findings include: Immediate Jeopardy (IJ): The IJ began on 4/29/23. The IJ was identified on 7/13/23. The Administrator was notified of the IJ on 7/13/23 at approximately 10:56 AM and a plan to remove the immediacy was requested. The immediacy was removed on 7/13/23 at approximately 3:41 PM based on the facility's implementation of an acceptable plan of removal as verified on site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. On 7/11/23 at approximately 10:03 AM, R53 was observed lying in bed. By the resident's side was a tube feeding pole. No tube feeding was running at the time of the observation. The resident was alert, but not able to answer any questions asked. An initial review of the resident's clinical record was conducted on 7/11/23 and revealed R53 was initially admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease, cerebrovascular accident (CVA), epilepsy and dysphagia (difficulty swallowing). A review of the resident's Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely cognitively impaired, required extensive one to two person assist for most activities of daily living, and received nutrition via a feeding tube. Continued review of R53's clinical record noted, in part: Order (6/22/23): NPO Diet. NPO texture related to Dysphasia following cerebral infarction. Nutritional Data Collection/Evaluation (6/27/23): .Resident is NPO with Osmolyte 1.5 via pump per PEG (Percutaneous endoscopic gastrostomy) @85 mL (Milliliters)/hr (Hour) x 18 hours per day to provide 1530 mL . Care Plan: Focus: The resident needs ADL (Activities of Daily Living) living assistance related to CVA diagnosis, Epilepsy, dysphasia .dependent on staff .Interventions: .Eating NPO (date initiated 3/30/23) . Care Plan: Focus: The resident is at risk for nutritional decline .receives 100% via formula. NPO status in place. Resident's family is known to bring in foods from outside even though resident is NPO, family has been educated multiple times .Interventions: Residents family is known to bring in foods from outside even though resident is NPO, family has been educated multiple times (5/2/23) . Care Plan: Focus: The resident has a potential psychosocial well-being problem r/t (related to) family not understanding disease process and diagnosis, mother states she gives him bites of pudding even though resident is NPO .Intervention: Educate family on risk vs benefit on not adhering to NPO order, including aspiration pneumonia, hospitalization and other further complications (3/30/23) . Progress Notes included: 4/27/23: Enteral Review: .Current PO order: NPO . 4/29/23: Nurses' Notes: .resident mother told care team member she fed him a baked potato and eggs . (Authored by Nurse J) 4/30/23: Nurses' Note: resident mother observed preparing to feed him .was asked to not feed him due to NPO status at that time she stated that she will speak to director regarding the issue . (Authored by Nurse J). 5/1/23: Nurse's Note: Writer spoke to resident's mother in regards to feeding resident food by mouth. Resident has trach and impaired speech/swallowing ability. Resident is an aspiration precaution is not able to form words. Resident's mother educated to NPO status, PEG tube feeding, Speech therapy evaluation, and the importance of healthcare compliance. Resident's mother continued to see no issue with her feeding the resident despite education . (Authored by the Director of Nursing/DON). 6/20/23: Nutrition-Hydration: .Interventions: NPO diet . 7/6/23: Nutrition-Hydration: .resident was readmitted .Interventions: NPO diet . 7/10/23 (3:00 PM): Patients family came in and against advice .fed him pureed foods. (Authored by Nurse K). 7/10/23: Nurse's Note: Patient was having trouble breathing. O2 (oxygen) at 80-84% not improving. MD (Medical Doctor), DON aware and family notified by message. Pt (Patient) otherwise alert and no extreme distress but does c/o (complain of) of SOB (shortness of breath) and lung sounds coarse all fields with wheezing . 7/12/23: Nurses' Note: Patient family keeps coming in and feeding patient against the advice of nurse. Patient later experienced wheezing and was in need of breathing treatment . 7/12/23: Nurses' Note: Contacted the Dr. Waiting on response. 911 called. 7/12/23: Social Service General Note: .Situation-New, follow-up, ongoing: Regarding outside foods.writer contacted (name redacted) R53's mother @ 4:30 PM today to set up a follow-up care-conference on Friday @ 10:30 .education or services provide: family has been educated on feeding patient puree food only . On 7/12/23 at approximately 3:10 PM, R53 was not observed in their room. On 7/12/23 at approximately 3:18 PM an interview was conducted with Nurse K. When asked as to where R53 was, Nurse K reported that he was sent to the hospital. When asked why, Nurse K reported that the family had come to the facility and fed the resident. Nurse K stated that after feeding the resident his O2 states dropped, he was wheezing and the physician ordered him out to the hospital. When asked if they were aware that R53 had an order for NPO, they reported that they were aware. Nurse K further stated that the resident's mother seemed to ignore the order and education provided to them. When asked if they knew what the family member fed to the resident, they stated they knew that the resident received cookies and milk but did not know any other food that was fed to him. Nurse K was asked if they were aware of this happening prior to 7/12/23, they noted that the same thing happened on Monday (7/10/23) and the resident was sent to the hospital again after his O2 levels decreased and he was wheezing. Nurse K reported that they informed the DON of what had happened. When asked about the education provided to them and the family, Nurse K reported that they were aware the resident was NPO and they had not provided any food/drinks to the resident. With respect to the family, Nurse K noted that the family had been instructed several times not to feed the resident and were uncooperative. Nurse K further noted that they were fearful that the resident's mother also brushed the resident's teeth with toothpaste and had him swallow water. On 7/12/23 at approximately 3:30 PM, a phone interview was conducted with the Speech/Language Pathologist (SLP L). SLP L reported that they are not employed by the facility and was hired to work as needed until the facility hired a full-time speech therapist. SLP L was asked if they worked with R53 and whether they were aware of the resident's family history of feeding the resident even if he is NPO. SLP L reported that they had completed a review of the resident's record and before they started working with him, they ordered a swallow study. According to SLP L the Swallow Study recommended a trial for thin liquid and pureed food. After the study SLP L stated they started to work with R53 by providing a half teaspoon of water and providing small bites of apple sauce and pudding. SLP L stated they wrote up a plan for R53 and had the family come in as they watched how they fed the resident. SLP L reported that on or about 6/29/23, the family was present in the building and watched as they fed R53 2 ounces of applesauce and a small sip of water with a spoon. The resident was in an upright position as he was being fed. SLPL stated that on 6/29/23 they asked the family to continue to wait before they fed the resident. SLP L reported that the last time they saw R53 was on 7/3/23 and he consumed strawberry apple sauce with a small spoon and water with a teaspoon. SLP L stated that on 7/6/23 they were asked to come to talk with the family because the DON needed to be in agreement with the family. They indicated they talked with the resident's sister and the DON and informed them that the only time the resident could eat was if he was in an upright position. At that time they thought it was acceptable to allow the family to provide pureed food and thin liquid. SLP L reported that R53's sister asked if they could bring in ice cream and Vernor's soda and baby food with curry. They stated that they told the family no meat and the resident nodded their head indicating they did not want curry. SLP L indicated that they believed the family had a clear understanding of what could be provided to the resident. However, SLP L stated that they had recently been informed from the DON (approximately one hour prior to the interview) that the family had provided unapproved food and the resident was sent to the hospital. When asked about the food provided to the resident on 7/10/23, SLP L reported that they were not aware that the family had provided food to the resident or that the resident was then sent to the hospital. A follow-up phone call was made with SLPL on 7/12/23 at approximately 4:25 PM. SLP L was asked where in R53's clinical record would the surveyor be able to view their notes pertaining to the resident. SLPL recommended obtaining the documents from either the Administrator or the therapy department. SLP L was also asked as to whether they had any contact with R53's treating Physician (hereinafter Dr. N) regarding allowing family to provide food to the resident. They were also asked if the treating physician had changed the resident's NPO order. SLP L stated that they never had any contact with Dr. N. On 7/12/23 at approximately 4:26 PM, Physical Therapy Staff M provided SLP L's notes. The notes were reviewed and documented, in part, the following: 6/27/23: .PEG tube provides nutrition. Therapeutic trials by SLP L educated the patient's nurse regarding the results of the MBSS (Modified Barium Swallow Study), recommended for trials by SLP .Pt. tolerated 10 small bites of pudding .oral movements were slow and labored .required verbal cues to move the pudding to the back . 6/29/23: .Patient was seated on the edge of the bed .His mother, sister, brother and niece were present for the Dysphagia treatment session. SLP provided education .Family was educated that only therapeutic feeding with SLP are approved at this time, family was asked not to feed him liquids/solids until SLP provides approval .Family offered to bring in some of patient's favorite foods, such as curry .for the SLP to use during sessions . 7/3/23: .Patient was difficult to understand when he spoke more than one word .Patient tolerated 1.5 oz of thin liquid .he required verbal cues 50% of time .Patient tolerated 2.5 oz of applesauce with tsp .His swallow trigger was delayed between 1-5 seconds; verbal cues to move food back of mouth and swallow .Provided instruction to patient with nursing staff in safe swallow strategies specifically, only therapeutic feedings with SLP, family may not feed patient at this time (emphasis added) . *There were no further documents provided by Staff M that noted SLP L had met with the resident, facility or resident family. On 7/13/23 at approximately 4:00 PM, a single sheet of paper from SLP L was provided that documented only one sentence as follows: Missed visit #1 for R53 on 7/6/23. Consulted with DON and called family to communicate that it is acceptable for him to enjoy PUREE FOODS and THIN LIQUIDS by cup or spoon when upright. No straws. Prefer patient is seated in a w/c (wheelchair) or side of bed for oral intake. DON to educate nursing staff. On 7/12/23 at approximately 4:39 PM, a phone interview was conducted with Dr. N. Dr N reported that she was familiar with R53 and the family. Dr. N was asked if they were aware that R53's family was feeding him even though they had issued an order for NPO. Dr. N reported that they were aware that the family had attempted to feed the resident in the past. They indicated that R53 had under gone a swallow study and had been working with SPL L on a specified pureed diet however, the NPO order had not been changed. When asked if they felt the family member could feed the resident, Dr. N reported no not until there was additional training and they were assured that they were following an ordered care plan. On 7/13/23 at approximately 8:41 AM, an interview and record review were completed with the DON. The DON was queried as to R53 and his family who continued to feed the resident even though he was still NPO. The DON reported that the family was found feeding the resident food by mouth a few months ago even though the resident was NPO. The DON indicated that the family was providing solid food to the resident and was educated not to do so as it was a risk to the resident. When asked about the two dates (7/10/23 and 7/12/23) that noted the resident was fed again by family members and subsequently sent to the hospital, the DON reported they were aware of both incidents. The DON also reported that the Hospital reported that they were aware family was feeding R53 despite NPO status. When asked what the facility did after they discovered the family was feeding food to the resident, the DON reported that they had set up a care conference meeting with the family on 7/14/23 to educate the family again on not feeding the resident. The DON was asked to provide hospital records for R53, including, but not limited to 7/10/23 and 7/12/23. On 7/13/23 at approximately 10:24 AM, a phone interview was conducted with family member (FM) O. FM O reported that the resident had been at the facility since March 2023. They noted that they had concerns about the air quality at the facility and the resident's cough. FM O was asked if they were aware of the resident's NPO order. FM O reported that the resident had been evaluated by the Speech Therapist and the family was told that R53 was on a soft diet and could be fed unsupervised if they used a small spoon. When asked about the foods they fed to the resident, FM O reported that yesterday (7/12/23) they fed R53 whipped potatoes and a sweet potato. They also noted that they were given milk by the facility and they poured the milk on top of a Windmill cookie. When asked if they were aware the facility knew what they had fed to R53, FM O reported that they were not sure, and stated that they went into the room to feed the resident and he then had a hard time breathing and the staff came in and gave him oxygen and then he was sent to the hospital. FM O noted that at the hospital they thought it was just a cough. They reported they knew the facility thought that he had aspirated, but the two times that happened, they thought it was just a respiratory issue. On 7/13/23 at approximately 11:48 AM, an interview was conducted with Nurse J. Nurse J was queried as to R53 being fed by family members. Nurse J reported that they were aware the resident was NPO and that the family had brought food in the past and continued to do so. Nurse J noted that they were aware that speech therapy had started feeding the resident and was not certain whether family was allowed to do so on their own as they had been off work for a few days. When asked if they had been trained to work with the family regarding feeding, Nurse J reported that if we noticed the family was feeding the resident they would try to redirect them, however it was often they would not listen. On 7/13/23 at approximately 2:40 PM, the Administration interview was interviewed. When asked if they were aware family had been bringing food into the facility and feeding R53 who was NPO, the Administrator reported that the issue had not initially been brought up in QA (Quality Assurance) meetings. The Administrator reported that they became aware of the concern after R53 had completed their swallow study and the family wanted his peg tube removed. On 7/13/23 at approximately 2:41 PM an interview was conducted with RD Q. RD Q reported they started working at the facility in February 2022. When asked about R53's swallowing and nutritional Status, RD Q reported that to her knowledge the resident was still NPO and they were working with the resident via feeding via a peg tube only. When asked if they were aware that R53's family had been feeding them food, RD Q reported they were not made aware until today (7/13/23). Additional requests were made to the DON to provide hospital records for R53. The DON reported that they were not able to retain any records pertaining to the swallow study and emergency department (ED)/hospital records with the exception of the following: 3/28/23: Medication Discharge Report *This report contained only medication to continue being taken by the resident. 6/22/23: Medication Discharge Report. *This report contained only medication to continue being taken by the resident. 5/31/23: Patient Discharge Instructions: Discharge Diagnosis: Aspiration pneumonia. *This report did not contain any notes from the hospital or detailed instructions. 7/12/23: Discharge instruction: I spoke with the patients mother. He has a history of asthma and was previously on Advair and Singular .please consider this cough may be related to underlying asthma . *This report did not contain any further notes from the ED. A review of the facility policy titled, Accidents and Supervision (revised 8/11/22) noted, in part: Policy: .Accident: refers to any unexpected or unintentional incident, which results in injury or illness to a resident .Risk refers to any external factor, facility characteristic (e.g. staffing .) or characteristic of an individual resident that influences the likelihood of an accident .Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .Identification of Hazards and Risks .All staff .are to be involved in observing and identifying potential risk of resident having an avoidable accident .the facility should make a reasonable effort to identify the hazards and risks in the resident environment .these sources may include, but are not limited to: i. Quality assessment and assurance (QAA) activities .Medical History .Physical exam .facility assessment .individual Assessment .Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents .Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk .Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: a. Communicating the interventions to relevant staff. b. Assigning responsibility. c. Providing training as needed. d. documenting interventions .e. ensuring interventions are put into practice .g. Developing of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility based-interventions may include but are not limited to: i. Educating Staff .i. Resident-directed approaches may include: 1. Implementing specific interventions as part of the plan of care. ii. Supervising staff and residents .Monitoring and Modification - a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of interventions. 5 Supervision: Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment . Removal Plan for IJ for F689: The facility identified the resident R53 was being fed by family on 4/29/2023, while the resident had NPO orders, the family was educated that they could not feed resident while NPO order was in effect and family continued to bring in food. The following were implemented immediately as listed below: - A Licensed Nurse examined resident #53 on 7/13/23. No adverse effects were found. - On 7/13/23, the Registered Dietitian (RD) audited all NPO residents to ensure accuracy, audited if any resident are receiving food or drink while on NPO diet and ensure care plan matches NPO status. - On 7/13/23, the Resident's family members were informed that they are not allowed to bring in food inside the facility and assist resident with meals while resident is NPO status. The Family members are also notified that all visits will be in the common area and in if they continue to feed the resident, all future visits will be supervised and/or visits will be suspended. The Guardian agreed to the terms on 7/13/23. - The receptionist at the front door will ensure R53 Family members do not bring food into the facility between the hours of 7am-8-pm, Nurses will oversee the 8pm-7am. - Facility started education with staff on 7/13/23 to include: - What is NPO Diet - Where to find diet order - If your unable to find a Diet order contact the nurse or RD - If the resident or visitor is not following diet orders what are the next steps - As of 7/13/2023, 18 of 36 Clinical staff have been educated. No nurses or Certified nurse aides will work without receiving education. - An AD Hoc QAPI (quality assessment and improvement performance) was held on 7/13/23. - Beginning on 7/13/2023, DON/Designee will audit new NPO diet orders M-F to ensure diets are being followed per the physician order. The RD and Unit Manager will round during meal to ensure compliance.

Based on interview and record review, the facility failed to ensure physician ordered laboratory tests were completed for two (R161 and R23) of two residents reviewed for laboratory services, resulting in a delay in detecting low hemoglobin levels in R161 which resulted in the need for a blood transfusion and hospital admission. Findings include: Review of R161's clinical record revealed R161 was admitted into the facility on [DATE], readmitted on [DATE], and was discharged to the hospital on 4/2/22 and on 4/12/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R161 had intact cognition. Review of R161's Physicians Orders revealed the following orders: An order dated 3/29/22 for cbc (complete blood count) vitd (vitamin D) one time only for [CONDITION(S)] until 03/30/2022. An order dated 3/31/22 for cbc one time only for [CONDITION(S)] until 04/01/2022. Review of R161's progress notes revealed the following: A Social Services Progress Note dated 3/28/22 documented, Care Conference held 3/24/2022 .(resident's family member) inquired about law <sic> draws, informed that labs are taken upon admission and by [CONDITION(S)], SW (social work) to follow up on how often lab draws are done with [CONDITION(S)]. A Social Services Progress Note dated 3/28/22 documented, .SW informed [CONDITION(S)] draws labs once per month and prn (as needed). (R161's family member) requested for labs to be drawn biweekly, stated resident has h/o (history of) needing blood [CONDITION(S)]. SW to inform IDT (interdisciplinary team). A Nurses' Note dated 3/29/22 documented, Resident lying in bed. Alert to verbal stimuli. Son with <sic> concerned about hemoglobin of the resident. Spoke with Physician T and aware of son's concerned <sic> . A Transcribed physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Chief Complaint/Nature of Presenting Problem: .[CONDITION(S)] .said she feels tired .Labs: Labs pending .Plan: .history of [CONDITION(S)] stat (immediately) labs ordered waiting for the results rule out any drop in hemoglobin . A Nurses' Note dated 4/2/22 documented, .Resident complaining that her hands and feet are cold. Family request to send her out to (hospital) for blood draw. Spoke with NP (Nurse Practitioner). Resident okay to send her out per family request .Transfer out .at 12:44 PM . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .In the emergency room her hemoglobin (HGB) was 5.8 (grams/deciliter - normal range is 11.59-15.11 g/dl) .Blood transfusion her hemoglobin went up to 8 (g/dl) .Plan: Acute on chronic blood loss [CONDITION(S)] multifactorial [CONDITION(S)] of chronic disease in the setting of end-stage [CONDITION(S)], possible underlying upper GI (gastrointestinal) bleed, patient got 1 unit packed red blood cells in emergency room patient hemoglobin went up to 8.6 (g/dl) . Review of R161's Admission Paperwork from the hospital when readmitted into the facility on [DATE] revealed the following: An Admission Worksheet documented, .Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/8/22 at approximately 12:00 PM, the results from the above-mentioned physician ordered laboratory tests (CBC) from 3/29/22 and 3/30/22 were requested from the DON. On 6/8/22 at 1:15 PM, the DON provided laboratory test results from 3/22/22 and 3/24/22 and reported she was unable to find results from the labs ordered on 3/29/22 and 3/31/22 and was not sure if they were drawn. The DON reported she contacted the [CONDITION(S)] agency and they did not have any laboratory tests for 3/29/22 and 3/31/22. Review of the laboratory test results from 3/22/22 revealed R161's HGB was 8.67 g/dl (low) and was 8.12 g/dl (critical low) on 3/24/22. On 6/8/22 at 1:30 PM, an interview with DON was conducted. When queried about the facility's process for residents who required laboratory tests, the DON reported if the physician wants a laboratory test, the nurse entered the order. The DON explained labs were drawn by a contracted company on Tuesdays and Thursday unless it was a STAT order. If it were a STAT order and the lab company was unable to come out on an immediate basis, the resident would be sent to the hospital. R161's lab results from 3/24/22 were reviewed with the DON. When queried as to whether the physician was notified of the critical HGB result, the DON reported that due to R161 being on [CONDITION(S)] her HGB ran lower. When queried about whether the physician should still be contacted, the DON did not offer a response. At that time, the DON was queried about why the physician ordered laboratory tests for R161 for 3/29/22 and 3/31/22 were not done. The DON reported because of the resident's history of low HGB, the family wanted to send her out before we were able to get the lab company out to draw R161's blood. On 6/8/22 at 4:00 PM, an interview was conducted with Physician T via the telephone. When queried about whether they were notified of R161's critical HGB level on 3/24/22, Physician T reported a HGB of 8.1 was not critical for a resident who received [CONDITION(S)], but they should have notified them. When queried about whether they were aware that the ordered labs were not completed from 3/29/22 and 3/31/22, Physician T reported their note documented a HGB level of 8.6 from 3/29/22, but they did not have a laboratory report to corroborate that value. Physician T further reported that there was a problem with the laboratory company coming to draw labs timely. Physician T stated, We call and call and they don't come. They say they are coming and they don't come. When queried about the progress note written by Physician T that mentioned waiting for STAT labs and that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/9/22 at 10:49 AM, an interview was attempted via the telephone with Nurse U. Nurse U was not available for an interview prior to the end of the survey. R23 On 6/9/22 at approximately 8:00 AM, a list of residents who had physicians' orders for laboratory tests in the last 30 days was requested. R23 was listed as a resident who currently had a laboratory test pending. Review of the Order Listing Report provided by the facility revealed R23 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R23's clinical record revealed R23 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/9/22 at approximately 11:00 AM, the DON was asked to provide the laboratory results of the tests ordered for R23 on 6/2/22. On 6/9/22 at 11:38 AM, Nurse S, who was assigned to R23 on that day, was interviewed. When queried about the process for obtaining physician ordered laboratory tests, Nurse S reported they were pulled up in the electronic system or faxed by the lab company and whoever gets them, brings them to the unit. When queried if there were any lab results for R23, Nurse S reported she did not have access to the laboratory system and the clerical nurse got all of the lab results from the fax machine. Nurse S reported that if there were any abnormal results, the physician would be contacted, otherwise they were placed in the physician's book to be reviewed and signed, then scanned into the record. When queried about who was responsible to follow up on labs that were previously ordered and still active in the physician orders, Nurse S reported it would be the nurse who entered the orders. On 6/9/22 at 11:45 AM, the DON was further interviewed about how the facility tracked what laboratory tests needed to be done and the results. The DON reported any labs were placed into a binder which would specify who needed blood drawn and who was pending results. When queried about R23, the DON reported since the lab company came on Tuesday and Thursday, R23's lab tests should have been drawn on 6/7/22. At that time, the DON reported she was still trying to find information about whether R23's ordered labs were completed. On 6/9/22 at 12:13 PM, the DON provided a Blood Requisition form for R23 dated 6/2/22. The DON reported she could not locate the results, the blood was not drawn, and they were now going to order STAT labs for R23. Review of a facility policy titled, Laboratory and Diagnostic Guidelines, revised 1/1/22, revealed, in part, the following: .When a new order for labs/diagnostics is received the nurse should review previous orders for like test to determine if there is conflict, overlap, or rescheduling required .STAT labs may be obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .The physician should be notified of all lab/diagnostic test results based on the below parameters .Critical lab results or urgent diagnostic should be called to the physician upon receipt .Non-critical or non-urgent test results that are abnormal should have physician notification within 24 hours unless the physician has provided specific notification parameters .All notifications, attempts at notifications, and response should be noted in the resident's medical record .

Based on observation, interview and record review the facility failed to ensure appropriate supervision per plan of care during peri-care to prevent a fall for one (R807) of four residents reviewed for falls, resulting in R807 falling and sustaining a left femoral neck fracture that required hospitalization for further evaluation. Findings include: Review of R807's progress notes included an entry on 11/8/21 at 10:40 PM, authored by Registered Nurse (RN 'I' which read, Date of Fall: 11/08/2021 .Situation Details: 9:30pm. Called by assigned Cena (Certified Nursing Assistant).Resident lying in the floor .near her bed .Per cena While changing her brief resident tried using her strength to pull her leg up, one the other after turning to right side her body.Weight went with her .Resident didn't hit her head .No change in loc .No change in baseline ROM.Resident with hx of of pain and discomfort upon turning . Assessment: transferred to bed using hoyer lift assist by 4 observed left knee with red mark and redness . <sic> Review of the clinical record revealed R807 was admitted into the facility on [DATE] with diagnoses that included: [CONDITION(S)] and [CONDITION(S)] affecting left non-dominant side, and [CONDITION(S)] due to excess calories. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R807 had no communication/comprehension concerns, had intact cognition, was totally dependent upon two or more people for physical assistance with bed mobility, transfers, and toilet use, had functional limitation in range of motion impairment on one side for both upper and lower extremities, was always incontinent of bowel and bladder, had no falls, and weighed 273 pounds. On 11/9/21 at 12:07 PM, R807 was observed lying in bed. R807 was very slow to respond to questions asked and repeatedly stated, I'm a little disoriented from the fall. I'm just very disoriented. At that time, Agency Nurse 'G' entered the room to administer medication. When asked about the resident's fall, Agency Nurse 'G' reported the resident fell yesterday and Might've rolled out but not sure and unable to see in the system (medical record) since agency (not an employee of the facility). Agency Nurse 'G' was then observed to hand the remote control for the bed to R807 who lowered the head of the bed only. Agency Nurse 'G' left the room without attempting to instruct or assist R807 in lowering the bed to a lower position. On 11/9/21 at 1:45 PM, R807 was observed lying in bed. The resident did not initially respond to questions, but suddenly became very alert and began responding to questions. When asked to explain about the events regarding the fall, the resident reported, I fell out of bed and hit the whole side of my body. She (Certified Nursing Assistant/CNA 'F') went to change me. It scared the hell out of me. I went over like a ton of bricks. I'm scared to get changed. I really need two people to change me. Like one on each side. On 11/10/21 at 9:00 AM, R807 was observed in their room in the process of being transferred from the bed to a stretcher via multiple emergency medical response staff. During this time, R807 was yelling out loudly and complaining of pain to their left leg. Review of R807's care plans included: -Resident is alert and able to make needs known. She requires extensive-dependent assist with ADLS r/t (related to) hx (history) of [CONDITION(S)] ([CONDITION(S)]) with residual left weakness. She requires mechanical lift x2 for transfers and is incontinent of bowel and bladder. Date Initiated: 04/03/2021 Revision on: 04/22/2021. Interventions included: BED MOBILITY: Dependent x2 assist from staff with bed mobility needs. Date Initiated: 04/22/2021. -The resident has fallen and is at risk for falls related to [CONDITION(S)] and inability to move in bed without assistance. Date Initiated: 04/03/2021 Revision on: 11/09/2021. Interventions included: Bed in low position when not providing care 2 persons assist for care. Date Initiated: 04/03/2021. On 11/9/21 at 12:55 PM, an interview was conducted with RN 'I'. At that time, RN 'I' reported they were the nurse assigned to R807 on the evening of the resident's fall on 11/8/21. When asked to explain the events that occurred, RN 'I' reported, (R807) was laying in bed. About 9:30 (PM) the aide came to her room and turned her on the left side away from the window. (R807's) so heavy and big, when you turn her, she will just flip over so all weight will go on that side, then the aide told me that (R807) was on knees and she helped lower (R807) to the floor. CNA is (name of CNA 'F'). She's a new CNA and I asked for help, we put her in the hoyer lift, it took four to five of us. When asked how many staff were providing assistance during peri-care at the time of the fall, RN 'I' reported they were unable to recall if there was one or two, but that R807 required two people. On 11/9/21 at 1:21 PM, a phone interview was conducted with CNA 'F' who confirmed they were the CNA that was assigned to R807 when they fell . When asked to recall the events surrounding the resident's fall, CNA 'F' stated, She was getting turned to the left side. (R807) was trying to position the right leg over the left and had extra strength and went over the side. I was trying to catch her, and she fell on her knees. When asked if they were the only one providing care, CNA 'F' stated, Yes. When asked to provide details at the time of the fall such as the height of the bed, CNA 'F' reported It was higher since that makes it easier to change. When asked whether they knew the resident's plan of care required two plus people for bed mobility and toilet use/hygiene, CNA 'F' reported they were aware but was not able to explain why they didn't have an additional staff with them. CNA 'F' reported they were not new to this type of work and had been at the facility for a little bit but been doing similar work for about [AGE] years. When asked how they became aware of how much assistance was required to provide care such as one or two people, CNA 'F' stated, Honestly, I'm not sure. On 11/9/21 at 1:50 PM, an interview was conducted with the CNA currently assigned to R807 (CNA 'E'). When asked about how they were aware of the specific details of how much help residents required, such as whether someone needed one, two, or more for assistance with care, CNA 'E' reported, Will go and try ourselves and if not comfortable, then get someone. When asked if there was any documentation they were able to review that identified the specific care required, CNA 'E' reported, It's on the Kardex. At that time, CNA 'E' was asked to review R807's KARDEX and upon review on the monitor in the hallway, CNA 'E' confirmed the resident was dependent upon two people for bed mobility. When asked about the high position of the bed, CNA 'E' reported the resident frequently wanted it higher. CNA 'E' was not observed to encourage the resident to lower the positioning of the bed. On 11/10/21 at 9:02 AM, Nurse Manager 'L' was asked about R807's emergency transfer and they reported, Got results (x-ray) and it actually is a fracture of the left femur. On 11/10/21 at 9:10 AM, Nurse Manager 'L' provided R807's x-ray results which read, .Date of Service: 11/09/2021 .RADIOLOGY REPORT .FEMUR MIN 2 VIEWS. LEFT Results: Fracture of the LEFT femoral neck with impaction . On 11/10/21 at 11:25 AM an interview was conducted with the DON. When asked about the resident's transfer to the hospital earlier, the DON reported R807's x-rays showed an impaction fracture which they explained further confirmed how the resident's fall had occurred. The DON reported they had another discussion with CNA 'F' to get a play by play and reported when CNA 'F' provided peri-care to R807, there was no other staff present and that CNA 'F' had been alone. The DON further reported CNA 'F' had been positioned by the window to the right side of the bed, and the resident was turned onto their left side facing the door and when the resident swung their right leg to try to help, the resident fell over onto and onto their knees. The DON reported CNA 'F' received re-education on the importance of checking the resident's care needs prior to providing care. The DON was informed of the observations of R807's bed being kept in a high position and lack of staff encouraging the resident to lower the bed down. The DON reported they would be following up with education to remind the staff as that was also part of their plan of care. On 11/10/21 at 1:20 PM, review of additional documentation provided by the DON included a hand-written statement from CNA 'F' dated 11/10/21 at 9:05 am per phone which read, As told to (name of DON) .When cleaning up the peri area of (R807), Resident was rolled to her left side with CNA on opposite side of the bed, near the window, providing care. Resident attempted to lift her right leg up and threw it over her straightened left leg which caused her to roll to the left and onto the floor on her knees with her upper body and head still on bed and nightstand. Resident stated she didn't hit her head and only c/o (complaint of) pain was her left knee with redness. CNA assisted the rest of her body to the floor and called for assistance of other staff, who used the Mechanical lift to return her to bed. Was assessed by nurse prior to return to bed. Review of the facility's Falls-Clinical Protocol policy, dated 1/1/21 documented, in part: .Interventions should be developed and implemented per the assessed needs .Resident's abilities and deficits .In addition, interventions for direct care givers should be placed on the CNA care card or similar format .The care plan and CNA Kardex in the electronic Health Record should be updated as interventions change .

Based on observation, interview, and record review, the facility failed to implement interventions in a timely manner to prevent the development of pressure ulcers for one resident (R54), of one resident reviewed for pressure ulcers, resulting in the development of a stage 3 pressure ulcer (Full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present) to the right heel as well as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured with slough or eschar) to the left heel and sacrum. Findings include: On 3/10/21 at approximately 10:40 AM, R54 was observed in their bed. An interview as attempted with R54, however; they did not verbally respond to the interview attempt. It was observed R54 was very thin and was on a low air loss mattress and had soft heel boots on both of their feet. A review of R54's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. It was further noted that on 2/17/21 [DIAGNOSES REDACTED]. Further review of R54's admission MDS assessment section M. Skin Conditions revealed that R54 was at risk for the development of pressure ulcers but did not have any upon admission. A review of R54's weights showed R54 had been weighed weekly and fluctuated between 88 and 92 pounds. A review of R54's nursing admission assessment dated [DATE] was conducted and revealed R54 admitted to the facility with a 1 cm (centimeter) x 1 cm x 0.1 cm skin tear on their right upper buttock. It was noted at the top of the assessment that R54 scored a 9.0 on the Norton Pressure Ulcer Risk Assessment Scale, indicating they were a high risk for the development of pressure ulcers. A review of R54's admission assessment dated [DATE] from their attending physician was reviewed and read, .No rashes or skin breakdown .Skin: Inspection: No rashes or ulcers . A dietary progress note dated 2/10/21 read, Note Text: Per nursing, resident is eating very little . A review of R54's weekly skin assessment dated [DATE] was reviewed and indicated that upon assessment R54 had a deep tissue injury to their left heel, a wound on their right heel with the documentation of UTD (unable to determine) under the description, and MASD (moisture associated [MEDICAL CONDITION]) on their right buttock. A nurse's note dated 2/17/20 was reviewed and read, Note Text: Upon skin assessment, two wounds found on bilateral heels . Continued review of R54's progress notes included a note from the wound care Nurse Practitioner (NP) dated 2/23/21 that read, .WOUND CARE CONSULT .Nature of presenting problem: Unstageable ulcer to left heel, stage III to right heel .Asked to evaluate .wounds to left heel, right, heel, and right sacrum .Skin .stage III ulcer to right heel, initially wound was a DTI (deep tissue injury), did require debridement (removal of dead or infected skin tissue to aid in healing) .Did yield a stage III measuring 1.6 x 1.9 x 0.2 cm .Left heel wound is unstageable, is measuring 3.8 x 4.8 x depth unable to determine. It is filled with eschar (dead tissue, black in color) .Sacral wound is unstageable measuring 4.3 x 3.8 x depth unable to determine. Wound bed is filled with 40% eschar and 60% granulation (new tissue). Surrounding perimeter of wound is DTI. There are 2 wounds noted within this measurement with a large skin bridge .Plan .use soft boots to help offload pressure .does have a low air loss mattress . It was not noted in the NP's notes whether R54's wounds avoidable or unavoidable. A review of a significant change MDS assessment dated [DATE] for R54 was conducted and section M. Skin Conditions indicated R54 had a pressure ulcer. A review of R54's physician's orders [REDACTED]. A review of R54's care plans was conducted and did not reveal any care plans for skin integrity, high risk pressure ulcers, or pressure ulcer prevention prior to the development of the wounds. It was noted, a pressure ulcer care plan was initiated on 2/16/20 with interventions dated 2/24/21 such as floating the heels and the use of the low air loss mattress. On 3/11/21 at 9:10 AM, an interview with the second floor unit manager was conducted regarding R54's facility acquired pressure ulcers. The unit manager was asked if R54 had either a low air loss mattress and or soft heel boots being used prior to the discovery of the three pressure ulcers and said she thought she had a low air loss mattress. At that time, the Unit Manager was asked to provide documented evidence of the mattress being in place prior to the development of the pressure ulcers, however; no evidence was provided by the end of the survey. On 3/11/21 at approximately 11:30 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding R54's facility acquired pressure ulcers. The DON indicated they were aware of them and they were not sure if the low air loss mattress or soft heel boots had been implemented prior to their development. A review of a facility provided document titled, Pressure Injury Prevention and Management with an implementation date of 1/1/21 was reviewed and read, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals and professional standards of practice; monitor and evaluate the impact of the intervention; or revise the interventions as appropriate .

Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to the facility's systemic failure to institute and operationalize appropriate Infection Control practices in accordance with the Centers for Disease Control and Prevention's (CDC's) recommended measures of the cohorting and isolation of residents with similar signs and symptoms of infection to prevent exposure and transmission of the Covid-19 virus to other facility residents and staff, including 21 residents (Residents #1, #2, #3, #4, #5, #6, #7, #9, #11, #12, #13, #14, #15, #17, #18, #20, #21, #23, #24, #25, and #27),. This included implementation of appropriate interventions, such as Transmission Based Precautions, timely creation of a Covid unit and designated staff for the Covid and Transitional monitoring units to prevent the spread of respiratory illness from the Covid-19 virus. The failure to maintain infection control practices resulted in the likelihood for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Immediate Jeopardy: During a tour of the facility on [DATE] at 1:05 PM the Director of Nursing (DON) identified the 1st floor North East Hall (NE) as the area designated for residents being monitored for potential Covid-19 exposure and those residents with signs and symptoms of Covid-19 (there were 5 residents identified by the DON in Rooms 111, 115, 117 and 119); with the remainder of the 10 residents on the hall who were asymptomatic residents (that had not had potential exposure to Covid-19 (Rooms ,[DATE]). This unit was not enclosed and was open to the hallway leading to the elevators and front entry hall. The DON indicated the first 5 rooms at the beginning of the hallway (,[DATE] a Transitional Unit) were residents being monitored for signs and symptoms of Covid-19 after potential exposure. This area was open and a continuous part of the rest of the hallway to include rooms ,[DATE]. The residents' doors were open to the hallway. room [ROOM NUMBER] was at the very front of the hallway, diagonal from the main elevators to the 2nd floor and basement (where offices and the Employee Break Room were located). While walking down the hallway, it was noted that many of the residents' rooms shared a bathroom with the room next door. room [ROOM NUMBER] had 2 Residents with potential exposure to Covid-19 who were being monitored for signs and symptoms of illness This room shared a bathroom with room [ROOM NUMBER]. The resident in 121 did not have potential exposure to Covid-19 but was placed at risk of exposure should either resident in room [ROOM NUMBER] become symptomatic. Resident rooms that shared a bathroom on the 1st floor NE unit: ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. In addition, the resident bathrooms did not have a shower. There was 1 shower on the NE unit located between rooms [ROOM NUMBERS] in the Transitional monitoring area. All residents, regardless of exposure status, were transported to this potentially infectious area for a shower, per the DON. The Director of Nursing said the 1st floor North West (NW) Hall, directly across from the 1 NE Hall, was the designated Covid-19 Unit. The double doors to the hallway were observed closed. The area was immediately adjacent to room [ROOM NUMBER] (a Transitional monitored room). The Covid Unit was approximately ,[DATE] feet from the main elevators. The designated area for staff to don (put on) and doff (remove) Personal Protective Equipment (PPE) was inside the doorway to the Covid Unit. The DON said there were 3 residents who tested positive for the Covid-19 virus on the 1 NW Covid Unit, including Resident #1 (who tested positive at the facility) and 2 residents admitted with Covid-19. During the tour on [DATE] at 1:25 PM, staff were observed walking from one unit on the first floor to the other unit. The Director of Nursing was asked if there were dedicated staff for the Covid unit and Transitional monitoring units and said they were usually the same staff who normally worked each hall. The Covid-19 Unit (1 NW) had 1 nurse and 1 Certified Nursing Assistant (CNA) on the day shift. The 1 NE unit that included the Transitional Monitoring rooms was staffed by 1 nurse and 2 CNA's; There was no separation of staff on the Transitional unit. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), last update: [DATE] . Any infectious agents transmitted in healthcare settings may, under defined conditions, become targeted for control because they are epidemiologically important .In determining what constitutes an epidemiologically important organism, the following characteristics apply: A propensity for transmission within healthcare facilities based on published reports and the occurrence of temporal or geographic clusters of >2 patients . A single case of healthcare-associated invasive disease . is generally considered a trigger for investigation and enhanced control measures because of the risk of additional cases and severity of illness associated with these infections . Common and uncommon microorganisms with unusual patterns of resistance within a facility . A newly discovered or reemerging pathogen . Numerous factors influence differences in transmission risks among the various healthcare settings . LTCF's (Long Term Care Facilities) are different from other healthcare settings in that elderly patients at increased risk for infection are brought together . Documented LTCF outbreaks have been caused by various viruses . and bacteria . prompt detection and implementation of effective control measures are required . Fundamental Elements Needed to Prevent Transmission of Infectious Agents in Healthcare Settings . Adherence to recommended infection control practices decreases transmission of infectious agents . Surveillance is an essential tool for case-finding of single patients or clusters of patients who are infected or colonized with epidemiologically important organisms . Surveillance of both process measures and the infection rates to which they are linked are important for evaluating the effectiveness of infection prevention efforts and identifying indications for change . Cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology and mode of transmission . Assigning or Cohorting healthcare personnel to care only for patients infected or colonized with a single target pathogen limits further transmission of the target pathogen to uninfected patients . A review of the facility Respiratory Infection Surveillance Line Listings for March - [DATE] revealed that 41 residents tested positive for Covid-19 and 20 residents had died . 34 residents were positive for signs and symptoms of Covid-19 including: fever, cough, congestion, sore throat, shortness of breath, decreased oxygen saturation levels, increased confusion, decreased appetite and lethargy. [DATE]: 16 residents tested positive for Covid-19 from a census of 82 = 19.5%. [DATE]: 20 residents tested positive for Covid-19 from a census of approximately 78 = 25.6%. [DATE]: 5 residents tested positive for Covid-19 from a census of approximately 55 = 9%. 33 of 53 resident rooms shared a bathroom. Between [DATE] and [DATE], 40 staff were identified with signs and symptoms of Covid-19. The facility did not have consistent dedicated and separate staff for Covid-19 positive residents, residents with potential exposure to Covid-19 and Covid-19 negative residents . On [DATE] the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) issued the following recommendations: . new recommendations to State and local governments and long-term care facilities (known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (Covid-19) . To provide critical, needed leadership for the Nation's long-term care facilities to prevent further spread of Covid-19, CMS and CDC are now recommending the following immediate actions to keep patients and residents safe: . To avoid transmission within long-term care facilities, facilities should use separate staffing teams for Covid-19 positive residents . and work with State and local leaders to designate separate facilities or units within a facility to separate Covid-19 negative residents from Covid-19 positive residents and individuals with unknown Covid-19 status . The goal is to decrease the number of different staff interacting with each patient and resident as well as the number of times those staff interact with the patient and resident. Also, staff as much as possible should not work across units or floors . Long-term care facilities should separate patients and residents who have Covid-19 from patients and residents who do not, or have an unknown status . Covid-19 positive units and facilities must be capable of maintaining strict infection control practices and testing protocols, as required by regulation . The facility did not designate a separate Covid-19 resident unit until [DATE]. This was 22 days after the CMS and CDC guidance was issued and almost 6 weeks after the facility began to identify multiple residents and staff with signs and symptoms of Covid-19. The first symptomatic staff member was identified on [DATE] and the first symptomatic resident was identified on [DATE]. The first Covid-19 positive resident was identified on [DATE] and first Covid- 19 positive staff member was identified on [DATE]. As of [DATE] the facility was still housing residents suspected of exposure to Covid-19 next to asymptomatic residents. Residents continued to share bathrooms. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: On [DATE] at 3:20 PM, a phone interview was conducted with Infection Control Nurse (IC) A, the Director of Nursing and the Administrator related to the positive Covid-19 resident and staff cases and those with signs and symptoms of Covid-related illness. The Administrator said the facility had started a Covid Unit on the 1st floor NW hall on [DATE]. The Administrator was asked why the facility waited so long to enact a designated closed unit. 15 residents tested positive for Covid-19; with most of those residents tested and diagnosed after transferring to the hospital with signs and symptoms of Covid-19. The Administrator said this was in response to a facility-wide testing of all residents on [DATE] with approximately 20 residents testing positive at that time. During the interview, the Director of Nursing (DON) and IC Nurse were asked about Transmission Based Precautions (Isolation precautions) for symptomatic residents and those with positive Covid-19 test results. The IC Nurse said the residents were placed in Transmission Based precautions. When asked for further clarification, the IC Nurse indicated Droplet Precautions. The IC Nurse was asked what precautions were recommended by the CDC for Covid-19 and said, It's Droplet and Contact, but they wear an N-95 in the Covid-positive rooms. Reviewed with the IC Nurse, DON and Administrator, that this was not clearly indicated outside of the room for each resident in precautions for Covid-19. Also, during the interview, the DON and IC Nurse were asked how the resident precautions were communicated to the staff. Was a physician's orders [REDACTED].? The IC Nurse said she documented a weekly SOC progress note that included if the resident was placed in Transmission Based Precautions, such as Droplet and Contact precautions. The DON said a physician's orders [REDACTED]. During the interview on [DATE] at 3:30 PM, the IC Nurse, DON and Administrator all said the facility staff were wearing an N-95 mask and isolation gown while caring for all residents including Covid-19 positive residents, Persons Under Investigation (PUI) or asymptomatic residents. They said this practice was discontinued several weeks prior to the survey. The process was clarified during the interview and the IC Nurse said the staff were wearing the same N-95 mask and isolation gown in every resident's room but would put another gown over top (wear 2 gowns) in the Covid-19 positive rooms. The staff were wearing the same mask and gown throughout the building during the course of their shift. They were not removing them or changing them to care for asymptomatic vs. residents symptomatic for Covid-19. The DON and Administrator were asked if there was dedicated staff assigned to the Covid-19 positive residents and they said the staff caring for the residents were Generally the same staff who worked on that hall prior to the designation of a Covid positive unit. A list of designated staff for Covid-19 residents and those with potential exposure was requested at this time. CDC, Strategies for Optimizing the Supply of Isolation Gowns, page last reviewed [DATE], . Crisis Capacity Strategies . Extended use of isolation gowns. Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP (Health Care Provider) when interacting with more than one patient known to be infected with the same infectious disease when these patients are housed in the same location (i.e. Covid-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. Disposable gowns are not typically amenable to being doffed (removed) and re-used because the ties and fasteners typically break during doffing . Staff that had signs and symptoms of illness were reviewed during the interview on [DATE] at 3:45 PM. The Administrator said there had not been an issue with having enough staff to care for the residents, but also said many staff had become ill with signs and symptoms of Covid-19 and several tested positive for Covid-19. When asked how long the symptomatic staff were off work with illness, the Administrator said it varied. In an interview on [DATE] at 4:20 PM, Epidemiologist H from the local health department stated, You need to be diligent about screening Residents and staff and make sure you have other measures in place such as Cohorting. You do not wait for the test result, because the result will not change what you need to do. That is why you don't wait until someone is symptomatic. Epidemiologist H was asked what other measures were needed to control an outbreak in a facility and said, Essentially dedicated staff. You don't have someone working the Covid unit one day and a different unit the next day. On [DATE] at 8:05 AM, during an interview with the IC Nurse A, a review of the March, April and [DATE] respiratory line listings for residents and staff indicated 14 staff with signs and symptoms of Covid-19 illness returned to work in less than 10 days from onset of symptoms and 9 staff returned in ,[DATE] days. The IC Nurse was asked if the facility was following the CDC recommendations for staff with signs and symptoms of Covid-19 and she said, some of the staff said they felt better, so they were allowed to return to work earlier. CDC, Coronavirus Disease 2019 (Covid-19), Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance), Last updated [DATE] and page last reviewed [DATE], Decisions about return to work for HCP (Healthcare Providers) with confirmed or suspected COVID-19 should be made in the context of local circumstances. Options include a symptom-based (i.e. Time-since-illness-onset and time-since-recovery strategy) or time-based strategy or test-based strategy . Symptom-based strategy. Exclude from work until: At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms . and At least 10 days have passed since symptoms first appeared . Test-based strategy. Exclude from work until: Resolution of fever without the use of fever-reducing medications and Improvement in respiratory symptoms . and Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for Detection [DIAGNOSES REDACTED]-CoV-2 RNA from at least two consecutive respiratory specimens collected (> or =) to 24 hours apart . On [DATE] at 9:07 AM the March- [DATE] respiratory line listing for residents and staff was reviewed with IC Nurse A. There were 11 staff members who were symptomatic for Covid-19 from [DATE]- [DATE]. From [DATE] to [DATE], 16 residents at the facility, were symptomatic for Covid-19 prior to testing positive at the hospital for Covid-19. The IC Nurse was asked what measures were put in place to attempt to stop the spread of illness and she said the residents were placed in Transmission Based precautions in their rooms. The IC Nurse said there were symptomatic residents on both the 1st and 2nd floors and the facility attempted to group some of the symptomatic residents together on the 2nd floor, but asymptomatic residents continued to reside in the same hall and share bathrooms with symptomatic residents. The IC Nurse said after the facility tested all residents on [DATE] and there were approximately 20 more residents positive for Covid-19, a Covid Unit was created on the 1st floor NW hall. The IC Nurse said she documented an SOC Note weekly for those resident with signs and symptoms of an illness. When asked if the facility had specific, dedicated staff on the Covid Unit and if there was a list of those staff, the IC Nurse was not sure. A list of dedicated staff for the Covid Unit was requested on [DATE] and not received until [DATE] as part of the Immediate Jeopardy Abatement plan. CDC, Long-Term Care (LTC) Respiratory Surveillance Line List, [DATE], 'The Respiratory Surveillance Line List provides a template for data collection and active monitoring of both residents and staff during a suspected respiratory illness cluster or outbreak . Using this tool will provide facilities with a line listing of all individuals monitored for or meeting the case definition for the outbreak illness . Each row represents an individual resident or staff member who may have been affected . The information . capture data on the case demographics, location in the facility, clinical signs/symptoms, diagnostic testing results and outcomes . ' Information gathered on the worksheet should be used to build a case definition, determine the duration of outbreak illness, support monitoring for and rapid identification of new cases and assist with implementation of infection control measures . CDC, Transmission-Based Precautions, [DATE], . Recommendation, V.A.1, In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission CDC, Coronavirus Disease 2019 (Covid-19), Page last reviewed: [DATE], update [DATE], Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, . Isolate symptomatic patients as soon as possible . cohort patients with COVID-19, limit the numbers of staff providing their care . A record review of the face sheet, vital signs, progress notes, physician orders, assessments, Minimum Data Set (MDS) assessments and Care Plans was completed for the following facility residents who were symptomatic or tested positive for Covid-19: Resident #1: Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] Resident #1 was positive for Covid-19. The MDS assessment, dated [DATE], indicated the resident had full cognitive abilities as evidenced by a Brief Interview for Mental Status score (BIMS) of 15 out of 15 and needed assistance with all care. A review of the progress notes for Resident #1 revealed the following: -[DATE] SOC Infection, 9:55 AM, . Transmission precautions (related to) positive COVID-19 . Transmission-Based precautions were started after the resident had a confirmed positive test for Covid-19. -[DATE]:52 AM, SOC Infection, Precaution type: Transmission-based precautions . The resident was placed on Transmission-based precautions 3 days after suspicion of infection with Covid-19. -[DATE] at 8:23 AM, . resident's test results came back positive for COVID-19 . move to room [ROOM NUMBER]A . -[DATE] 11:06 AM. (Nurse Practitioner- NP) ordered COVID-19 swab . There was no documentation that the resident was placed into specific Transmission Based precautions. Per prior interview with the IC Nurse, staff were wearing a mask and gown throughout the building, while going room to room to care for residents. -[DATE] 3:30 PM, . resident altered mental status . -[DATE] at 6:27 PM, Phone call received from resident's (family) . concerned that resident was dehydrated and possibly septic . (0xygen saturation (pulse oximeter), Mayo Clinic, [DATE], . Normal pulse oximeter readings usually range from ,[DATE]% .) 92% (room air- ra) . -[DATE] SOC Infection note, . Transmission based precautions throughout the facility r/t Covid-19 in the building . -[DATE] . transferred from (room) 108 . (No explanation documented). -[DATE] .Unable to give shower as resident is isolated at this time (related to) neighbor isolation . -[DATE] . resident has had poor fluid intake . (Doctor J) notified and orders taken for (IV fluids). -[DATE] . less than 50% taken for breakfast and approx. 50% taken for lunch (IV fluids) running in left arm . -[DATE] . Resident is not at her baseline and is not conversing or interacting with staff . (Doctor J) ordered (IV fluids) . -[DATE] 8:30 PM, . Resident was readmitted from hospital ([DATE]) on [MEDICATION NAME] (antibiotic) for UTI . Standard precautions . -[DATE] 9:55 AM, . After meeting with the resident, the (family) requested that the nurse send the resident to the hospital . -[DATE] 1:42 PM, . Resident continues to not be at baseline and has increased confusion . A review of the physician orders [REDACTED]. A previous order for Isolation precautions was not located in the medical record. A review of the Care Plans, indicated a Care Plan titled, Infection, dated [DATE], Transmission-Based precautions. with no details of what this included. Resident #3: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated [DATE], revealed the resident had full cognitive abilities as evidenced by a BIMS score of ,[DATE] and needed assistance with all care. Per the March - [DATE] Respiratory surveillance report, Resident #3 was the first identified Covid-19 positive resident in the facility. He was transferred to the hospital on [DATE] for a change of condition including fever and shortness of breath. A review of the progress notes for Resident #3 revealed the following: -Per the admission provider note dated [DATE], the resident had abnormal lung sounds rhonchi bilateral. -February 28, 2020, The residents oxygen saturation (02sat) was 89% on room air and oxygen at 3 liters/minute was administered [MEDICAL CONDITION]. expectorating copious amounts of yellow tinged secretions. -[DATE], 02sat 87% room air (ra), encouraged deep breathe and cough, sat increased to 93% ra. -[DATE], Resident had two episodes of emesis. Resident was suctioned multiple times, sp02 (02sat) 85% on 5L/02. Temp 100.8 HR (heart rate) 120 . Resident went 911 (to the hospital) . at 915. A review of the Medication Administration Records (MAR's) and Weights and Vitals indicated blood pressure, pulse and respirations were documented every shift, but temperatures were taken less than daily. There was no documented temperatures on [DATE], [DATE], [DATE], [DATE], ,[DATE] to [DATE], [DATE], ,[DATE] to [DATE] and [DATE]. There were 3 only skilled nursing notes dated [DATE]-[DATE] and documentation in the nurse's notes was less than daily. On [DATE], during the survey, Nurse K made a late entry note for 2 months prior. It was dated [DATE], Resident had [MEDICAL CONDITION]. Resident also developed respiratory distress and was sent out to the hospital. A review of the resident's Care Plans indicated a Care Plan titled, Monitor for signs and symptoms of infection . date initiated [DATE], with interventions, Monitor temperature every shift, dated [DATE] and Monitor vital signs daily, dated [DATE]. Resident #9: Resident #9 was initially admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated [DATE], indicated the resident had moderate cognitive impairment as evidenced by a BIMS score of ,[DATE] and needed extensive assistance with all care. The progress notes revealed the resident began to have a fever and cough on [DATE]. The resident had several falls during her illness: [DATE] and [DATE]. A respiratory panel completed [DATE] was negative. The resident was tested for Covid-19 on [DATE] and the test was negative, although the resident was symptomatic. The resident was treated with antibiotics ( ,[DATE]-[DATE] and ,[DATE]-[DATE]) for pneumonia after a chest x-ray showing opacities on [DATE] and infiltrates [DATE]. The resident was transferred to the hospital on [DATE], returned to the facility on [DATE] and transferred to the hospital again on [DATE] where she died . Progress Notes: -[DATE] at 5:53 PM, Resident BG (blood sugar) 419 (very high) . (physician) gave order to send to the hospital . -[DATE] at 2:36 PM, . Temp 100.5 . Resident not eating or drinking this shift . -[DATE] provider note by Physician M, . We will monitor this patient closely since she is at high risk for decline and hospitalization . -[DATE] provider note be Physician M, .low grade fever Fall ([DATE])[DATE] Monitor temp every shift . -[DATE] Provider note- I am evaluating this patient today to assess her low-grade fever and cough. On [DATE] she had a temp of 100.1 as well as a productive cough . -[DATE] New onset of fever with a cough. Resident is currently on droplet precautions . A review of the IC Nurses SOC Infection Notes for Resident #9, indicated there were 4 notes for the year 2020: [DATE], [DATE], [DATE] and [DATE]. The IC Nurse had said she documented weekly on residents with signs and symptoms of illness, but Resident #9 began with a fever and cough on [DATE]. The IC note prior to [DATE] was dated [DATE]. The [DATE] note said, . presumptive Covid-19 .Transmission based precautions throughout the facility . During this timeframe, the facility staff were wearing PPE throughout the building (1 gown and mask for the entire shift- in all resident rooms). The Electronic Medical Record (EMR) indicated from [DATE] to [DATE], Resident #9 had been moved to several different rooms between the 2nd and 1st floors (3 room moves) prior to transfer to the closed Covid unit on [DATE]. The transfers between rooms and floors could have potentially exposed many residents to Covid-19. A review of Resident #9's Care Plan titled, The resident is on transmission based precautions r/t (related to) presumptive Covid-19 in the facility, date initiated and revised [DATE], with interventions, Staff to wear appropriate PPE including gowns, gloves, N-95 masks and goggles during care, date initiated and revised [DATE]. There was no further clarification. The Care Plan did not mention Droplet precautions, as indicated in the [DATE] progress note. Resident #11: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated [DATE], indicated the resident had mild cognitive loss as evidenced by a BIMS score of ,[DATE] and needed some assistance with care. A review of the progress notes for Resident #11 provided the following: -The resident developed a fever on [DATE]. The physician ordered lab tests to be completed STAT (meaning immediately with results in ,[DATE] hours). The lab tests were not obtained until 2 days later on [DATE]. The residents condition declined, and he was sent to the hospital on [DATE], where he was diagnosed with [REDACTED]. -[DATE], . resident went to hospital . temp=102.0 Tylenol given . 99.8 . persistent cough . to ER . -[DATE] at 2020, 8:56 PM, .started a 20-gauge peripheral IV in resident's right wrist . IV infusing well . toileted x1 with extensive assist . extensive assist x1 for ambulation and clothing . The resident had become weaker and needed more assistance with care. -[DATE] at 7:02 PM, . resident lethargic, and not eating and drinking . orders given for BMP/CBC stat with IV fluids . x1 day or 24 hours at 75ml/hr. The STAT labs were drawn on [DATE] and reported to the facility on [DATE]. They indicated the resident was dehydrated (BUN 40 and Creatinine 2.2- both high). The IV fluids were not started until approximately 24 hours later. -[DATE] at 6:56 AM, Pt declines STAT labs . becomes agitated quickly . -[DATE] at 6:54 PM, Temp 100.4, (Physician M) notified and gave order for STAT BMP (Basic Metabolic Profile) CBC (Complete Blood Count) RSV (Respiratory [MEDICAL CONDITION] test) . A review of the physician's orders [REDACTED]. A review of Resident #11's Care Plan titled Monitor for signs and symptoms respiratory infections . date initiated [DATE], with interventions, Monitor temps ever shift (8 hour shifts) and Monitor vital signs daily, both dated [DATE]. There was no update to indicate the most recent orders for monitoring. A review of the Weights & Vitals, for the resident revealed multiple days that vital signs were not taken as ordered. Vital signs were not taken 4 times/day as ordered on [DATE], 0xygen saturation was not assessed every shift or daily. Vital Signs: Temperatures not taken as ordered on [DATE], [DATE], [DATE], [DATE]/ [DATE]. Oxygen saturation, Blood pressure, pulse, respiratory rate we (TRUNCATED)

This citation pertains to intake #MI 770 Based on observation, interview and record review the facility failed to ensure pain was appropriately managed for one resident (R#902) of three residents reviewed for pain management, resulting in R#902 experiencing severe pain, mental anguish, anxiety and shortness of breath. Findings include: On 5/14/19 at approximately 10:00 a.m., R#902 was observed in their room lying in their bed. R#902's legs were observed to be in a bent angle with their feet pressed up against the footboard of their bed. R#902 was queried if they were receiving their medications in the facility and they stated, no, they missed a few doses of my oxy ([MEDICATION NAME]) on Saturday. I was in so much pain. I felt like I wanted to die. It was unbearable. They didn't give me anything for it. All they could offer me was Tylenol. I take Oxy 10 MG ( milligram) every 4 hours. I also have it as needed every 12 hours. I know my medications. I don't know how a medical facility can run out of medication. The nurse told me they ran out and they had to reorder it and that it wouldn't be there for hours. I usually take my PRN (as needed) oxy at around 11 or 12 and that holds me over until my afternoon dose. I was in so much pain, I couldn't wait that long. I couldn't even eat. The only thing I could eat was some pudding. The nurse didn't even call the doctor to see if they could get me something else. I just laid there in pain. I had to call 911 because of my pain and my anxiety. I was in so much pain and because of the pain I started getting severe anxiety and I couldn't breath. I had to go to the hospital On 5/14/19 the medical record for R#902 was reviewed and revealed the following: R#902 was initially admitted to the facility on [DATE] was last readmitted on [DATE] and had [DIAGNOSES REDACTED]. A review of R#902's MDS (minimum data set) with an ARD (assessment reference date) of 3/11/19 revealed R#902 needed limited assistance from facility staff with dressing, personal hygiene and needed extensive assistance with bathing. R#902's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A review of R#902's physician's orders [REDACTED]. related to ACUTE GASTRITIS WITH BLEEDING .; DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE -Start Date- 02/09/2019 0800 (miilitary time) .[MEDICATION NAME] HCl Tablet 10 MG Give 1 tablet by mouth every 12 hours as needed for pain related to PAIN, UNSPECIFIED-Start Date- 02/11/2019 1330 A review of R#902's Care Plan revealed the following: Focus-The resident has chronic pain related to stomach ulcers, gastritis, and worsens with anxiety .Goals-The resident will have no interruption in normal activities due to pain .Interventions: The resident's pain is aggravated or increased by anxiety. The resident's pain may be relieved by scheduled and prn pain medications. Administer pain medications as ordered. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Avoid spicy foods. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to [MEDICATION NAME] including pain relief, side effects and impact on function. Monitor/record/report to Nurse any signs or symptoms of non-verbal pain. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal or resistance to care. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain relieving methods (i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound). Resident takes anti-anxiety meds to assist with pain reduction since pain increases with anxiety. A nursing progress note dated 5/11/19 revealed the following: Resident called 911 ambulance transportation to hospital because of [MEDICATION NAME] dosage not available. Resident stated she could not breath and that because she didn't have dosage available it was causing the difficulty breathing. Ambulance came around 1:15 to transport to hospital. Ambulance return with resident at 2:30. No change in status and no new order. A medication administration note dated 5/11/19 revealed the following: [MEDICATION NAME] HCl Tablet 10 MG Give 1 tablet by mouth every 4 hours for Pain. related to ACUTE GASTRITIS WITH BLEEDING (K29.01);DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE Medicine was not available. A review of R#902's (MONTH) 2019 MAR (medication administration record) revealed R#902 was not administered their scheduled [MEDICATION NAME] 10 MG dosage at 1400 (military time) nor where they provided their PRN (as needed) [MEDICATION NAME] dosage. A pain evaluation dated 5/14/19 revealed the following: A 1.Pain Presence- .Have you had pain or hurting at any time in the last 5 days? (Yes) .B. 1. Pain Frequency .How much of the time have you experienced pain or hurting over the last 5 days (Almost Constantly) .C. Pain Effect on Function .1. Over the past 5 days, has pain made it hard for you to sleep at night? (Yes) .2. Over the past 5 days, have you limited your day-to-day activities because of pain? (Yes) .3. Areas impacted by pain a. appetite (checked), b. day to day activities (checked), d. mood (checked), e. sleeping (checked) .D. Pain Intensity: .1. Numeric rating scale 00-10: (8) .2. Verbal Descriptor Scale: (3-Severe) .E. Pain Description: .1. Location(s) of Pain: (stomach) .Characteristics of Pain: 3. a. (constant) .4. Descriptors of Pain: .b. (burning) .5. Additional symptoms associated with pain: a. (anxiety) .7. Describe how resident currently manages their pain: ([MEDICATION NAME]) .8. Strategies/Factors that reduce pain ([MEDICATION NAME]) . On 5/14/19 at approximately 11:00 a.m., R#902's roommate (R#901) stated the following, it's good that your here, someone needs to take a look at this place. On Saturday my roommate (R#902) didn't get her pain medication. I guess the place ran out of her medicine. I don't know how a medical place runs out of medicine. She was in a lot of pain and she was hysterical. She was crying and cussing and in so much pain that she couldn't breath and called the ambulance herself. Nobody should have to do that. On 5/14/19 at approximately 3:00 p.m., staff member B was queried regarding R#902's [MEDICATION NAME] not being available on 5/11/19. Staff member B indicated that R#902 was in pain because the medication wasn't available and that they had to call the pharmacy to try to get it dropped shipped. Staff member B was queried how the facility ran out of R#902's medication and they stated, she has a few regular nurses, they should have reordered her medication a few days before so she didn't run out. They count the medications and if they're running low they are supposed to reorder it so they have it. That was ridiculous. On 5/14/19 at approximately 3:43 p.m., during a conversation with the Director of Nursing (DON), the DON was queried it R#902's [MEDICATION NAME] should have been ordered earlier to avoid running out of their pain medication and they indicated that it should have. the DON stated, I was just livid that she ran out. We are going to have to do some nursing education. The DON was queried what their expectation was regarding pain medication and they DON indicated that it was their expectation that the medication be reordered so that it is available. The DON further indicated that it was their expectation that the nurse should have called the Doctor to see if anything else could have been ordered to relieve R#902's pain. The DON stated, they're are workarounds. On 5/15/19 at approximately 10:48 a.m., during a conversation with staff member B via phone, staff member B was queried if they had notified R#902's attending Physician regarding their [MEDICATION NAME] not being available and they indicated that they didn't. Staff member B was queried if they had called the DON to see if the situation could be resolved somehow and they indicated that they didn't. Staff member B was queried if they attempted any non-pharmacological interventions to relieve R#902's pain and they indicated that they didn't. On 5/15/19 a facility document titled Pain-Clinical Protocol (last reviewed/revised 03/2011) was reviewed and revealed the following: Assessment and Recognition-1. The physician and staff will identify individuals who have pain or who are at risk for having pain, a. This include review of known [DIAGNOSES REDACTED].b. It also include a review of any treatments that the resident is currently is receiving for pain, including all complementary (non-pharmacologic) treatments .Treatment/Management- 2. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain 4. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain .Monitoring- 3. The staff will discuss significant changes in level of comfort with the attending physician who will adjust interventions accordingly. A. This may include adjustments of regular and PRN [MEDICATION NAME] doses to find the best combination of effectiveness and tolerable side effects, or possible addition of non-pharmacologic interventions .

Based on observation, interview and record review the Facility failed to prevent Resident to Resident abuse for four Residents (#84, #49, #4 and #68) out of 12 Residents reviewed for abuse out of a total sample of 28 resulting in Resident #68 entering into Resident #84's room unaccompanied and without permission and making physical contact to the face and chest causing pain, extreme fear and continued mental anguish to Resident #84, Resident #4 entering into Resident #49's room/bathroom unaccompanied and without permission resulting in Resident #4 striking Resident #49's leg with a belt and the potential for continued physical contact and mental anguish. Findings include: Resident #84 and Resident #68 On 11/28/17 12:45 p.m., Resident # 84 was observed lying in bed in her room. Posted on her wall was a communication sheet with pictures. When questioned about life in the Facility, Resident #84 presented with impaired speech, but was able to use gestures and respond to yes/no questions presented. When questioned about life in the Facility, Resident #84 started pointing towards the window and started crying. When asked do you want to leave, the Resident said,yes. When asked if she felt safe in the Facility, the Resident shook her head no and used her finger to point up towards the ceiling. When asked if she was hurt by someone, the Resident made a fist and again pointed her finger up towards the ceiling and then towards her chest and cheek. The Resident asked if she was hurt by a male or female. The Resident responded by shaking her head yes to male. The Resident was asked if the male was a staff member, the Resident shook her head no. When asked if the male lived in the Facility, the Resident responded, yes. The Resident was asked if the incident happened up stairs, she again pointed her finger up. When asked how many times it happened, the Resident shook her head, yes. The Resident continued to cry during the interview and pointing her finger toward the window and then placed her hand near her ear as if trying to use a phone. A second Surveyor entered the room and again the Resident continued crying, made a fist, pointing to her cheek and chest and then pointed to the outside window. A Nurse working on the floor reported that the Resident had been transferred from a room upstairs to the room in which she resides a few weeks ago. A review of the Residents clinical record revealed that the Resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's MDS (minimum data set) dated 8/15/17 documented that the Resident had a BIMS (brief interview for mental status) score of 13 (cognitively intact) and required extensive two person assist for transfers, mobility, toileting and showering. On 11/29/17 at 9:08 a.m., a second interview was conducted with Resident #84. Again, the Resident became teary eyed, started crying, pointed toward the window, making a fist and pointing towards the ceiling. The Resident was queried as to whether she had ever told a staff member about the incident. The Resident nodded Yes. When asked if staff was female, the Resident responded yes. A CNA (certified nursing assistant) entered the room with a breakfast tray. The Resident refused the breakfast tray. When asked if she wanted an alternative meal, the Resident refused. The CNA stated that she had been refusing her meals recently. Further review of Resident #84's records revealed, in part, the following: Nurse Note (8/20/17) Resident was very upset and crying when another resident entered into her room and moved her bedside table while touching her stuff. Staff attempted comfort resident but she was crying forcefully. After exiting the room the writer heard the resident making a strange repetitive noise . Review of the Resident's clinical record was conducted and revealed, in part, the following: Psych Service Visit (November 7, 2017): Met with patient individually. Patient is essentially nonverbal. She is able to nod yes or no and make gestures. Patient indicated she would like to be at another facility. When asked if someone touched her she lifted her hand up to indicate a tall person and then put her hand to her face and squeezed her checks. When asked if a tall person came into her room and squeezed her cheeks she nodded yes. When asked if it was a staff person she nodded no. When asked if the person was upstairs she nodded yes. When asked if she had any visitors from family she nodded no and became tearful . It should be noted that the last visit by Psych Services prior to the November 7, 2017 visit was on March 29, 2017. Nurse Note (11/12/17): Resident observed lying in bed crying. This nurse asked resident what was wrong, using hand resident put a phone symbol to ear .this nurse asked if calling family would help, resident shook head no. Nurse Note (11/25/17): Res having increased sadness unable to console, social work notified via 24 hour binder Nurse Note (11/26/17): Resident having increased sadness refused dinner x3 attempted as well. Offered a snack x3 res still refused. Res non verbal writer attempted to guess what was upsetting the res .when writer asked Res if she was sad about family res didn't respond or shake head .Social work notified via 24hr binder. On 11/30/17 at 2:04 p.m., a conversation between Social Worker A and Resident #84 was observed in the Resident's room. The Resident was lying in bed crying and SW A asked about a man hitting the Resident in the face. The Resident answered yes. SW A asked if it was a man with a beard. The Resident nodded yes. The Resident continued to cry and shakes her head Yes when asked if she told SW A about the Resident with a beard entering her room and hitting her in the face. An interview with SW A was conducted following the observation. SW A was queried as to the Resident #84's response about a man hitting her in the face. SW A responded that she had investigated an allegation of abuse pertaining to Resident #84. SW A reported that the Facility had determined that the Resident who entered her room was Resident #68. SW A reported that she talked with the Resident on 11/6/17, but she denied that anyone had been in her room or touched her in appropriately, but did acknowledge that a tall man sometimes comes into her room and touches her. SW A reported that Resident #84 never told her that he hurt her or that she was in fear prior to the interview on 11/30/17 at 2:04 p.m. as noted above. SW A reported that the Resident has a history of crying and sometimes can be consoled with junk food and soda drinks. Resident #68 A review of Resident #68's clinical record was conducted on 12/6/17 at 11:17 am. The record indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #68's most recent MDS assessment dated [DATE] indicated severely impaired cognition, daily wandering, and independence with ambulation. Behavior monitoring tasks included target behaviors of: agitation, aggression, and aggression towards others, but not include monitoring for wandering. A review of progress notes was conducted and revealed the following: Standard of Care (S(NAME)) note 11/16/17 at 11:01 am, 11/9/17 at 9:48 am,- .Resident is up daily and wanders throughout the unit . S(NAME)-[MEDICAL CONDITION] medication note 11/2/17 at 10:01 am- .He wanders throughout the unit often entering others rooms . RAI (Resident Assessment Instrument) Progress note on 10/30/17 at 1:14 pm- .He ambulates with a steady gait on the unit and staff report he wanders in and out of other residents room . Activity Progress Note 9/1/17 at 3:32 pm-Resident displays restlessness and tends to wander into rooms of peers . RAI progress note on on 7/28/17 at 1:36 pm- .He ambulates with a steady gait on the unit and staff report he wanders in and out of other residents room . S(NAME)-Behavior progress note on 7/20/17 at 9:56 am- .wandering on unit into other resident's room, resident wandered into lower level of facility . S(NAME)-Behavior progress note on 7/13/17 at 10:04 am- .wandering on unit into other resident's room resident wandered into lower level of facility . S(NAME)-Behavior progress note on 7/6/17 at 9:59 am- .wandering on unit into other resident's room . S(NAME)-Behavior progress note on 6/7/17 at 9:44 am- .wandering throughout unit into other resident's room . Nursing note 5/22/17 at 9:50 pm- .Resident was made aware he can not be physical with other residents or staff . Nursing note 5/18/17 at 7:03 pm- Resident removed his pants and underpants and entered rooms [ROOM NUMBERS]. Nurse had a difficult time redirecting him . Nursing note 5/14/17 at 2:57 am- .Assisted back to bedroom .after ambulating hall and roaming into other residents room; found in room [ROOM NUMBER]B at one time this shift .redirected multiple time Nursing note 5/11/17 at 11:01 pm- .Resident is non-stop wandering halls and in and out of other resident rooms . Nursing note on 5/11/17 at 6:59 am- .up most of shift walking up and down hall; enters other resident rooms . Nursing note on 5/7/17 at 3:33 pm- .Resident went into room (not resident's assigned room) and was sitting on their toilet .Resident took his pants and brief off and would not put anything on then proceeded to walk to his room with only a shirt . Nursing note on 5/6/17 at 2:44 pm- .awake all day long wanders back and forth wanders to other res (resident) rm (room) as well, been redirected to his rm so many times . Nursing note on 5/1/17 at 7:45 pm- .Resident in and out of other resident's rooms .Went into room (not resident's assigned room) and resident told family that he sat on her bed 4 times .Family is getting pretty upset when he goes in there. He continues to go into other resident's room as well . A review of Resident #68's care plan was conducted at that time and and included the focus: Resident exhibits wandering behavior .Interventions for wandering included: Allow for safe wandering . The care plan's last revision was noted to be 7/20/17 and did not address Resident #68 wandering into the rooms of his peers. On 11/30/17 at 2:51 p.m., an interview was conducted with the Administrator/Abuse Coordinator pertaining to Resident #84 and #68. The Administrator/Abuse Coordinator reported that the Facility had received a website review that alleged a Resident who could not talk or walk complained of inappropriate touching and abuse. The Facility was able to determine that the Resident at issue was #84 and the alleged perpetrator was #68. The Administrator reported that she never interviewed Resident #84, but that SW A had conducted an investigation and determined that it was Resident #68 had entered the Residents room, touched her, but that abuse was not substantiated because the Resident showed no signs of physical harm (ie. bruising, cuts or bleeding). The Administrator reported that Resident #68 was a wanderer with dementia and had no history of aggressive behavior. * Please note Resident #68's clinical record note as documented above. When queried as to Resident #84 expressing uncontrollable crying, sadness and signs of fear, the Administrator reported that Resident #84 was moved from the second floor unit to the first floor, but again reported the Facility determined no harm, mental anguish or abuse of the Resident. Resident #49 and Resident #4 On 11/30/17 at 2:09 pm, a review of the facility reported incident on 11/19/17 between Resident #4 and Resident #49 was conducted. During the review it was discovered that Resident #4 (male resident) had wandered into Resident #49's (female resident) room and into the bathroom in that room on 11/19/17. CNA (certified nursing assistant) 'D' was in Resident #49's room when Resident #4 wandered into the bathroom. CNA 'D' attempted to re-direct Resident #4 out of the bathroom, and that time it was documented that (Resident #4) made contact to (Resident #49's) right leg with his belt . On 12/6/17 at 12:17 pm, an interview with Nurse 'C', the nurse caring for Resident #4 on 11/19/17 was conducted. During the interview, Nurse 'C' indicated she was aware of the incident and stated, Somehow he had a belt. The aide came and told me he wandered in the room, was attempting to hit her, she tried to re-direct him, and then he started hitting (Resident #49). An attempt to interview CNA 'D' was unsuccessful as phone calls were not returned. A review of Resident #4's clinical record was conducted on 12/6/17 at 12:10 pm. The record indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #4's most recent MDS assessment on 11/14/17 indicated severely impaired cognition, and daily wandering, and independence with ambulation. Behavior monitoring tasks included target behaviors of: aggression towards others and combativeness, A review of progress notes was conducted and revealed the following: Nursing note 7/16/17 at 10:17 pm- .pacing hall non-stop throughout shift. entering room (not assigned room) each time resident reaches end of hall . Nursing note on 8/21/17 at 9:02 pm- .non-stop pacing hall entering room (not assigned room) each time he reaches end of hall . Nursing note on 11/20/17 at 12:36 am- .resident wandered into room (not assigned room) Nursing note on 11/27/17 10:41 pm- .pacing hall throughout shift, grabbing staff by the wrists or arms, squeezing and twisting . A review of Resident #4's care plan read .Interventions: Resident often wanders into others others rooms On 12/6/17 at 1:55 pm, an interview with Social Worker 'A' was conducted regarding the wandering residents on the second floor. Social Worker 'A' stated, We are aware people end up in others' rooms. On 12/6/17 at 3:30 p.m., a subsequent interview with the Administrator was conducted. When queried as to Resident #4 and #68 wandering into other Residents rooms and making physical contact with other Residents, the Administrator reported that she was aware that Residents are wandering, but stated, we do not feel the wandering Residents are aggressive or are abusing other Residents. On 12/6/17 at 4:00 p.m., a review of the Facility Polity titled Abuse Prevention Program was conducted and documented, in part, the following: Policy Interpretation: Our facility is committed to protect our resident from abuse by anyone including, but not limited to: facility staff, other residents . 2. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse .Our abuse prevention program provides policies and procedures that govern, at a minimum .identifications of occurrences and patterns of potential mistreatment/abuse .the development of investigative protocols governing .resident to resident abuse .timely and thorough investigations of all reports and allegations of abuse .assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect identifying areas within the facility that may make abuse . more likely to occur . Abuse: The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish incidents of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish (emphasis added). It includes .physical abuse and mental abuse . Neglect: is the failure of the facility .to provide goods and services to resident that are necessary to avoid physical harm, pain or mental anguish (emphasis added). 16. The individual conducting he investigation will, at a minimum: review the resident's medical record to determine events leading up to the incident: interview the person(s) reporting the incident: interview an witnesses to the resident: interview the resident .:interview staff members (on all shifts) who have had contact with the resident: .review all events leading up to the alleged incident 18. While the investigation us being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents

Based on observation, interview and record review the Facility failed to protect Residents in the Facility from actual and potential Resident to Resident abuse by Residents with a known history of wandering and aggressive behaviors and thoroughly investigate an allegation made by Resident #84 pertaining to physical abuse by a wandering and aggressive Resident (#68) who struck the Resident in the face and chest, resulting in loss of appetite, prolonged crying and unresolved mental anguish for Resident #84, Resident #38 expressing fear of assault by Resident's #4, #68, and #69, Resident #49 being struck with a belt by Resident #4, and the potential for continued and/or identified abuse that could affect all 89 Residents that reside in the Facility. This resulted in Immediate Jeopardy to the health and safety of Residents and the potential for serious injury, harm and/or death. The IJ started on 11/19/17. The Administrator was notified of the Immediate Jeopardy on 12/01/17 at 1:42 p.m A plan to remove the immediacy was requested. The immediacy was removed on 12/01/17 at approximately 5:00 p.m. based on the Facility's implementation of an acceptable plan of removal as verified on-site by the surveyor team. Although the immediacy was removed the Facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings include: On 11/28/17 at 8:45 a.m., an entrance interview was conducted with the Administrator. The Administrator was queried about the layout of the Facility and whether there were any dementia units. The Admistrator reported that the Facility had no specific dementia units. Resident(s) #38, #4, #68, & #69 (observation, interview and record review(s) On 11/28/17 at 10:34 am, an interview with Resident #38 was conducted. Upon being invited into the room a paper stop sign was observed to be taped on the open door at aproximately the door handle level. During the interview, Resident #38 was asked general questions about living in the facility. During the interview, Resident #38 stated, It's terrible here. There are men coming in my room night and day. When asked if Resident #38 knew who any of the men were that were coming and going in and out of her room, Resident #38 stated Yes, (Resident #68), (Resident #69), and (Resident #4). Resident #38 was asked if she had let any of the facility staff know about her concerns and stated, I told (Social Worker 'A'), she knows about it. Observations: On 11/28/17 at 11:31 am, Resident #4 was observed non-purposefully wandering/pacing the corridor on the second floor. On 11/28/17 at 12:48 pm, a follow-up interview with Resident #38 was conducted regarding her concern with the wandering residents. Resident #38 said, I stay up all night watching my door. There is one man, he's very big and strong, he comes in here and I'm afraid I'm going to get raped. On 11/28/17 at at 2:30 pm, Resident #69 was observed non-purposefully wandering/pacing the corridor on the second floor. Resident #69 was observed to enter room [ROOM NUMBER] (not his assigned room or assigned unit), take some papers and a marker from the room, exit the room, and continue to pace the halls. Staff were not observed to be present in the hallway supervising Resident #69 at that time. On 12/1/17 at 3:55 pm, Resident #69 was observed from the hallway to wander into room [ROOM NUMBER], not the resident's assigned room. Resident #69 was observed to remove his pants and sit on the bed (belonging to someone else) nearest the door in his incontinence brief. Staff were not observed to notice or assist Resident #69 until 4:00 pm, when a staff member walking by saw him. Interviews: On 12/6/17 at 12:17 pm, an interview with Nurse 'C' was conducted regarding a facility incident between Resident #4 and Resident #49. When asked about Resident #4's behavior Nurse 'C' explained that Resident #4 paces the hallways and goes into other resident's rooms quite frequently. She explained that Resident #4 wandered into Resident #49's room, attempted to hit the the CNA with a belt then, .started hitting (Resident #49) with the belt. On 12/6/17 at 1:55 pm, an interview with Social Worker 'A' was conducted regarding the wandering residents on the second floor. Social Worker 'A' stated, We are aware people end up in others' rooms. Record reviews: A review of Resident #38's clinical record was conducted on 11/29/17 at 9:31 am. The review included a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #38's Minimum Data Set (MDS) assessment indicated intact cognition. A review of Resident #4's clinical record was conducted on 12/6/17 at 12:10 pm. The record indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #4's most recent MDS assessment on 11/14/17 indicated severely impaired cognition, daily wandering, and independence with ambulation. Behavior monitoring tasks included target behaviors of: aggression towards others, removing clothing, and combativeness, A review of progress notes was conducted and revealed the following: Nursing note on 11/27/17 10:41 pm- .pacing hall throughout shift, grabbing staff by the wrists or arms, squeezing and twisting . Nursing note on 11/20/17 at 12:36 am- .resident wandered into room (not resident's assigned room) . Nursing note on 8/21/17 at 9:02 pm- .non-stop pacing hall, entering room (not resident's assigneed room) each time he reaches end of hall . Nursing note 7/16/17 at 10:17 pm- .pacing hall non-stop throughout shift. entering room (not resident's assigned room) each time resident reaches end of hall . A review of Resident #4's care plan read .Interventions: Resident often wanders into others others rooms A review of Resident #68's clinical record was conducted on 12/6/17 at 11:17 am. The record indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #68's most recent MDS assessment dated [DATE] indicated severely impaired cognition, daily wandering, and independence with ambulation. Behavior monitoring tasks included target behaviors of: agitation, aggression, and aggression towards others, but not include monitoring for wandering. A review of progress notes was conducted and revealed the following: Standard of Care (S(NAME)) note 11/16/17 at 11:01 am, 11/9/17 at 9:48 am,- .Resident is up daily and wanders throughout the unit . S(NAME)-[MEDICAL CONDITION] medication note 11/2/17 at 10:01 am- .He wanders throughout the unit often entering others rooms . RAI (Resident Assessment Instrument) Progress note on 10/30/17 at 1:14 pm- .He ambulates with a steady gait on the unit and staff report he wanders in and out of other residents room . Activity Progress Note 9/1/17 at 3:32 pm-Resident displays restlessness and tends to wander into rooms of peers . RAI progress note on on 7/28/17 at 1:36 pm- .He ambulates with a steady gait on the unit and staff report he wanders in and out of other residents room . S(NAME)-Behavior progress note on 7/20/17 at 9:56 am- .wandering on unit into other resident's room, resident wandered into lower level of facility . S(NAME)-Behavior progress note on 7/13/17 at 10:04 am- .wandering on unit into other resident's room resident wandered into lower level of facility . S(NAME)-Behavior progress note on 7/6/17 at 9:59 am- .wandering on unit into other resident's room . S(NAME)-Behavior progress note on 6/7/17 at 9:44 am- .wandering throughout unit into other resident's room . Nursing note 5/22/17 at 9:50 pm- .Resident was made aware he can not be physical with other residents or staff . Nursing note 5/18/17 at 7:03 pm- Resident removed his pants and underpants and entered rooms [ROOM NUMBERS]. Nurse had a difficult time redirecting him . Nursing note 5/14/17 at 2:57 am- .Assisted back to bedroom .after ambulating hall and roaming into other residents room; found in room [ROOM NUMBER]B at one time this shift .redirected multiple time Nursing note 5/11/17 at 11:01 pm- .Resident is non-stop wandering halls and in and out of other resident rooms . Nursing note on 5/11/17 at 6:59 am- .up most of shift walking up and down hall; enters other resident rooms . Nursing note on 5/7/17 at 3:33 pm- .Resident went into room (not resident's assinged room) and was sitting on their toilet .Resident took his pants and brief off and would not put anything on then proceeded to walk to his room with only a shirt . Nursing note on 5/6/17 at 2:44 pm- .awake all day long wanders back and forth wanders to other res (resident) rm (room) as well, been redirected to his rm so many times . Nursing note on 5/1/17 at 7:45 pm- .Resident in and out of other resident's rooms .Went into room (not resident's assigned room) and resident told family that he sat on her bed 4 times .Family is getting pretty upset when he goes in there. He continues to go into other resident's room as well . A review of Resident #68's care plan was conducted at that time and and included the focus: Resident exhibits wandering behavior .Interventions for wandering included: Allow for safe wandering . The care plan's last revision was noted to be 7/20/17 and did not address Resident #68 wandering into the rooms of his peers. A review of Resident #69's clinical record was conducted on 11/30/17 at 3:51 pm and 12/6/17 at 9:39 am,The record indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #69's most recent MDS assessment dated [DATE] indicated severely impaired cognition, physical, verbal and other behaviors towards others, daily wandering, and independence with ambulation. Behavior monitoring tasks included target behaviors of: aggressive behaviors toward others, combative with care, and difficult to redirect. The behavior monitoring not include monitoring for wandering. A review of progress notes was conducted and revealed the following: Nursing note on 11/22/17 at 10:13/17 pm- .res removed his clothes a few times during the shift . Nursing note 11/21/17 at 20:32 pm- .writer observed res removing his clothes from his body, res unable to redirect by writer . Nursing note on 11/10/17 at 10:55 pm- .wandering through hall and rooms . Nursing note on 11/9/17 3:02 pm- .Resident observed in another resident's room with a brief and gown on . Nursing note on 11/8/17 at 9:41 pm- .Res walked in/out of residents' rooms a few times during shift . Nursing note on 11/7/17 at 11:24 pm- .Res wandered into other residents room a few times .Res took own clothes off twice during shift. Writer able to put on gown on res second time . Nursing note on 11/5/17 at 10:26 pm- .wandering in and out of various rooms throughout shift . Nursing note on 10/31/17 at 7:57 pm- .res started wanting to take off his clothes .a few minutes later res was observed walking, in hallway without his shirt .Res later took off his pants . Nursing Note on 10/30/17 at 11:58 pm- .wandering throughout shift. in and out of various rooms .frequently noted in other resident's beds . Nursing note on 10/27/17 at 10:24 pm- .wandering in and out of rooms .cont (continues/continued) to wander and get into other unoccupied beds. wandering unit at this time . Nursing note on 10/26/17 at 11:30 pm- .wandering into other rooms and aggressive at times .One to one with staff/standby as much as possible . Nursing note on 10/25/17 at 10:33 pm- .wandering throughout shift .noted in beds of other residents . Nursing note on 10/22/17 at 9:42 pm- .wandering in and out of various rooms throughout shift .often noted sitting on beds of other residents .noted sitting on roommates bed . Nursing note on 10/21/17 at 10:50 pm- .ambulating in hall throughout shift, wandering in and out of various rooms . Nursing note on 10/20/17 at 10:36 pm- .pacing hall throughout shift, wandering in and out of rooms . Resident #4 and Resident #49 On 11/30/17 at 2:09 pm, a review of the facility reported incident on 11/19/17 between Resident #4 and Resident #49 was conducted. During the review it was discovered that Resident #4 (male resident) had wandered into Resident #49's (female resident) room and into the bathroom in that room on 11/19/17. CNA (certified nursing assistant) 'D' was in Resident #49's room when Resident #4 wandered into the bathroom. CNA 'D' attempted to re-direct Resident #4 out of the bathroom, and that time it was documented that (Resident #4) made contact to (Resident #49's) right leg with his belt . On 12/6/17 at 12:17 pm, an interview with Nurse 'C', the nurse caring for Resident #4 on 11/19/17 was conducted. During the interview, Nurse 'C' indicated she was aware of the incident and stated, Somehow he had a belt. The aide came and told me he wandered in the room, was attempting to hit her, she tried to re-direct him, and then he started hitting (Resident #49) with the belt. An attempt to interview CNA 'D' was unsuccessful as phone calls were not returned. On 11/30/17 at 10:00 am, a group interview was conducted with cognitively intact residents. During the interview Resident #38 expressed concerns of three men that wander into her room on the second floor. Resident #38 indicated one of those men wanders around naked and stated, It's scary, I am afraid I am going to get raped. A resident who wished to remain anonymous from the group interview also indicated he has seen a man with no clothing wandering the hallways on the second floor. Resident #84 On 11/28/17 12:45 p.m., Resident # 84 was observed lying in bed in her room. Posted on her wall was a communication sheet with pictures. When questioned about life in the Facility, Resident #84 presented with impaired speech, but was able to use gestures and respond to yes/no questions presented. When questioned about life in the Facility, Resident #84 started pointing towards the window and started crying. When asked do you want to leave, the Resident said,yes. When asked if she felt safe in the Facility, the Resident shook her head no and used her finger to point up towards the ceiling. When asked if she was hurt by someone, the Resident made a fist and again pointed her finger up towards the ceiling and then towards her chest and cheek. The Resident asked if she was hurt by a male or female. The Resident responded by shaking her head yes to male. The Resident was asked if the male was a staff member, the Resident shook her head no. When asked if the male lived in the Facility, the Resident responded, yes. The Resident was asked if the incident happened up stairs, she again pointed her finger up. When asked how many times it happened, the Resident shook her head, yes. The Resident continued to cry during the interview and pointing her finger toward the window and then placed her hand near her ear as if trying to use a phone. A second Surveyor entered the room and again the Resident continued crying, made a fist, pointing to her cheek and chest and then pointed to the outside window. A Nurse working on the floor reported that the Resident had been transferred from a room upstairs to the room in which she resides a few weeks ago. A review of the Residents clinical record revealed that the Resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's MDS (minimum data set) dated 8/15/17 documented that the Resident had a BIMS (brief interview for mental status) score of 13 (cognitively intact) and required extensive two person assist for transfers, mobility, toileting and showering. On 11/29/17 at 9:08 a.m., a second interview was conducted with Resident #84. Again, the Resident became teary eyed, started crying, pointed toward the window, making a fist and pointing towards the ceiling. The Resident was queried as to whether she had ever told a staff member about the incident. The Resident nodded Yes. When asked if staff was female, the Resident responded yes. A CNA (certified nursing assistant) entered the room with a breakfast tray. The Resident refused the breakfast tray. When asked if she wanted an alternative meal, the Resident refused. The CNA stated that she had been refusing her meals recently. On 11/29/17 at 11:00 a.m., the Administrator provided documentation pertaining to an incident related to Resident #84. A review of the documentation documented, in part, the following: Type of Investigation: Alleged physical abuse One the evening of 11/4/17 Administrator received notification from (name redacted) marketing that a website review was written on the facility. The Administrator proceeded to (webpage facility review) to find a review written by (name redacted) stating amongst other complaints, that her mother complained about being abused and touched inappropriately (name redacted) Social Service Director met 1:1 with Resident on morning of 11/5/17 in regards to a possible abuse situation She denied that anyone had been in her room and touched her inappropriately. No distress was observed .Upon conclusion of the investigation, the facility is unable to substantiate abuse as stated from a (website) review .a skin and pain assessment did not result in anything suspicious, the resident with a BIMS of 13 denied any abuse . Review of the Resident's clinical record was conducted and revealed, in part, the following: Psych Service Visit (November 7, 2017): Met with patient individually. Patient is essentially nonverbal. She is able to nod yes or no and make gestures. Patient indicated she would like to be at another facility. When asked if someone touched her she lifted her hand up to indicate a tall person and then put her hand to her face and squeezed her checks. When asked if a tall person came into her room and squeezed her cheeks she nodded yes. When asked if it was a staff person she nodded no. When asked if the person was upstairs she nodded yes. When asked if she had any visitors from family she nodded no and became tearful . It should be noted that the last visit by Psych Services prior to the November 7, 2017 visit was on March 29, 2017. Further review of Resident #84's records revealed, in part, the following: Nurse Note (8/20/17) Resident was very upset and crying when another resident entered into her room and moved her bedside table while touching her stuff. Staff attempted comfort resident but she was crying forcefully. After exiting the room the writer heard the resident making a strange repetitive noise . Nurse Note (11/12/17): Resident observed lying in bed crying. This nurse asked resident what was wrong, using hand resident put a phone symbol to ear .this nurse asked if calling family would help, resident shook head no. Nurse Note (11/25/17): Res having increased sadness unable to console, social work notified via 24 hour binder Nurse Note (11/26/17): Resident having increased sadness refused dinner x3 attempted as well. Offered a snack x3 res still refused. Res non verbal writer attempted to guess what was upsetting the res .when writer asked Res if she was sad about family res didn't respond or shake head .Social work notified via 24hr binder. On 11/30/17 at 2:04 p.m., a conversation between Social Worker A and Resident #84 was observed in the Resident's room. The Resident was lying in bed crying and SW A asked about a man hitting the Resident in the face. The Resident answered yes. SW A asked if it was a man with a beard. The Resident nodded yes. The Resident continues to cry and shakes her head Yes when asked if she told SW A about the Resident entering her room and hitting her in the face when first interviewed. An interview with SW A was conducted following the observation. SW A was queried as to the Resident #84's response about a man hitting her in the face. SW A responded that she never told me that before, she just told me that someone came into her room, but not that she was abused or in fear. When queried as to whether she responded to nurse notes on 11/25/17 & 11/26/17 and the 24 hour report that indicated the Resident was inconsolable and crying, SW A responded that she was not aware of the 24 hour report. SW A reported that she did see the Resident over the weekend and provided her with a cola drink and refered her to psych services. On 11/30/17 at 2:51 p.m., an interview was conducted with the Administrator/Abuse Coordinator pertaining to Resident #84. The Administrator/Abuse Coordinator was queried as to the I&A report dated 11/6/17. The Administrator reported that upon looking over website reviews of the Facility she noted a review that was disturbing indicating that a Resident who couldn't talk or walk complained of inappropriate touching and abuse. After investigation, the Facility was able to determine that the the online review was written by the daughter of Resident #84. Attempts by the Facility to contact the daughter resulted without a response. The Administrator was queried as to whether she every interviewed the Resident. The Administrator reported that she did not. The Administrator reported that SW A spoke with her. A review of a progress note written by SW A dated 11/6/17 that documented .She denied that anyone has been in her room or touched her inappropriately recently, but did acknowledge that a tall man sometimes comes into the room. When asked if the tall man touched her, she said yes. When asked where the tall man touched her, she put her hand on her cheek. When asked if the tall man hurt her, she shook her head. When asked if she felt scared when someone enters into her room, she paused and nodded her head . was discussed with the Administrator. It should be noted that the last social work note prior to 11/6/17 note was dated 1/12/17. The Administrator was queried as to whether the facility investigation included information pertaining to the tall man. The Administrator reported that there was not any documentation pertaining to the tall man, but that the Facility came to the conclusion that it was probably Resident #68. A request for all I&A's pertaining to Resident #68 was requested by the Surveyors. No documentation pertaining to Resident #68 and Resident #84 was provided by the Facility prior to exit. When queried as to why the Facility determined it could not substantiate abuse with respect to Resident #84, the Administrator responded that the Resident showed no signs of harm and a physical assessment showed no injury. The Administrator further reported that while there were residents, including Resident #68 that resided on the second floor that wandered, they showed no signs of agressive behavior and as such, abuse could not substantiated. A review of the resident council meeting minutes dated 8-07-2017, 8-25-17, 9-27-17 and 10-27-2017 that asked the question Are you ever disturbed or bothered by residents wandering into your room? was reviewed on 12/1/17 at 4:00 p.m All of the above dated minutes reflected the answer Yes. to the question. The question can you identify the resident was also answered. Yes. An interview with Activities Director I was conducted on 12/06/17 11:28 AM. Staff I was queried as to the questions pertaining as to are you ever disturbed or bothered by residents wondering into your room as recorded in the resident council minutes. Staff I reported that her job is only to ask the questions and then the Administrator is provided the information to determine what to do about it. Staff I stated that she never received any follow-up pertaining to the continued responses to the question. On 12/6/17 at 3:30 p.m., a subsequent interview with the Administrator was conducted. When queried as to the resident council meeting notes (8/7/17,8/25/17, 9/27/17 and 10/27/17) indicating that Residents were disturbed or bothered by residents wandering in to their rooms, the Administrator responded that the question was designed to see if there was any issues and didn't always trigger an investigation. The Administrator reported that no concern forms/investigation forms were completed by the Facility as related to the Resident Council notes. The Administrator stated, I did not consider the answer Yes to the question posed (are you ever disturbed or bothered by resident wandering into your room) as a concern and therefore it was not investigated as a concern. In the beginning of November, after the incident involving Resident #4 striking Resident #49 we decided to move some of the men with wondering issues to a different room down the hall. We did not consider these Residents to be aggressive or abusive, just wanderers with dementia who were not abusing the residents. * Please refer to resident progress notes (#4, #68 & #69) as documented above. On 12/6/17 at 4:00 p.m., a review of the Facility Polity titled Abuse Prevention Program was conducted and documented, in part, the following: Policy Interpretation: Our facility is committed to protect our resident from abuse by anyone including, but not limited to: facility staff, other residents . Abuse: The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish incidents of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish (emphasis added). It includes .physical abuse and mental abuse . Neglect: is the failure of the facility .to provide goods and services to resident that are necessary to avoid physical harm, pain or mental anguish (emphasis added). 16. The individual conducting he investigation will, at a minimum: review the resident's medical record to determine events leading up to the incident: interview the person(s) reporting the incident: interview an witnesses to the resident: interview the resident .:interview staff members (on all shifts) who have had contact with the resident: .review all events leading up to the alleged incident 18. While the investigation us being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents 22. The results of the investigation will be The Facility submitted the following acceptable plan (unsigned by the Administrator) including supporting documentation to remove the immediacy on 9/20/2017: As a result of the finding of Immediate Jeopardy by the survey team on 12/01/2017 related to resident's #84, #68, #38, #4, #69, and #49, the facility has reviewed the below to determine causation. Findings include: Resident #84 was re-assessed on 12/1/17 for mental anguish by the Administrator, Social Services and the Nurse Practitioner. She remains at baseline and has no signs of emotional distress or mental anguish. The responsible party and physician have been notified. Resident #68 was re-assessed on 12/1/17 by Social Services for aggressive behavior. He has had no incidents of aggressive behavior towards other residents. Resident #4 was re-assessed by on 12/1/17 Social Services for aggressive behavior. He has had no further incidents of aggressive behavior towards other residents. Resident #69 was re-assessed on 12/1/17 by Social Services for aggressive behavior. He has had no incidents of aggressive behavior towards other residents. Resident #49 was re-assessed on 12/1/17 by a Licensed Nurse and Social Services. She remains at baseline and has no signs of emotional distress or mental anguish. The responsible party and physician have been notified. Resident #38 was re-assessed on 12/1/17 by Social Services for fear of assault. She remains at baseline and requests a room change. She will be moved 12/1/17 from the second floor to the first floor. The responsible party and physician have been notified. A Hall Monitor has been assigned to each Unit every shift to ensure wandering residents do not wander into other residents rooms, and all residents feel safe and secure. Total of 87 residents, 33 of 87 residents that are cognitively impaired have been assessed by Licensed Nurses for s/s of abuse using a skin assessment on 12/1/17. Any signs of physical abuse? Any signs of psychosocial distress? Any bruising or skin tears? 33 of 87 residents had no findings of abuse on their skin assessments. The remaining 54 residents that are capable of making their own decisions have been interviewed by the IDT regarding abuse concerns from other residents on 12/01/2017. Do you have any abuse concerns? Resident #1 stated concerns about the food. A concern form for dietary was initiated. Resident #2 stated she would like a room change because she is not getting along with roommate. Social Services notified and will move resident when the next available room opens up. Resident #3 requested a room change. The room change was initiated. Resident #4 stated a concern about call light response times. A concern form for nursing was initiated. Resident #5 stated she would like a fan. Maintenance notified. Resident #6 stated he was missing clothes. A concern form for laundry was initiated. Resident #38 stated she does not feel safe on second floor. A room change was completed, Social Services assessed resident. The Administrator has reviewed the grievance log and incident and accident reports for the past 30 days to ensure there are no other occurrences of abuse. Systemic Changes Include: When an allegation of resident to resident abuse occurs the facility staff will: Immediately separate the residents Ensure residents are safe by providing supervision as needed Notify the Administrator Nurse will complete a physical assessment to ensure no harm Social Services will complete an assessment to ensure psychological stability. Psych services will be notified for additional support as needed. Administrator will ensure other residents safety by interviewing other like residents for identification of previous events. Administrator will interview staff witnessing the event. The Administrator will screen grievances as well as Incident Reports daily Monday-Friday for possible events that involve resident to resident abuse. Social Services will review Resident Rights and Ombudsman information with residents. The Administrator has reviewed the Abuse Policy and the Resident to Resident Altercations/Catastrophic Events/Abuse policy and deemed them appropriate. All current staff will be re-educated on the Abuse Policy regarding resident to resident abuse and wandering residents, as well as reporting and investigating guidelines by the Staff Development Coordinator on 12/1/2017. Any staff not currently working will be re-educated prior to their next scheduled day to work. The Administrator will audit incident reports for possible resident to resident abuse daily M-F and via phone on the weekends. Social Services will complete random interviews of residents for verbalization of resident to resident abuse concerns. The Medical Director/designee has been notified of the Immediate Jeopardy

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to assess and manage pain for one resident (#711), with a known history of pain, out of 10 residents reviewed for pain, out of a total sample of 19 residents, resulting in frustration, restlessness, repeatedly getting out of bed, crying, and yelling out due to unresolved pain. Findings include: On 10/17/16 at 8:25 am, an initial tour of the facility's second floor was conducted. During the tour, Resident #711 was crying out saying, Look at my feet, look how swollen they are, look at that blister! Resident #711's legs were observed to be wrapped in compression dressings and his feet were reddened, grossly [MEDICAL CONDITION], and weeping. On the top of Resident #711's foot, across his first four toes was a fluid filled blister measuring approximately 6.0 x 3.0 x 2.0 centimeters that had begun to weep serous (clear) fluid. Resident #711 was restless, agitated, writhing in bed, and crying out saying that his feet hurt. On 10/17/16 at 8:30 am, Registered Nurse (RN) 'B' was queried about Resident #711. Resident #711 could be heard crying out from the hallway. When RN 'B' heard Resident #711, she explained that he had a history of [REDACTED]. When asked about the blister on the top of Resident #711's foot she indicated she did not know about a blister, but after observing it, stated, That is quite the blister. On 10/17/16 at 9:15 am, Resident #711 was observed ambulating from his bed into the hallway, yelling out. RN 'B' was observed attempting to calm Resident #711 and direct him back into his room and back to bed. On 10/17/16 at 12:05 pm, Resident #711 was observed in bed. The facility's Director of Nursing (DON) was in the room with Resident #711 sitting with him, attempting to calm him. The DON stated, We are having some difficulty. Resident #711 was yelling out, I hurt. Resident #711 was restless and attempting to get out of bed as the facility's DON attempted to re-direct him. It was noted at this time that a large occlusive dressing had been placed on the fluid filled blister on the left foot. On 10/17/16 at 12:15 pm, a review of Resident #711's Medication Administration Record [REDACTED]. At that time, the MAR indicated [REDACTED]. On 10/17/16 at 12:40 pm, a second review of the MAR indicated [REDACTED]. On 10/17/16 at 12:55 pm, ambulance personnel arrived to transfer Resident #711 to the emergency room . The ambulance personnel were heard to ask Resident #711 if he was having any pain, to which Resident #711 cried out, I hurt all over, my feet and my stomach. Resident #711 was audibly crying. On 10/17/16 at 3:10 pm, a review of Resident #711's medical record was conducted and revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of admission assessments did not include an initial assessment for pain, despite the [DIAGNOSES REDACTED]. At the time of the review, Physician's orders did not include an order for [REDACTED]. 10/15/16 at 2:36 pm, a Nurse Practitioner's (NP) note that indicated that the NP visited Resident #711 for follow up to weeping [MEDICAL CONDITION]. 10/16/16 at 5:12 am, a nursing progress note reading, .The writer observed that the resident's BLE (bilateral lower extremities) are very [MEDICAL CONDITION] to the point that blisters have formed on his feet . The note did not indicate an assessment for pain. 10/16/16 at 12:32 pm, a Skin note reading, .Pitting [MEDICAL CONDITION] to ble (bilateral lower extremities) with weeping in areas to bilat (bilateral) feet .Multiple blisters to top of left foot at base of toes . The note did not indicate an assessment for pain. 10/17/16 at 12:36 pm, a nursing progress note reading, .Left LE (lower extremity) noted as red and warm to the touch, resident complaining of pain to bilateral LE and generalize pain, Tylenol give by charge nurse. Resident noted yelling and crying . It was noted that the Tylenol administration was documented in the note on 10/17/16 at 12:36 pm, several hours after the resident's complaints of pain and several hours after the order was received at 9:30 am, on 10/17/16. Continued review of Resident #711's medical record included a care plan for pain that read, .Resident at risk for pain .Anticipate Resident's need for pain relief and respond immediately to any complaints of pain . On 10/19/16 at 3:10 pm, an interview with the facility's DON regarding pain and pain assessments was conducted. The DON indicated that pain assessments and treatment for [REDACTED]. On 10/19/16 at 3:30 pm, a review of the facility's policy titled, Pain Assessment read, .A comprehensive pain assessment will be completed as part of the initial nursing assessment . The facility was asked if they had any additional information to provide, none was received by the end of the survey. ( ) Deficient Practice #2: Based on interview and record review, the facility failed to adequately maintain complete documented communication with the [MEDICAL TREATMENT] center for coordination of care for one (#705) of one resident reviewed for [MEDICAL TREATMENT] treatment of [REDACTED]. Findings include: On 10/18/16 at 3:00 pm, review of the clinical record for Resident #705 revealed the following. Resident #705 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the minimum data set resident assessment instrument, dated 9/29/16, Resident #705 had moderate cognitive impairment and was dependent on staff for transfer, ambulation, hygiene and grooming. The physician orders, dated October, 2016, included [MEDICAL TREATMENT] at (name) [MEDICAL TREATMENT] center, Monday, Wednesday and Friday. Further review of the clinical record revealed no evidence communication with the [MEDICAL TREATMENT] center for 9/26, 9/28, 10/3, 10/7, 10/12, 10/14 and 10/17/16. According to the facility policy, [MEDICAL TREATMENT], dated 3/23/11, .The following information should be recorded on [MEDICAL TREATMENT] Communication Record: l. The date and time the procedure was performed 2. List of medications administered in the prior six hours 3. All assessment data 4. Last weight 5. Any changes or information to resident's condition 6. The signature and title of the person recording the data Original is sent with resident to [MEDICAL TREATMENT] Center (Copy retained until original is returned); [MEDICAL TREATMENT] Center documents on bottom of form: 1. Medications given during/after [MEDICAL TREATMENT] treatment 2. Pre and post treatment weights 3. Pre and post vital signs 4. Special instructions/comments and/or changes in resident's condition 5. The signature and title of the person recording the data. Retained as part of resident medical record. Post-[MEDICAL TREATMENT] Log completed upon resident return from [MEDICAL TREATMENT] 1. Vital signs 2. Weight 3. Assessment of shunt site 4. Check shunt site for bleeding, pain, redness, swelling every hour for six hours Retained as part of resident medical record. On 10/18/16 at 4:00 pm, during an interview, Unit manager ., confirmed that the facility had not received [MEDICAL TREATMENT] communication record from the [MEDICAL TREATMENT] center on the aforementioned dates. The unit manager further explained the facility had not completed the [MEDICAL TREATMENT] communication per facility policy. On 10/19/16 at 3:00 pm, during an interview, the director of nursing confirmed there was no evidence that the facility had maintained communication with the [MEDICAL TREATMENT] center. .we have to follow the policy . ( )

This citation pertains to M 8085 Based on observation, interview and record review, the facility failed to transfer a resident with a two person Hoyer lift for one (#705) of three sampled Residents reviewed for Activities of Daily Living (ADL) from a total sample of three 3 resulting in pain and swelling to the left patella and diagnosed fracture. Findings include: On 3/8/16 at 10:00 a.m., during an initial tour of the facility, Resident #705 was observed lying in bed. The Resident was queried about life in the facility and the quality of care she was receiving. Resident #705 stated, Things are up and down here. I've felt better before. I have pain in my knee (left). A few weeks ago, two girls were trying to get me out of bed into my chair, and my leg got caught underneath and was twisted. They were supposed to use a Hoyer lift (a lift that utilizes a sling to transfer patients from one loction to another) to get me out of bed, but they used a belt instead. I told them I use a lift. Since then my knee has been hurting me. I went to the doctor and he said it was fractured. They give me pills for pain and I have this cast thing for my knee. On 3/8/16 at 2:00 p.m. the clinical record for Resident #705 was reviewed and revealed that Resident #705 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment ((MDS) dated [DATE] was reviewed and revealed that Resident #705 had a Brief Interview for Mental Status score of 15 (cognitively intact/able to make herself understood). Further review of the clinical record revealed a Fall Care Plan (dated 7/1/15) that revealed, in part, the following: * Resident safety and manage Risk for Falls * Dependant on 2 person assist with mechanical lift A General Progress Note dated 3/1/16 at 15:34 and authored by Nurse C revealed, in part, the following: pt c/o (complains of) left knee pain and swelling, NP (nurse practitioner) notified, new orders for stat x-ray, PRN (as needed) Tramadol (a narcotic used to treat moderate to severe pain) 50 mg Q 6 hours, ice pack 4 times daily as needed for 20 minutes at a time, ortho (orthopedic doctor) appointment for 3/3/16, incident report written Xray results shows a patella Fx (fracture) . A General Progress Note dated 3/3/6 at 15:11 and authored by Nurse C revealed, in part, the following: Resident alert and responsive. Resident back from Orthopedic appointment around 1500 with staff via stretcher and (Transfer Company). Resident transferred back to bed and resting comfortably in bed. Ortho wants Left knee immobilizer on when transferring or moving around (ambulating per consult sheet). Resident can have the immobilizer off while in bed and may bend knee slightly to prevent stiffness if comfortably. F/u (follow-up) appointment within 1 month. Immobilizer to be worn for a month and the Ortho stated that the fracture should heal within 1 month. A Progress Note dated 3/8/2016 and authored by Nurse Practitioner (NP) D revealed, in part, the following: Assessments: 2. Patellar fracture Treatment 2. Patellar fracture: Notes: 1, knee immobilizer, Ultram for pain, fu (follow-up) with ortho one month. A Facility Investigation Report (IR) dated 3/1/16 was reviewed on 3/8/16 at 2:30 p.m., and revealed, in part, the following: Date of Incident: 3/1/16 Time of Incident: 11:30 a.m. Resident: #705 Condition prior to Incident: Alert Brief Description: Pt stated on 2-29-16 during a two person assist transfer her left leg was caught up under the w/c (wheel chair) causing her left leg to be bent backward completely. Injury type: Fracture A Statement of Witness included in the IR and dated 3/1/16 was reviewed and revealed, in part, the following: Name and Position of Witness: Staff D (physical therapy) Date and time of incident: 2/29/16 11:45 a.m? Resident name: #705 Statement of Witness: Staff D went to see patient, patient was up in wheelchair without Hoyer sling. When Staff D asked about transfer, patient mentioned that 2 new aides got her up in wheelchair and twisted her left knee. Foot of patient got caught under chair because wheelchair was not locked. Patient c/o pain. Staff D took patient to nurse and reported incident. Staff D requested pain meds for patient and nurse called DR(doctor) to get ok for pain pill and bring pain medicine to therapy gym. Staff Dapplied ice pack and Biofreeze and reinforced Hoyer lift for all transfers. On 3/9/16 at 1:15 p.m., an interview was conducted with Staff D regarding the incident that occurred on 2/29/16. When queried as to what his recollection of the occurrence, Staff D stated, I remember that day very well. I entered the room to take her to therapy and she was complaining of pain in her Left knee. The first thing I noticed when I came to get the Resident was that she did not have the sling in her chair and I was unsure why. She told me she was transferred without the Hoyer lift and her foot got caught and her knee was twisted. I immediately told the nurse. She never had therapy that day, I did apply ice and Biofreeze to the knee. Continued review of the IR documented a Statement of Witness dated 3/1/16 revealed, in part, the following: Name and Position of Witness: CNA E Date and time of incident: 2/29/16 at 12 p.m. Statement of Witness: I went to Resident's room to help another CNA transfer Resident #705. We put a Gait Belt around her waist. Resident was asked can you stand. She replied, I do not believe so, but she did. We proceeded to put her into her wheelchair, as we were positioning her, Residents left leg slid under the wheelchair, her Left knee twisted as she sat down. She was saying ouch my knee is hurting CNA F scooted her leg over and straightened it out. Then I left and went back to my assignment. On 3/9/16 at 9:45 a.m., a telephone interview was conducted with CNA E. CNA E was queried about the incident that occurred on 2/29/16 during the transfer of Resident #705. CNA E stated, I remember the day. I had just starting working at the Facility. I was hired on 2/24/16. I was working in that unit with another CNA. I heard CNA F asking me to help her so I went into the room. CNA F had a Gait Belt out and I just helped her with the transfer and the Resident's foot got caught underneath the wheelchair and she told us it hurt her knee. When further queried if she reported the incident to anyone, CNA E stated, CNA E stated, No. I was very new. It was not my Resident. When asked whether she was aware of the Resident's care plan that required a two person transfer with a Hoyer lift, CNA E stated, No, I had not been trained on how to view the care plans. On 3/9/16 at 10:00 a.m., an attempt to contact CNA F by phone was conducted. No contact was made with CNA F by the end of the survey. On 3/9/16 at 11:30 a.m., an interview and record review was conducted with the Director of Nursing (DON) and the Administrator. Both the DON and the Administrator were queried as to incident and injury that occurred to Resident #705. The DON and Administrator stated, Both CNA E and F were new to the Facility. They should have know to use the Hoyer lift. CNA E should have been with her mentoring person and not assisting CNA F. We initially suspended them and then reinstated them and put them back in orientation so they could be retrained. The DON continued and stated, I know that the CNA's should have followed the Care Plan regarding the lift, but I really don't think the resident sustained [REDACTED]. Both the DON and Administrator were asked to provide evidence from the treating orthopaedic physician that the Resident had not sustained a fracture to the Left patella as evidenced in the Resident's clinical records. No evidence was provided from the treating orthopaedic physician prior to the exit. A document titled Facility Past Non-Complaince Checklist dated 3/9/16 was provided prior to exit on 3/916 at 1:40 p.m. and revealed, in part the following: Date of Report: 3/9/16 Resident: #705 Date of Event: 2/29/16 Was the Resident Injured? NO On 3/9/16 at 2:00 p.m., the Facility was asked to provide a Policy pertaining to staff following care plans. A Policy titled Care Planning -Interdisiplilary (revised 10/7/2010) was provided, but did not provide clarification on how staff should follow Interdisiplinary care plans. ( )

This citation refers to Intake #MI 642. Based on interview and record review, the facility failed to thoroughly investigate and report to the State Agency multiple injuries of unknown origin for one (#501) of three sampled residents reviewed for abuse, from a total sample of three, resulting in a traumatic laceration that required emergency care and sutures, a skin tear, and bruises of multiple stages of healing not being investigated or reported to the state agency and the potential for undetected abuse. Findings include: On 2/10/16 at 10:00 A.M., a review of Resident #501's clinical record was conducted and revealed the following: Resident #501 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessments, dated 10/21/15 and 1/18/16 documented that Resident #501 had moderately impaired cognition (Decisions poor; cues and supervision required); an MDS assessment dated [DATE] indicated that Resident #501 had severely impaired cognition (never/rarely makes decisions). The above mentioned MDS assessments documented that Resident #501 required extensive physical assistance from staff for bed mobility, transfers, and all activities of daily living, and did not walk. Injury #1 A review of nursing progress notes for Resident #501 from June 2015 through February 2016, documented the following: 12/6/15 at 4:00 P.M., a note created by the day shift nurse (Nurse E) documented , Res. drsg change (resident dressing change) 1:50 P.M. blood in the (dressing), skin tear from last night as reported by the previous shift, measured 7 (centimeters - cm) by 1 (cm), slight bleeding noted while being cleanse, applied TAO (triple antibiotic ointment) and cover with foam drsng and kerlix .dhtr (daughter) demand to send her to hosp (hospital) afraid of getting infection on her right lower leg where the skin tear was .(physician) been called and order to send her to (hospital) .Dhtr been notified that the Dr. ok to send her out .(ambulance) arrive 3:42 P.M . 12/6/15 at 4:29 P.M., a note created by nurse on duty during the afternoon and midnight shifts on 12/5/15 (Nurse D) documented, At 2245 (10:45 P.M. the previous night) resident observed by nurse with three areas of dried blood to anterior distal right lower extremity (front of the lower leg). Dried blood spotting 1-2 cm diameter, circular. Nurse [MEDICATION NAME] residents bilateral lower extremities, finding skin tear 5.5 cm length x 0.5-0.75 cm depth .asked by nurse what happened .Resident responds to each question 'I don't know' .Facility protocols followed: IPC notified (physician), wound care nurse notified, DON (director of nursing) notified, Incident report (wound of unknown origin) filed and Look at Me form is filled out . 12/7/15 at 10:27 A.M., a nursing note by the Unit Manager (Nurse F) documented, .Skin tear observed to right lower extremity. Wheelchair assessed and no sharp edges noted. Nails assessed and dried blood noted under nail .Resident returned from hospital with sutures to area. Per nurse the area was not bleeding but began to bleed through the dressing several hours after first observation . 12/7/15 at 10:40 A.M., a nursing note completed by the afternoon shift nurse (Nurse G) on 12/6/15 documented, Late charting for 12/6/15; Resident sent out to hospital per daughter's request at approximately 3 P.M. Return back to facility at approximately 7:30 P.M. 13 sutures in place . Emergency Services Discharge Instructions dated 12/6/14, documented that Resident #501 arrived at the hospital at 4:04 P.M. and also documented, Follow up with your physician for suture removal in 10 days .Extremity laceration .a laceration is a cut through the skin. This will usually require stitches (sutures) or staples if it is deep .Prescription (an antibiotic) three times a day for 5 days .Diagnosis: [REDACTED]. A note completed by the NP, dated 12/7/15, documented, .Reason for appointment: Laceration with sutures .Asked by staff to evaluate, resident sent out over the weekend due to laceration to right lateral lower extremity. She returned with 13 sutures .there is slight sero-sanguinous drainage .Unknown mechanism of injury A note completed by the Wound Care NP, dated 12/8/15, documented, .This is initial consult for evaluation and treatment of [REDACTED]. Staff reports this area was noted over the past week; however, traumatic injury was not witnessed. Resident was subsequently evaluated that day be emergency room or urgent care and 13 sutures were placed along this linear area of traumatic leg injury .Resident has very limited cognition and is confused and is not able to answer questions on command .This injury was not witnessed and is unclear how she sustained it .The linear measurement is 9.0 cm . Shower Sheets for November and December 2015 were reviewed at 12:15 P.M. and revealed that Resident #501 did not have a shower or skin assessment completed between 12/3/15 and 12/13/15. An interview was conducted with Nurse E (the oncoming day shift nurse on 12/6/15) on 2/10/16 at 12:45 P.M. regarding Resident #501 and the transfer to the hospital on [DATE]. Nurse E stated, She (Resident #501) had a skin tear, I think from the afternoon shift the day before. The midnight shift nurse (Nurse D) worked a double, and didn't know what happened, maybe she bumped it, but reported a skin tear on her leg, but it was really bad and actually needed stitches. It was bleeding a little bit in the morning, but the daughter was here and there was more blood later and we sent her out (to the hospital) around 2:30 P.M. or so. Nurse E was asked if there was a bandage or dressing on Resident #501's leg and reported there was a bandage and it had been applied on the night shift. The Treatment Administration Record and Physician's Orders were reviewed at this time and it was revealed that there was no physician's order for treatment to Resident #501's right leg until after she was sent out to the hospital on [DATE]. Nurse E was queried about the process for skin assessments. Nurse E reported the aides do them during showers (typically once or twice a week) and the nurses sign off on the shower sheets and document in the progress notes. The shower sheetsand nursing progress notes for Resident #501 were reviewed with Nurse E. Nurse E reported that there was no documentation of a shower or skin assessment between 12/3/15 and 12/13/15. An interview was conducted with Nurse D (the nurse on duty at the time the leg wound was identified) via the telephone on 2/10/16 at 1:30 P.M. Nurse D was asked about the above documented skin tear on Resident #501's right leg. Nurse D stated, I came in the next day and her daughter was upset. When I saw it (Resident #501's leg) the previous night, it was just a small tear so I treated it and bandaged it, then when I came in the next day, she (Resident #501's daughter) demanded that she go to the hospital. They sent her right back. She got stitches. Something must have happened in between for it to open up that much. It was just a 1 inch (equivalent to 2.54 cm) and a millimeter deep skin tear when I saw it. Nurse D was asked how Resident #501 got the skin tear and replied, It was of unknown origin. She must have done something else to it. Nurse D was asked if the skin tear of unknown origin was reported to anyone and stated, By the time I could do anything, the nurse already reported it and the daughter was there. It already happened by the time I came in the next day so I filled out a 'Look at Me' form and the DON would get that. Nurse D was asked if he contacted the physician when the skin tear was identified and stated, I put it on the log for her to be seen. Incident reports and corresponding investigations were requested from the administrator for Resident #501 from June 2015 through February 2016 on 2/10/16 at 12:45 P.M. An incident report for Resident #501 was reviewed on 2/10/16 at 2:00 P.M. and documented the following: Date of Incident: 12/5/15 Time of Incident: 22:45 P.M. (10:45 P.M.) Resident: Memory impaired, Physically impaired .Decision making impaired . Incident Type: Unobserved Was incident witnessed: No Location: hallway .skin injury .injury of unknown origin Brief description: Nurse observed resident sitting in wheelchair immobile, with dried blood on the distal right lower extremity, cleansed wound, 5 cm x 0.1-0.75 cm depth, no drainage (blood/serous, etc.) Treatment: First aid, assessment Action taken: staff re-education, resident education Name of physician notified: (physician's name) IPC log, 12/5/15 at 23:00 Name/Relationship of representative notified: (Resident #501's family member) arrived at 14:00 (2:00 P.M.), notified by attending nurse on arrival, 12/6/15 at 14:00 Person preparing report: Nurse D 12/5/15 Director of Nursing signed on 12/7/15 Administrator signed on 12/7/15 Attached to the incident report was a seven page document titled, Quality Assessment & Assurance (QA&A) Investigation Report that documented the following: Resident #501's name on page 1 On page 6, it was documented under the section that asked, Were the resident's clinical records reviewed? that on 12/7/15 (two days after the injury of unknown origin was identified), safety (no staff name) reviewed the care plan and medications. The section for residents, staff and visitors interviewed was left blank. The section for any related secondary sources of information reviewed was left blank. Results of Investigation were documented as follows and signed by the DON on 12/7/15: Resident alert, able to self propel wheelchair. Skin tear observed to right lower ext. Wheelchair assessed and no sharp edges noted. Nails assessed and dried blood noted under nail. Nail care provided and all nails filed. Resident returned from hospital with sutures to area. Per nurse the area was not bleeding but began to bleed through dressing several hours after first observation. No s/s of pain or distress . There was no other information included in the investigation. Injury #2 On 2/10/16 at 10:00 A.M., a nursing progress note dated 12/7/15, documented, At approximately 3:30 P.M., Unit Manager informed this nurse that resident's daughter (responsible party) had reported a bruise of unknown origin to the administrator. Upon assessment, bruise observed to left forearm. Ranges in colors from green/yellow to spots of purple .When asked what happened, resident looked at nurse then closes eyes shut and moans out, mmm . On 2/10/16 at 2:00 P.M., an incident report, dated 12/7/15 was reviewed and documented the following: Date of incident: 12/7/15 Time of incident: 3:30 P.M. Incident type: unobserved Was incident witnessed: No Location: resident's room Incident type: injury of unknown origin Brief description: Daughter reports of bruise to resident's left forearm. Bruise observed greenish/yellow with small spots of purple . Physician notified on 12/7/15 at 3:30 P.M. Name/Relationship of representative notified: (Resident #501's daughter) on 12/7/15 at 3:30 P.M. Signed by the DON and administrator on 12/8/15 The attached QA&A Investigation Report documented the following: Type of injury: bruise Location of injury on body: left forearm Details of injury: greenish yellow with spots of purple ecchymosis (bruising) Staff member who found injury: Nurse F and Nurse G (nurse note by Nurse G documented that Resident #501's daughter reported the bruise to the administrator) Last activity attended: meals in room Residents explanation/opinion of how injury occurred (even if confused): Resident kept eyes closed and stated, mmm. The section for residents, staff and visitors interviewed was left blank It was documented that Resident #501's careplan and medication was reviewed by safety on 12/8/15. The section for any related secondary sources of information reviewed was left blank. Results of investigation was signed by the DON on 12/8/15 and documented, Resident alert, has poor safety awareness. Self propels wheelchair around unit and runs into items such as tables. No pain noted to area. Doesn't affect resident ROM (range of motion) or ability to complete ADLs. Cont (continue) POC (plan of care). Injury #3 On 2/10/16 at 11:00 A.M., during a review of Resident #501's clinical record, the following progress note completed by the nurse practitioner (NP) documented the following: 11/27/15 Acute Care Visit by the NP documented, Staff request evaluation of right eye. She is LTC (long term care) resident with advanced dementia. She has ecchymosis noted to right outer corner eyebrow. She has .no recollection of how discoloration occurred. DW (discussed with) nurse . The NP previously evaluated Resident #501 on 11/24/15. The 11/24/15 note does not document ecchymosis to Resident #501's eye brow. No incident reports or investigations were received regarding the bruising to Resident #501's right eyebrow. Injury #4 An incident report, dated 10/10/15, documented the following: Date of incident: 10/10/15 Time of incident: 2:30 P.M. Location: bathroom of (another resident's room) Incident type: unobserved Incident type: fall Was incident witnessed: no Brief description: observed resident on bathroom floor, left lateral side, brief soiled with BM (bowel movement) and urine .brief and pants around ankles . Injury type: skin tear Person preparing report: Nurse H The incident report was not signed by the DON or administrator The attached QA&A Investigation Report documented the unwitnessed incident as a fall with skin tear in another resident's bathroom. The resident's explanation of incident was documented as I didn't fall .I don't remember. The section for Injury of Unknown Origin was completed, as follows: Type of injury: skin tear Location of injury on body: inner left buttock Staff member who found injury: (first name of a staff member) Staff responsible for resident at time injury found: Nurse H The section for interviews of residents, staff or visitors was left blank. It was documented that on 10/15/15 (five days after the incident) at 10:40 A.M., safety reviewed Resident #501's care plan and medication The results of the investigation were signed by the DON on 10/15/15 and documented, Resident alert, able to make needs known. Resident entered bathroom and attempted to use. Brief soiled. Requires assistance with transfers. Resident was toileted and cleaned up. No pain. Skin tear to buttock cleansed and treatment applied as ordered. Will do 3 day bowel and bladder patterning to assess toileting needs. Progress notes for October 2015 were reviewed for Resident #501 at 11:15 A.M. and documented the following: A nursing note by Nurse H (nurse who completed the incident report) on 10/10/15 that documented, Unable to read note. An interview was conducted with the DON and administrator (abuse coordinator) on 2/10/16 at 2:50 P.M. The administrator was asked to explain the facility's process for investigating injuries of unknown origin. The administrator reported that an incident report would be filled out, an assessment would be done, the staff were required to notify the administrator, and the administrator would report it to the state agency. The administrator was asked how an investigation of an injury of unknown origin would be conducted. The administrator stated, If the resident can't say what happened, we would interview all staff that took care of that resident, interview other residents, try to figure out what happened, and depending on the injury we would notify the police. When queried about who would conduct the investigation, the administrator reported that either herself or the DON would do it. The incident report from 12/5/15 (laceration of unknown origin that required sutures) was reviewed with the DON and the administrator. The DON indicated that the investigation was completed by her and safety. The DON was asked how Resident #501 got the laceration on her right leg and stated, Our conclusion was that she had dried blood under her nail so we trimmed and filed her nails. The DON was asked if any staff were interviewed to determine what happened. The DON reported that she had not interviewed any staff members or other residents and that Resident #501 could not state what happened. The DON was asked if any skin assessments were reviewed as part of the investigation and stated, I'm sure they were. The Shower Sheets and nursing notes from December 2015 were reviewed with the DON at this time. The DON was queried about the lack of documented shower or skin assessment between 12/3/15 and 12/13/15 and did not offer an explanation. The administrator was queried about the process for investigating injuries of unknown origin and stated, It wasn't done. There are no witness statements or interviews done. When asked if interviews should have been completed as part of the investigation, the administrator reported that they should have been done. The incident report from 12/7/15 (bruises of unknown origin in multiple stages of healing on Resident #501's left forearm) was reviewed with the DON and administrator. The DON was asked about the investigation. The DON reported that it was concluded that she bumped her arms because she self propels in the wheelchair and bruised easily. When queried about whether or not her skin assessments were reviewed or any staff were interviewed, the DON stated, We didn't have to because we came to a conclusion of what happened. She banged her arms. The DON was asked if there was a care plan for Resident #501 that documented the history of banging into walls and bruising easily. The care plans were reviewed with the DON and did not document those issues. The administrator was asked why the laceration of unknown origin from 12/5/15 and the bruises of unknown origin were not reported to the state agency. The administrator stated, I guess they should have been. They weren't considered an injury of unknown origin once we came to a conclusion about what happened. The DON and administrator were asked how a definite conclusion was made without interviewing anyone and did not offer an explanation. The progress note completed by the NP on 11/27/15 that documented ecchymosis to Resident #501's eyebrow was reviewed with the DON and administrator. The DON reviewed the NP note and nurses notes and stated, There's no nurse documentation of it, maybe the nurse practitioner documented on the wrong resident. When queried about why she thought the NP documented on the wrong resident, the DON stated, Because the nurses would document and report it to me and we would investigate it. When asked if it was possible that the nurse did not follow the protocol, the DON did not offer an explanation. The DON was queried about how the staff notify the physician or NP to request a visit. The DON reported that it was typically written on a log. The physician/NP visit request log for November 2015 was requested. The DON stated, They throw them out. The incident report from 10/10/15 (skin tear of unknown origin to buttock) was reviewed with the DON and administrator. The DON was interviewed about the investigation of how Resident #501 got the skin tear. The DON stated, She wheeled herself into the other resident's bathroom and tried to go to the bathroom. When queried about how it was determined that this caused the skin tear and if anyone was interviewed or skin assessments reviewed, the DON reported that they did not have to because they knew how it happened. The DON was asked how it was known what happened if it was unwitnessed and did not offer an explanation. The administrator was queried about the above incidents/injuries of unknown origin and if they were investigated per the facility's policy. The administrator stated, Thorough investigations were not done. The facility's policy titled, Abuse Investigations (revised October 2012) was reviewed on 2/10/16 at 1:50 P.M. and documented the following: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management . .The individual conducting the investigation will, as a minimum: Review the resident's medical record to determine the events leading up to the incident; Interview the person reporting the incident; Interview any witnesses to the incident; Interview the residents (as medically appropriate); .Interview the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors; Review all events leading up to the alleged incident . .The results of the investigation will be recorded in a report form. .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .within five working days of the reported incident . The facility's policy titled, Reporting Abuse to Facility Management (Revised October 2012) documented the following: When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals will immediately (as described in state and federal guidelines) notify the following persons or agencies of such incident as indicated by State of Federal Licensure Policy .The State licensing/certification agency responsible for surveying/licensing the facility . ( )

This citation refers to Intake #MI 642 Based on interview and record review, the facility failed to provide emergency care to a traumatic leg laceration for one (#501) of three residents reviewed for quality of care, from a total sample of three, resulting in the delay in treatment of [REDACTED]. Findings include: On 2/10/16 at 10:00 A.M., a review of Resident #501's clinical record was conducted and revealed the following: Resident #501 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessments, dated 10/21/15 and 1/18/16 documented that Resident #501 had moderately impaired cognition (Decisions poor; cues and supervision required) and required extensive physical assistance from staff for bed mobility, transfers, and all activities of daily living. A review of nursing progress notes from June 2015 through February 2016, documented the following: 12/6/15 at 4:00 P.M., a note created by the day shift nurse on 12/6/15 (Nurse E) documented , Res. drsg change (resident dressing change) 1:50 P.M. blood in the (dressing), skin tear (a partial or complete separation of the outer layer of skin from the inner tissue) from last night as reported by the previous shift, measured 7 (centimeters - cm) by 1 (cm), slight bleeding noted while being cleansed, applied TAO (triple antibiotic ointment) and cover with foam drsng and kerlix .dhtr (daughter) demand to send her to hosp (hospital) afraid of getting infection on her right lower leg where the skin tear was .(physician) been called and order to send her to (hospital) .Dhtr been notified that the Dr. ok to send her out .(ambulance) arrive 3:42 P.M . 12/6/15 at 4:29 P.M., a note created by the afternoon and midnight shift nurse from 12/5/15 (Nurse D) documented, At 2245 (10:45 P.M. the previous night) resident observed by nurse with three areas of dried blood to anterior distal right lower extremity (front of the lower leg). Dried blood spotting 1-2 cm diameter, circular. Nurse [MEDICATION NAME] residents bilateral lower extremities, finding skin tear 5.5 cm length x 0.5-0.75 cm depth .asked by nurse what happened .Resident responds to each question 'I don't know' .Facility protocols followed: IPC notified (physician), wound care nurse notified, DON (director of nursing) notified, Incident report (wound of unknown origin) filed and Look at Me form is filled out . There were no nursing notes regarding Resident #501's leg until the following day, 12/6/15, at 4:00 P.M., after Resident #501 had been sent to the hospital. 12/7/15 at 10:27 A.M., a nursing note by the Unit Manager (Nurse F) documented, .Skin tear observed to right lower extremity. Wheelchair assessed and no sharp edges noted. Nails assessed and dried blood noted under nail .Resident returned from hospital with sutures to area. Per nurse the area was not bleeding but began to bleed through the dressing several hours after first observation . 12/7/15 at 10:40 A.M., a nursing note documented by the afternoon shift nurse on 12/6/15 (Nurse G), Late charting for 12/6/15; Resident sent out to hospital per daughter's request at approximately 3 P.M. Return back to facility at approximately 7:30 P.M. 13 sutures in place . A note completed by the Nurse Practitioner (NP), dated 12/7/15, documented, .Reason for appointment: Laceration with sutures .Asked by staff to evaluate, resident sent out over the weekend due to laceration to right lateral lower extremity. She returned with 13 sutures .there is slight serosanguineous drainage (blood tinged drainage) . A note completed by the Wound Care NP, dated 12/8/15, documented, .This is initial consult for evaluation and treatment of [REDACTED]. Staff reports this area was noted over the past week; however, traumatic injury was not witnessed. Resident was subsequently evaluated that day by emergency room or urgent care and 13 sutures were placed along this linear area of traumatic leg injury .The linear measurement is 9.0 cm . Emergency Services Discharge Instructions (from the hospital) dated 12/6/15, documented that Resident #501 arrived at the hospital at 4:04 P.M. (approximately 18 hours after the wound was first identified) and also documented, Follow up with your physician for suture removal in 10 days .Extremity laceration .a laceration is a cut through the skin. This will usually require stitches (sutures) or staples if it is deep. Minor cuts may be treated with surgical tape closures .Prescription (an antibiotic) three times a day for 5 days .Diagnosis: [REDACTED]. An interview was conducted with Nurse E (the oncoming day shift nurse on 12/6/15) on 2/10/16 at 12:45 P.M. regarding Resident #501 and the transfer to the hospital on [DATE]. Nurse E stated, She (Resident #501) had a skin tear, I think from the afternoon shift the day before. The midnight shift nurse worked a double, and didn't know what happened, maybe she bumped it, but reported a skin tear on her leg, but it was really bad and actually needed stitches. It was bleeding a little bit in the morning, but when the daughter was here there was more blood later and we sent her out (to the hospital) around 2:30 P.M. or so. Nurse E was asked if there was a bandage or dressing on Resident #501's leg and reported there was a bandage and it had been applied on the night shift. The Treatment Administration Record and Physician's Orders were reviewed at this time and it was revealed that there was no physician's order for treatment to Resident #501's right leg until after she was sent out to the hospital on [DATE]. An incident report for Resident #501 was reviewed on 2/10/16 at 1:00 P.M. and documented that on 12/5/15 at 10:45 P.M., Nurse D observed dried blood on Resident #501's right lower extremity, cleaned the wound, and it measured 5 cm x 0.1-0.75 cm depth, no drainage (blood/serous, etc.) Treatment: First aid, assessment Action taken: staff re-education, resident education Name of physician notified: (physician's name) IPC log, 12/5/15 at 23:00 An interview was conducted with Nurse D (the nurse on duty when the leg injury was identified on 12/5/15) via the telephone on 2/10/16 at 1:30 P.M. Nurse D was asked about the above documented skin tear on Resident #501's right leg. Nurse D stated, I came in the next day and her daughter was upset. When I saw it (Resident #501's leg) the previous night (12/5/15), it was just a small tear so I treated it and bandaged it, then when I came in the next day, she (Resident #501's daughter) demanded that she go to the hospital. They sent her right back. She got stitches. It was just a 1 inch (equivalent to 2.54 cm) and a millimeter deep skin tear when I saw it. Nurse D was queried about his above statement and the discrepancy between the documentation in the nursing progress note on 12/6/16 and the incident report on 12/5/16 that documented the skin tear as 5 cm x 0.1-0.75 cm depth. Nurse D stated, I don't know. She must have done something else to it. Nurse D was asked if he contacted the physician or nurse practitioner when the leg wound was identified and stated, I put it on the log for her to be seen. I don't know if I talked to the doctor. When queried about how Resident #501's leg was treated, Nurse D stated, I cleaned it, put ointment on it and bandaged it. An interview was conducted with the Director of Nursing (DON) on 2/10/16 at 2:50 P.M. regarding Resident #501 and how she obtained a 9 cm laceration that required sutures on her right leg. The DON reported that Resident #501 had blood under her finger nail and probably scratched it. When queried about whether or not Nurse D should have called the physician on 12/5/15 when the leg wound was first identified, the DON stated, I'm sure he did and they called the doctor the next day when the nurse noticed it was bleeding more. When queried about the lack of documentation from 12/5/15 from Nurse D, the DON did not offer an explanation. The facility's policy titled, Accidents and Incidents - Investigating and Reporting was reviewed on 2/10/16 at 4:00 P.M. and documented the following: .Medical Attention .The Nurse Supervisor and/or Charge Nurse shall: Examine all accident/incident victims .Notify the Medical Director or the victim's personal or Attending Physician, and inform the physician of the accident or incident .Provide treatment per physician's orders; If necessary, transfer the injured person to the emergency room medical treatment center, hospital; .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor must conduct an immediate investigation of the accident of incident . ( )

Based on observation, interview and record review, the facility failed to monitor, assess nutritional intake, and re-consult psychiatry services for the prevention of weight loss for one (#817) of five sampled residents reviewed for weight loss, out of a total of 20, resulting in a severe significant weight loss of 24 pounds within 34 days. Findings include: On 10/12/15 at 9:10 a.m., during the initial tour, accompanied by the Unit Manager (Nurse B), Resident #817 was observed sitting on the side of his bed eating breakfast. Undigested food (appearance and sour smell of vomit) was noted in his waste basket that sat next to his bed. Particles of partially chewed food were noted on his mattress. Parts of his sheet were noted wet from partially chewed food and liquid. Fifty percent of his breakfast was left on his tray. Nurse B stated, He always spits his food out .mouth regurgitates. He has chronic stomach distress. Resident #817 was alert and answered selective simple questions. He reported the food was Ok. Bilateral [MEDICAL CONDITION] (2+ to 3+) was noted to his lower legs. Nurse B reported that he has chronic [MEDICAL CONDITION] to both his legs, is non-compliant with interventions to reduce the [MEDICAL CONDITION], and that he has vascular ulcers. On 10/14/15 at 8:55 a.m., Resident #817 was observed eating breakfast sitting on the side of his bed. Partially chewed food was noted in the waste basket and on his mattress. Fifty percent of the breakfast was consumed. When he was asked if the food was ok, he nodded yes. On 10/14/15 at 10:00 a.m., Resident #817 was weighed by Certified Nursing Assistant (CNA D). He was weighed using a chair scale. The chair scale revealed a weight of 137.2 pounds (lbs). On 10/14/15 at 10:20 a.m., Resident #817's prior weights were reviewed on a print out provided by the facility's Dietician (Employee C). Review of Resident 817's weights revealed the following: - 4/13/15, weight was 166.8 lbs - 5/15/15, weight was 165.6 lbs - 6/1/15, weight was 165 lbs - 6/3/15, weight was 165 lbs - 7/9/15, weight was 165 lbs - 8/10/15, weight was 165.4 lbs - 9/10/15, weight was 165 lbs This indicated a significant weight loss of 27.8 pounds (within 34 days) based on the most current weight for Resident #817. On 10/14/15 at 10:35 a.m., review of Resident #817's clinical record revealed the following: The face sheet indicated an original admission into the facility on [DATE] and a re-admission on 7/9/2013 with [DIAGNOSES REDACTED].), [MEDICAL CONDITION] [MEDICAL CONDITION] of legs ([MEDICAL CONDITION]), Depression, and Dementia. Resident #817's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/18/15, indicated a moderately impaired cognition, required minimal assistance to being independent with activities of daily living (ADLs). The MDS also indicated his height as 66 inches and his weight as 165 lbs. The last history and physical (H & P) assessment was completed on 7/13/15. The H & P revealed the following: Past medical history; GERD, Stroke, Dementia, [MEDICAL CONDITION], Hypertension . The H & P listed him as having a PEG (feeding tube) in the past. Under the section titled Plan, there was documentation written, Change [MEDICATION NAME] to [MEDICATION NAME]. [MEDICATION NAME] is used to treat GERD. [MEDICATION NAME] is used to treat and prevent ulcers in the stomach and intestines. [MEDICATION NAME] also [MEDICAL CONDITION] other conditions in which acid backs up from the stomach into the esophagus, causing heartburn. Resident #817's physician's orders [REDACTED]. - Order dated 7/9/2013 to current revealed an order for [REDACTED].>- Psych; consultation as needed treat and eval purging behavior and [MEDICAL CONDITION]. The consult start date was 7/12/15 and it was ordered to end on 10/13/16. The order showed as still being active. - The psych consult, dated 7/13/2015, revealed the following documentation: Staff contacted this writer, as he spits out food. He has not been losing weight. Resident #817 minimizes the above complaints tells me that he only spits out if the food is not good. He denies swallow difficulties. He denies nausea and emesis. The diagnostic impression listed on the consultation was OCD ([MEDICAL CONDITION]). The current psychoactive medication listed was [MEDICATION NAME] 50 mg every day. The consultation listed the plan as: We have discussed risk and benefit at this time. As [MEDICATION NAME] helps with OCD, recommend to continue with the same. Per review of Resident #817's medication orders, [MEDICATION NAME] was ordered on [DATE] for the treatment of [REDACTED]. There were no further consultations regarding this concern despite the continuation of the symptoms exhibited. - The doctor's orders revealed an order for [REDACTED]. There were no documentation of adjustments for the [MEDICATION NAME] since both admissions into the facility. Overall, there have been no changes in his medications since admission. Resident #817's medications review listed [MEDICATION NAME] as the only diuretic. - Resident #817's Medication Administration Record [REDACTED]. The MAR for the month of October 2015 indicated that he refused it eight times. - Resident #817's Nutrition care plan, dated 6/16/15, revealed the following interventions: Observe for chewing or swallowing difficulties and diet as ordered (mechanical soft). There were no other interventions listed. Resident #817's most recent quarterly dietary assessment, dated 9/14/15, revealed the following documentation: Resident continues on mech (mechanical) diet for chewing ease. Resident does eat and then will spit out food in garbage can, but this is what resident usually does, then later will walk outside room and ask for food and staff will bring more food/snacks .oral intake varies, at times will eat approximately 50% to 75% intake. Current weight at 165# (pounds). Previous weight at 165.4# (8/10/15), 167 # (3/6/15). Resident has weight stable x 180 days. However does have [MEDICAL CONDITION] and may see weight fluctuation .current intake meets nutritional needs . Resident #817's Food Acceptance Records (FARs) revealed inconsistent/missing documentation of food intakes: The time period of 8/13/15 thru 9/12/15 revealed the following: For breakfast, he consumed 100% on 14 days. For lunch he consumed 100% on 13 days and 75% on one day. For dinner, he consumed 100% on 10 evenings and 75% on one evening. The rest of the days were blank. There was no documentation that indicated how much he consumed. It was documented that he consumed snacks eight times for that time period of 8/13/15 thru 9/12/15. The time period of 9/13/15 thru 10/12/15 revealed the following: For breakfast, he consumed 100% on eight days, for lunch he consumed 100% of lunch for six days and 65% on one day. For dinner, he consumed 100% of dinner for three evenings and 50% for one evening. The rest of the days were blank. There was no documentation that indicated how much he consumed. It was documented that he consumed snacks three times for that time period of 9/13/15 thru 10/12/15. Review of Resident # 817's medications revealed there were no medications ordered to treat [MEDICAL CONDITION] his food indigestion. On 10/14/15 at 11:10 a.m., the facility's dietician (Employee C) stated, We re-weighed him again. We used the chair scale. We got a weight of 141 lbs. It is a weight loss of 24 lbs. These are all chair weights (weights done via chair scale). He has [MEDICAL CONDITION]. His clothes still fit him. When asked if he was aware of the order for the psychiatry (psych) consultations as needed for Resident 817's purging of food, Employee C stated, I was not aware of the psych order. On 10/14/15 at 1:15 p.m., Resident #817 consumed approximately 75% of lunch. He was observed ambulating with a slow steady gait. [MEDICAL CONDITION] (2-3+) still present in bilateral lower legs. On 10/14/15 at 2:05 p.m., review of Resident #817's weight note, dated 10/14/15 at 1:43 p.m., written by Employee C revealed the following documentation: New monthly weight obtained at 141 # (10/14/15) and was done by the unit manager and was witnessed by writer and chair scale was calibrated. Previous weight at 165 # (9/10/15), 165.4 # (8/10/15), 165.2 (7/9/15), 166.8 # (4/13/15). Resident had significant weight loss at approximately 14.5% X 30 days .Resident does eat and then will spit out food in garbage can, but this is what resident usually does . On 10/14/15 at 3:50 p.m., review of the facility's policy titled Documentation of Meal and Fluid Intake, dated 3/11/15, revealed the following documentation: The purpose of this procedure is to document meal and fluid intake for all residents to ensure adequate intake. Nursing staff will use facility approved form to record percentages for each resident's meal intake daily. On 10/14/15 at 3:20 p.m., the Director of Nursing (DON) was interviewed regarding Resident #817's significant weight loss of 14.5% within 30 days. The DON stated, All of his (#817) weights were consistent. He likes a lot of snacks. It's not shocking that he had weight loss. There was no further explanation nor any additional documents presented before the survey's exit. ( )

This pertains to intake #MI 333. Based on interview and record review, the facility failed to ensure that meat was provided in a puree consistency for one (#301) of four sampled residents reviewed for swallowing difficulties from a total of seven, resulting in the resident experiencing aspiration, brain anoxia (lack of oxygen), cardiac/respiratory arrest and emergency hospitalization after consuming and choking on solid pieces of meat. Findings include: On [DATE] at 11 AM, the daughter of resident #301 was interviewed by phone and reported that the following occurred: On [DATE], resident #301 was seated in the dining room awaiting dinner. The resident was to receive food items in puree form due to swallowing difficulties from a recent stroke. She stated that the resident's wife was usually present during meals and on several occasions had to intercept trays of solid foods that staff had given to the resident. The daughter said, She (the wife) would just ask them for another tray without reporting it or complaining. She came in earlier that day (on [DATE]) and left before dinner due to an appointment. The daughter said, Somehow, (resident #301) ate some chicken and choked to death. Three pieces were removed. It took 20 minutes before EMS got there. They (facility staff) waited too long to call them. By that time, it was too late. Too much time had passed. They took him to the hospital and pronounced him dead there, but he was already gone (dead) before they took him. On [DATE] at 3 PM, resident #301's clinical record was reviewed with the Dietician. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets dated [DATE] and [DATE] noted that the resident had severe cognitive impairment and required extensive to total assistance from staff for all activities of daily living, including eating. Resident #301 was prescribed a puree diet. According to the resident's Nutritional assessment dated [DATE] written by the Dietician, the resident was unable to eat independently, was aphasic (difficulty speaking), and received a puree diet upon admission. A Nutrition care plan dated [DATE] listed interventions that included: diet as ordered (puree), observe for chewing or swallowing difficulties, and provide assistance as needed. Per review of Speech Therapy records for resident #301, a Speech Therapist (ST) conducted an evaluation and began treating the resident on [DATE]. The ST recommended pureed food, close supervision while eating and noted: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, increased dependency upon caregivers On [DATE], the ST documented in a Speech Therapy Discharge Summary when the resident's therapy ended: Diet recommendations-Puree Consistencies and close supervision while eating. The Dietician documented in a progress note dated [DATE], that resident #301 remained on a puree diet, gets help in feeding, and family visits frequently. Per review of progress notes written by nurse 'A', the following occurred on [DATE]: At approximately 6:20 PM, nurse aide 'C' observed resident #301 attempting to cough out and trying to gasp for breath. A nurse ('D') in the dining room instructed the resident to cough more and patted the resident on the back aggressively attempting to dislodge anything in resident with no results. At this time resident was brought out of dining room with crash cart (a cart with resuscitation equipment) and EMS was called at approximately 6:21 PM. The resident was unresponsive and his face was turning gray. The [MEDICATION NAME] maneuver was administered and the resident was suctioned with no results. The resident was then lowered to the floor and staff began CPR. At approximately 6:30 PM, EMS was in facility and working on resident. Deep suctioning was performed by EMS staff. (There was no mention of any contents being suctioned or removed from the resident by EMS staff.) At approximately 7 PM EMS left with the resident to the hospital. When asked what caused resident #301 to cough and choke, the Dietician said, I don't know what happened. I heard about it. We talked about it, but I don't know all of the details. He was on a puree diet. The nursing staff passes out the (meal) trays. When asked if he and the rest of the facility's interdisciplinary team (IDT) discussed the incident and any modifications in interventions to prevent reoccurrence, the Dietician said, I don't know. Not with me. You would have to ask the DON (Director of Nursing). On [DATE] at 3:20 PM, nurse 'A' was interviewed by phone and stated that she was in the hallway when aide 'C' brought the resident, who was coughing, out into the hallway from the dining room. She stated that nurse 'D' was in the dining room when the resident first began to cough and he went unresponsive. When asked how this could have happened, nurse 'A' said, I was told he choked on a chicken bone and he died . He was on puree (foods). She said that she did not know what the resident had on his dinner plate or who was assisting him with the meal. On [DATE] at 3:40 PM, nurse 'D' was interviewed and said that she was present when the resident began to cough, she did not see what was on his dinner plate or who was assisting him with the meal, and that she called 911. When asked, she stated that the resident was sitting at the dining room table with one other resident, who was on the opposite side of the table with their tray out of resident #301's reach. On [DATE] at 12:35 PM, aide 'C' was interviewed by phone and said, I called (nurse 'D') into the dining room when (resident #301) started coughing and I took him into the hallway, away from the other residents. When asked, aide 'C' said that she was not assisting the resident with his meal and did not recall who was. She said that she did not see what was on his plate and that resident #301 did not have a history of trying to take food from another resident's plate. (The resident's assigned aide at that time (aide 'F') was no longer employed at the facility and unavailable for comment.) On [DATE] at 1:45 PM, the Activity Coordinator, who was overseeing food/dining services on [DATE], was asked about resident #301's choking incident. She said, I don't know how it happened. I don't know the whole story and indicated that she was unaware of, and was not involved in any IDT discussion and corrective actions following the incident. On [DATE] at 1:50 PM, resident #301's hospital records (obtained earlier at 9:30 AM from the hospital) were reviewed and revealed the following: Emergency Department Report- The resident arrived at the hospital on [DATE] with CPR in progress and arrived pulseless. Emergency Department Nursing Assessment- The resident arrived at 7:26 PM with his pupils fixed, dilated and non-reactive, unconscious, no gag reflex, and flaccid extremities. History and Physical Report- Patient is intubated (breathing tube inserted) on mechanical ventilation Chief complaint-Acute [MEDICAL CONDITION] after aspiration with chicken pieces admitted to emergency room (hospital name) after EMS were called and arrived to (facility) where the nursing staff were giving the patient CPR for 20 minutes before arrival after he choked on three pieces of chicken Consult Reports-The resident's wife said that she was with the resident at 6 PM and then she got a call from the nursing home at 6:20 (PM) stating that the patient will be going to (name of hospital) after he had a cardiopulmonary arrest. Per them (the facility) the patient was sitting in the dining room and then he had the arrest; The patient was found by the nursing home staff to be pulseless. They did CPR on him for about 20 minutes. (EMS) arrived and they managed to sweep 3 chunks of chicken from his throat Discharge/Transfer Summary- The resident was pronounced dead on [DATE] at 10:27 PM. Discharge [DIAGNOSES REDACTED]. On [DATE] at 3:50 PM, the DON was interviewed regarding why and how resident #301 obtained and consumed solid, non-pureed chicken causing him to choke. The DON said, I was told that his wife claimed it was chicken. That was not confirmed. They (staff) said he had a puree tray. I don't know. His food was puree. When shown the hospital emergency room documentation about the resident aspirating pieces of chicken, the DON read the record, shrugged her shoulders, and did not respond. When asked if she and the IDT had discussed the incident and made any recommendations or modifications to prevent reoccurrence with other residents, the DON said yes, but indicated that there was no documentation of this occurring. When asked if an incident report and investigation were documented, the DON said, We did an incident report and a whole investigation on it. We have a whole file. When this information was requested, the DON said, We can't find the file. When asked if the facility's Corporate Office could provide the file, the DON said, They don't have it either. Following the interview, when asked if all available or additional information on the choking incident involving resident #301 had been provided as requested, the DON said, Yes. On [DATE] at 9 AM, per review of the facility's Serving of Food policy revised [DATE]: Nursing personnel and Feeding Assistants will serve resident trays and will help residents who require assistance with eating. Resident's who cannot feed themselves will be fed with attention to safety, comfort, and dignity. ( )

This pertains to intake #MI 412. Based on observation, interview, and record review, the facility failed to provide proper supervision, assessment, care planning, and consistent implementation of timely, appropriate safety interventions for one (#306) of two sampled residents reviewed for accidents from a total of seven, resulting in falls with hematomas, a skin tear, a fracture, and emergency hospitalization s requiring surgery. Findings include: On 9/30/15 at 1:15 PM, resident #306 was observed sitting in a wheelchair in the dining room. The resident was alert, confused and unable to respond appropriately to questions. Per staff, the resident had just been fed his lunch. On 10/1/15 at 3:50 PM, resident #306's clinical record, Incident/Accident (I/A) Reports, and investigations were reviewed with the Director of Nursing (DON). The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets ((MDS) dated [DATE], 10/13/14, 6/2/15, and 8/31/15 all noted the following: The resident had severe cognitive impairment, was non-ambulatory, required extensive assistance for transfers and bed mobility, had experienced falls, and had unsteady balance when walking and moving from surface to surface. Resident #306's At Risk for Falls care plan dated 8/1/13 thru 10/21/14 noted bed safety interventions: anti-skid floor strips, turning bars for safe transfers (even though the resident was not supposed to self-transfer), and Family to notify staff when they are leaving. The DON said that this intervention was added so that the resident would not be left alone in his room and would be brought to an activity for supervision. There was no mention of bed safety interventions in the care plan, such as fall floor mats, fall safety alarms to alert staff of attempts to self transfer, or a low bed. Progress notes dated 7/3/14 thru 8/14/14 documented that resident #306 was observed transferring and ambulating without assistance with an unsteady gait. The following incidents occurred when the resident attempted transfers from bed without assistance: 1. I/A report dated 10/7/14 at 9:30 PM and progress notes dated 10/7/14 and 10/8/14-Observed resident sitting on the floor next to his bed and observed sleeping 30 minutes prior; The resident said, I was going somewhere, but I decided to turn around; no documented injury; no new actions taken to prevent reoccurrence in the investigation (continue current care plan). A Fall Risk assessment dated [DATE] noted a fall risk score of 17. A score of 10 or greater indicated high risk. The assessment noted that the resident was chairbound, had experienced 3 or more falls in (the) past 3 months, and had balance problem while standing. 2. I/A report dated 10/18/14 at 8:10 AM and progress notes dated 10/18/14 and 10/22/14-lying on the floor on his back in his room no injury noted except lump (hematoma) on front head; complaining of pain right upper leg when trying to move for lunch at 12:30 PM transfer to hospital observed attempting to self transfer at times. (Earlier at 11 AM, nurse 'E', who wrote the I/A report, stated that the resident was previously in bed before this fall and was found on the floor near the bed.) The investigation contained the following written statement by resident #306's roommate (who had since been discharged from the facility): I saw my roommate attempting to stand up near the door to our room. I knew (resident) could not stand unassisted. (Resident) began to shake and tremble from the weakness of his legs (resident) began falling to his right onto the floor. He struck his head against the door as he fell He stayed on the floor until I could summon help for him. (Resident #306 was in the first bed closest to the door.) On 10/18/14, resident #306 was transferred to the hospital and returned to the facility on [DATE] with 12 staples following surgical repair of a right hip fracture from the fall. Per 10/23/14 progress notes, the resident was confused and Sensor alarm to bed per (resident's) sister. There was no documented order for a sensor alarm. When asked why, the DON said, There are no orders written for alarms. We just put them on the care plan. A review of the resident's At Risk for Falls care plan dated 10/24/14 noted: Sensor alarm to bed per family request. When asked why the family had to request the alarm, the DON said, The family was very pro-alarm, so it was put on. When asked why the facility did not implement an alarm before the fracture occurred, in lieu of the resident's history of falls and self transfers, the DON said, We were thinking about it, but sometimes alarms can cause more falls. They won't prevent falls from occurring. We had to decide if he should have them. When discussed with the DON that sensor-type alarms served the purpose of detecting body motion to allow staff to possibly intervene before ambulation and falls could occur, the DON did not respond. The alarm was added to the care plan on 11/5/14. When asked why the alarm was care planned 13 days later and not on 10/24/14, the DON said, I don't know why. It should have been. 3. I/A report dated 11/18/14 at 9:30 PM and progress notes dated 11/18/14 and 11/19/14-Observed resident lying on the floor next to his bed send out to emergency room readmitted from (hospital) at 3 AM (on 11/19/14) .has hematoma to forehead .Sensor alarm working at the start of the shift but did not work during the incident. There were no new care plan interventions or actions in the investigation and no indication why the alarm did not sound. 4. I/A report dated 11/30/14 at 7:30 AM and progress notes dated 11/30/14 and 12/1/14-Resident was sitting on the floor next to his bed skin tear noted on left knee resident has been noted pulling cord off of the alarm box. Alarm box was moved out of resident reach. Resident will be part of the Rise and Shine club. The investigation noted: Resident had history of removing his alarm and falling out of bed Will assess resident for a fall mat at bed floor area. Bed alarm moved out of resident's reach. When asked why the alarm control box was not moved prior, since the resident had a known history of disconnecting the alarm, the DON did not respond. Interventions were added to the care plan on 12/1/14: Include in rise and shine club, i.e. up and dressed for breakfast as per resident preferred routine and move sensor alarm box out of resident's reach. 5. I/A report dated 12/8/14 at 3:40 AM and progress notes dated 12/8/14 and 12/9/14-Staff responded to alarm resident noted on floor sitting at bedside; no injuries documented; Resident put on sleep study to get better idea of resident's schedule if resident has predictable schedule. When queried about the sleep study, the DON provided a form indicating the study took place over a 72-hour period. When asked about the results, the DON did not verbally explain or provide written results and recommendations. A Fall Risk assessment dated [DATE] noted a score of 26. On 1/8/15, the score increased to 30 and on 1/16/15, the score was 22. 6. I/A report dated 6/7/15 at 4:15 AM and progress notes dated 6/7/15 and 6/8/15-Resident observed sitting on floor next to bed; Resident stated 'I was trying to get up, it's time to get up!' No apparent injuries noted. The investigation noted: Charge nurse was walking down the hall when she found this resident sitting on the floor There was no indication that an alarm sounded or floor mats in place. The DON acknowledged this and then said, Floor mats can be a trip hazard, but did not address the mats as being cushioning devices in case of falls out of bed. The care plan intervention added on 6/8/15: Close window blinds at night to decrease ambient light. The fall risk score on 6/8/15 was 19. 7. I/A report dated 8/29/15 at 4:40 AM and progress note dated 8/29/15- resident was on his knees on the floor in front of his bed; resident stated, 'I was trying to go to the garage' no new skin injuries noted. There was no indication that an alarm sounded, which the DON acknowledged. The recommendation: A 72-hour sleep study. The DON provided the sleep study form. When asked about the results, again the DON did not explain or provide the results. This incident was the third fall occurring between 3:40 AM and 4:40 AM. Following the chart review, when asked if all available or additional information on resident #306's previously mentioned incidents had been provided as requested, the DON said, Yes. On 10/2/15 at 9 AM, per review of the facility's Fall Prevention Process Guidelines dated 8/17/13 and undated Fall Prevention Strategies: -Obtain orders if needed for fall prevention interventions or devices as needed; Initiate risk reducing interventions; Implement care plan interventions; Provide ongoing risk reducing interventions as needed; Document use of devices; Evaluate the resident's response to interventions. -Fall and injury reduction interventions include: bed alarm, motion detector, floor mat, check for broken or non-functioning equipment, hip protectors, low bed, keep resident in close visual placement. ( )

This citation pertains to intake # MI 222. Based on observation, interview and record review the facility failed to provide wheelchair leg rests to prevent a fall for one of one sampled resident (#503) out of a total sample of three residents reviewed for falls, resulting in a forward fall and hospitalization for intracranial bleed (Bleeding on the brain). Findings include: On 1/12/15 at 11:15 a.m., an unannounced abbreviated survey was conducted at the facility. At this time the facility's Director of Nursing (DON) provided a copy of an incident/accident/investigation report dated 1/5/15 for resident #503. The report documented that resident #503 "observed on floor on stomach in front of wheelchair. Certified Nurse Assistant (CNA) stated while pushing resident into room resident abruptly put feet firmly on ground and threw self forward landing on floor. Range of motion -normal. Bump to left temple. Laceration to upper lip. Evaluated by Nurse Practitioner (NP). Ordered transfer to (hospital name) for further evaluation. Results of investigation: ...Resident was being wheeled into room and put her feet down and body went forward out of chair. Resident assessed by NP and sent to hospital...Leg rests to be provided for resident upon return." On 1/12/15 at 11:48 a.m., resident #503 was observed laying in bed. The resident was alert with confusion and mumbling non-scenical words. Large purplish, red and yellow bruises were observed around both eyes, chin, right cheek, right hand and right arm. A cut was noted on the upper lip. On 1/12/15 at 12:10 p.m., record review revealed that resident #503 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]." Resident #503's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required total assistance from staff for all activities of daily living and wheelchair mobility. The "Assessment-Fall Risk" dated 11/12/14 for resident #503, had a fall risk score of "18"(If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential FALLS)." The care plan titled, "Safety: Risk for fall. Altered safety awareness related to visual impairment" dated 10/16/13 had interventions which included, "anti-rollback device to wheelchair and resident up to high back wheelchair as tolerated." On 1/12/15 at 12:30 p.m., CNA "A" was queried regarding the incident with resident #503. CNA "A" said that CNA "B" was pushing (resident #503) in a standard wheelchair from the hallway outside the dining room to the resident's room. CNA "A" said that the resident kept sliding down in the wheelchair and she told her to keep her feet elevated up during the transport. When the CNAs and resident entered into the resident room, "(Resident name) pushed her feet to the ground real fast. She had non-skid shoes on and she just fell forward onto the ground." CNA "A" was queried if this was the resident regular wheelchair and stated, "No. She got a new wheelchair a few days prior to the fall. In this wheelchair she can touch the ground. In her other wheelchair she couldn't touch the ground. She has been known to put her feet down like that and that is why she was in the high back wheelchair...There were no leg rests on the wheelchair." On 1/12/15 at 12:50 p.m., CNA "B" was interviewed regarding the incident with resident #503. CNA "B", who was regularly assigned to the resident, indicated that resident #503 use to have a high back wheelchair that leaned back and had leg rests. CNA"B" said that the Unit Manager (who no longer works at the facility) issued a standard wheelchair a few days prior to the fall. The CNA indicated that with the standard wheelchair the resident was able to touch her feet to the ground, but was not able to propel herself. The CNA went on to say that on the day of the fall, the resident was in the hallway outside the dining room and was sliding out of her wheelchair. He then got permission from the staff nurse to lay the resident down for a nap. The CNA said he transported the resident with her feet elevated up in the air for about 20-25 feet to her room. The CNA said that when he got the resident into her room, the resident "slammed her feet down, she fell forward, face first onto the floor". On 1/12/15 at 1:20 p.m., the DON was queried about the incident with resident #503. The DON admitted that a new standard sized wheelchair was issued to the resident, but was unclear as to the exact dated. She stated, "I was not made aware that a standard size wheelchair was being issued to the resident. The Unit Manager did that all on her own." The DON reviewed the nursing progress noted, which did not document the issuance of any new equipment. The DON reviewed the "Safety: Risk for fall. Altered safety awareness related to visual impairment" care plan and stated, "She should have been in a high back wheelchair. Either way, there should have been foot rests provided for her safety and comfort." When asked what the facility's policy was on wheelchair transports, the DON stated, "Our facility's policy is to have footrests on the wheelchairs when transporting a resident. And, any time new equipment is issued, it is to be evaluated and the care plan updated." On 1/12/15 at 2:00 p.m., review of the facility's policy titled, "Restorative Nursing", dated 9/13 documented, "Good wheelchair positioning begins with the feet and legs, The wheelchair legs affect posture, stability, and body alignment. The leg rests should always be in place if the chair is moving, unless the resident propels the chair with one or both feet. Never allow the resident's legs to dangle...". ( )

This pertains to Intake # MI 77 Based on observation, interview and record review, the facility failed to perform resident fall risk reassessments, update the nursing care plans, or add new interventions to prevent falls after falls, and after a significant decline in function and cognition, for one (#501 of three residents reviewed for falls, out of a total sample of three, resulting in ten falls in the facility within ten months, including a fall with fracture (broken bone) which resulted in transfer to the hospital for a surgical repair of a broken hip (ORIF). Findings include: On 11/10/14 at 8:25 A.M., Resident #501 was observed at breakfast in the dining room. The resident was in a wheelchair with no personal safety devices or alarms, and was confused. The resident had already eaten all the food on his plate, and was drinking his beverages and scraping his empty plate. The Unit Manager, Nurse "D", who was in the dining room, reported that Resident #501 had a personal safety alarm (device which alarms when the resident stands up) on his bed, but not the wheelchair. On 11/10/14 Certified Nursing Assistant (CNA) "A" was interviewed regarding Resident #501. CNA "A" reported that she had been duty when Resident #501 fell and broke his hip on 10/18/14. CNA "A" reported, "(CNA "B", Resident #501's assigned CNA) yelled for help and I came running. (Resident #501) had taken off all his clothes and his brief (incontinence product) and was on the floor. I would have had him up and in the dining room. He's a big falls risk. (CNA " B") usually works midnights. She stayed until 11:00 A.M. that day because we were short (short of staff). He (Resident #501) likes to eat breakfast in the dining room." When queried, CNA "A" reported that breakfast is usually served between 7:30 to 8:30 A.M. On 11/10/14 at 10:30 A.M., Resident #501's Charge Nurse at the time of the fall with fracture on 10/18/14, was asked about Resident #501's broken hip and stated, "When I heard (CNA) "B" yell for help, I ran to the room and saw (Resident #501) on the floor. He was totally naked. He usually eats breakfast in the dining room. Most of the time we try to get him up for breakfast in the dining room because he has a history of a lot of falls. Sometimes he gets agitated and moves around in his (wheel) chair. When he does, we know that its time to take him to the bathroom and change him. (CNA "B") worked the midnight shift. She told me that she got him dressed between 5:00 to 6:00 A.M., and then left him sleeping in bed." On 11/10/14 at 10:30 A.M., Resident #501's roommate at the time of the fall on 10/18/14, Resident #100, was interviewed. Resident #100 was alert and oriented with good recall of past and present events. Resident #100 reported that he was in the room in bed at the time of Resident #501's fall on 10/18/14, and could see some of what happened, as Resident #501's privacy curtains obstructed the view of the upper half of Resident #501's bed. Resident #100 stated, "The aide (CNA) got him ready for breakfast, and then went away and left him. I thought that was foolish because (Resident #501) had dementia, and he had a tendency to get out of bed. He got up and started walking towards the (hall) door. He made it to the door, but his legs were shaking. They (his legs) gave out, and he hit his head on the door and fell on his side. He didn't yell or make any noise, so I put my call light on and called for help." On 11/10/14, at 11:30 A.M., Resident #501's clinical record was reviewed with the Director of Nursing (DON), and revealed the following: A face sheet documented that Resident #501 was originally admitted into the facility on [DATE], and was readmitted on [DATE] after a hospitalization for a surgical repair of a fractured femur (thigh bone). Readmission [DIAGNOSES REDACTED]. Review of Resident #501's most recent Minimum Data Set Assessment (MDS), dated [DATE] revealed Resident #501 had severe cognitive impairment (dementia) and needed extensive assistance for mobility in bed and transfers to the wheelchair, did not walk, was incontinent of bowel and bladder, had fallen in the past quarter year, and had impaired balance. Review of Resident #501's annual MDS assessment, dated 7/25/14, and a quarterly MDS, dated [DATE], revealed no changes.(abilities and cognition the same). A quarterly MDS assessment dated [DATE] documented that Resident #501 had a significant decline in cognition and in function between 10/28/13 and 1/27/14. The MDS dated [DATE] documented that Resident #501 had (near high functioning score cutoff) moderately impaired cognition, needed limited assistance for transfers, had not fallen, and was continent of bowel and bladder. When queried, the DON was unable to provide documentation to indicate that a significant change MDS was done, or that Resident #501's risk for falls and care needs were reassessed to reflect these declines in cognition and abilities. Review of facility incident and accident forms (I&A) for Resident #501 for the 2014 calendar year, revealed that Resident #501 had fallen 10 times since January 1, 2014. Review of Falls Risk assessments for Resident #501 revealed a falls risk assessment dated [DATE], which was incomplete (many sections left blank) and had no score to indicate whether or not Resident #501 was at risk for falls. Review of the clinical record with the DON revealed no other falls risk assessment was done for Resident #501 until 10/15/14. The falls risk assessment dated [DATE] documented that Resident #501 was at high risk for falls with a score of 17. Per the facility fall risk assessment form, "If the score is ten or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Review of Resident #501's Nursing Care Plans in place at the time of the resident's fall with fracture on 10/18/14, revealed a care plan entitled, "Resident is at risk for falls subsequent to (s/t) unsteady gait and requires assistance with activities of daily living (ADLs), transfers, dated 8/1/13. Safety interventions included: "observe for safety awareness and encourage safety precautions" (dated 8/1/13), "antiskid strips at bedside and toilet floor" (dated 8/16/13), "escort resident to dining room for meals" (dated 12/19/13), "encourage use of turning bars for safe transfers" (dated 12/19/13, non skid soled socks in bed and non skid socks or rubber soled shoes when up" (dated 8/1/13). There was only three new safety intervention documented as added during 2014, "antiskid strips at bedside and bathroom"(originally added on 8/16/13), anti rollbacks to wheelchair" (prevents wheelchair from tipping over backwards), and "family to notify staff when they are leaving", all documented as added on 8/14/14. Review of Resident #501's I&A and post fall interventions to prevent further falls was discussed with the DON at this time and were as follows: 1. 1/30/14 at 7:20 A.M., Resident #501 was found on the floor in the room next to his bed. Review of the attached fall investigation report with the DON revealed that the plan to prevent further falls was "Get resident up in A.M." When queried, why this was not already done, per the resident's fall care plan intervention dated 12/19/13, the DON stated, "sometimes he likes to sleep in." When asked if any new interventions were added to prevent Resident #501 from falling again, the DON reported that Resident #501 was referred to Therapy for an evaluation, but was unable to provide any documentation of this or of any skilled therapy done at this time. 2. 2/25/14 at 9:30 A.M., Resident #501 was found on the floor of the room next to the bed, wearing a gown (not in day clothing). When queried, the DON was unable to explain why the fall care plan intervention, "escort resident to dining room for meals"was not followed, despite the repeat of this recommendation after the previous fall. When queried, the DOn stated that no new interventions were added to the care plan, and Resident #501's fall risk was not reassessed, because, "It was an isolated incident." 3. 3/10/14 at 12:55 A.M., Resident #501 was found on the floor in the room next to his bed. When asked what was done to prevent additional falls, the DON referred to the"Plan of Action", documented on the I&A which noted, "Resident re-educated on waiting for assistance before transferring." When asked, the DON was unable to explain how a resident with severely impaired cognition would remember this teaching. When queried, the DON reported that no new interventions were added and no fall risk assessment was completed at this time. 4. 3/15/14 at 7:00 A.M., Resident #501 was found on the floor by the bed. When queried, The DON stated that no new interventions were added, despite two other falls in the morning before breakfast. The DON stated that Resident #501 was receiving skilled Occupational Therapy (work on upper body) at the time. 5. 3/21/14 at 4:15 P.M., Resident #501 was found on the floor next to his wheelchair in the dining room. This was documented as an "unobserved fall". When queried, the DON reported that Bingo (game) had just finished. When queried, the DON was unable to state who was providing supervision for residents at risk for falls in the dining room, and why Resident #501's fall was documented as "unobserved" if staff were supervising residents left in the dining room after the activity. 6. 4/28/14 at 8:25 P.M., Resident #501 was found on the floor in the room. There were no new interventions added to prevent falls, and no falls risk assessment was done. When queried about this, the DON reported that Resident #501 received skilled Occupational Therapy, but was unable to explain how therapy to improve upper body strength and skills would help prevent falls from transferring and ambulating without assistance by a resident with poor balance and leg strength. The DON stated that more antiskid strips were added to the floor in Resident #501's room as a plan to prevent additional falls. Review of Resident #501's falls care plan revealed this was not documented as added until 10/08/14. When asked how this would prevent a fall due to poor balance and poor leg strength and unsteady gait, the DON stated, "It might decrease the risk of slipping." 7. 5/14/14 at 10:50 P.M., P.M., Resident #501 was found on the floor next to the bed. The I&A documented that the resident sustained [REDACTED]. A Nursing Progress Note for Resident #501, dated 7/3/14 at 2:01 A.M., documented, "observed resident walking back from bathroom at this time by self." 8. 8/13/14 at 2:40 P.M., Resident #501 was found on the floor of the room. An intervention to Resident #501's fall care plan, dated 8/14/14, noted, "family to notify staff when they are leaving." When asked about the additional interventions added at this time to the care plan, the DON was unable to explain why the intervention to add more anti skid strips was not added after the fall on 4/28/14 as stated, and was unable to explain why the anti rollbacks were added to the wheelchair at this time, as Resident #501 had not tipped over the wheelchair, and most of the falls had occurred after the resident transferred himself out of bed without assistance. 9. 10/7/14 at 9:30 P.M., Resident #501 was found on the floor of the room The I&A documented that the resident had self transferred out of bed without assistance. When queried, the DON was unable to explain what was done to protect Resident #501 from falling due to further unassisted transfers from bed. When queried, the DON stated that no new safety interventions were added, but noted that a falls risk assessment was done on 10/1514, revealing that Resident #501 was at high risk for falls. When asked why no new interventions or a new plan to prevent falls due to unassisted transfers was implemented at this point, after nine previous falls and one observed unassisted self transfer without a fall, documented severe dementia and unsteady gait, and needing extensive physical assistance from staff to transfer, the DON stated, "It's easy to see now, looking back." 10. 10/18/14 at 8:10 A.M., "Resident (#501) was lying on the floor on his back in his room, alert and awake. Lump on front head." The I&A noted, "Resident is at risk for falls s/t unsteady gait and requires assistance with ADLs, transfers and bed mobility. When queried about this, the DON stated that Resident #501 was sent to the hospital for evaluation, and found to have a broken hip. When asked why the resident was left in the room unsupervised at breakfast time, the DON stated, "(CNA "B") didn't usually work day shift. She probably didn't know who needed to be gotten up first and brought to the dining room." { )

REFER TO INTAKE #MI 874 AND #MI 880 BASED ON OBSERVATION INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SAFETY INTERVENTIONS AND APPROPRIATE SUPERVISION TO MAINTAIN SAFETY AND PREVENT FALL FOR 2 RESIDENTS (#101 AND #103) OF 6 SAMPLED RESIDENTS OF A TOTAL SAMPLE OF 6, ALL REVIEWED FOR FALLS, RESULTING IN INJURY FOR BOTH RESIDENTS. FINDINGS INCLUDE: RESIDENT #101 WAS admitted to the facility on [DATE]. HISTORY AND PHYSICAL DATED [DATE], REVEALED RESIDENT #101 S/P FALL ON [DATE], SUSTAINING CERVICAL FRACTURE, VASCULAR DEMENTIA DIFFICULTY IN WALKING IN ADDITION TO OTHER DIAGNOSES. RESIDENT #101 WAS ASSESSED AS HIGH FALL RISK BUT fell TWICE ON [DATE] AND ON [DATE] AND SUSTAINED INJURIES AS A RESULT FROM FALL. MDS (MINIMUM (MDS) data set [DATE], SHOWED A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS ) OF ,[DATE] (HIGHEST SCORE IS 15). RESIDENT #101 REQUIRED AN EXTENSIVE ASSISTANCE ON ADLS (ACTIVITIES OF DAILY LIVING) SUCH AS BED MOBILITY, TRANSFERS, AMBULATION EATING AND TOILET USE REQUIRING 1 PERSON ASSISTANCE. BALANCE DURING TRANSITION AND WALKING WAS UNSTEADY. RESIDENT #101 WAS INCONTINENT WITH BOWEL AND BLADDER ELIMINATION PATTERN. ACCORDING TO THE INCIDENT/ACCIDENT REPORT DATED [DATE] AT 2:10 AM, RESIDENT #101 WAS OBSERVED ON THE FLOOR LYING ON THE RIGHT SIDE WITH WHEELCHAIR FLIPPED OVER CLOSE TO HIS LEGS, MODERATELY BLEEDING NOTED FROM SKIN TEAR AND ABRASION ON FOREHEAD AND SKIN TEAR LEFT BACK OF HAND. RESIDENT #101 VERBALIZED DIZZINESS AFTER FALLING. RESIDENT WAS discharged TO THE HOSPITAL ON [DATE]. ACCORDING TO THE INCIDENT /ACCIDENT REPORT INVESTIGATION DATED [DATE], THE FALL WAS UNWITNESSED. RESIDENT #101 ROUTINELY REQUIRED A SENSOR ALARM AND IT WAS FOUND "OFF". THE FACILITY'S PLAN OF ACTION WAS 1:1 INSERVICE TO CNA (NURSE AIDE # 6) WAS: RELATED TO ALARM NOT APPLIED AND TOILETING RESIDENT. NO NEUROCHECK WAS FOUND FOR RESIDENT #101 FROM TIME OF FALL 2:10 AM UNTIL THE TIME TRANSFERRED TO THE HOSPITAL AT APPROXIMATELY 8:00 AM (6 HOURS). INITIAL VITAL SIGNS WAS OBTAINED IMMEDIATELY AFTER THE FALL BUT THERE WAS NO EVIDENCE OR RECORD OF FOLLOW-UP NEURO OR VITAL SIGNS ASSESSMENT AND MONITORING PER FACILITY PROTOCOL. EMS (AMBULANCE) RUN SHEET DATED [DATE], WAS REVIEWED. DISPATCH CALL WAS RECEIVED AT 7:14 AM. RESIDENT #101 ARRIVED THE emergency room AT 8:20 AM. HOSPITAL RECORD WAS OBTAINED ON [DATE]. ER (emergency room ) PHYSICIAN CONSULT DATED [DATE], IT WAS NOTED IN THE HISTORY THE LOCATION OF THE INCIDENT (FALL) WAS AT THE NURSING HOME. HEAD SCALP HAVE 2 SMALL SUPERFICIAL LACERATIONS WITH SOME SOFT TISSUE SWELLING ON THE FOREHEAD AND HAS SMALL ABRASION ON THE LEFT WRIST. [DIAGNOSES REDACTED]. HEAD CT (COMPUTED TOMOGRAPHY) SCAN DATED [DATE] AT 10:15 AM SHOWED SMALL CEPHALHEMATOMA IN THE FRONTAL REGION BUT NO ACUTE INTRACRANIAL PROCESS. CT SPINE: DISLOCATED FRACTURE OF C 1 FRACTURE OF DENSE OF ADENOID PROCESS. RESIDENT#101 WAS admitted for C SPINE FRACTURE. CNA # 6 STATED ON [DATE] AT 11:20 AM, THAT RESIDENT#101 WAS RESTLESS AND WAS ATTEMPTING TO GET OUT OF THE WHEELCHAIR THAT NIGHT. RESIDENT #101 HAD DEMENTIA AND WAS ORIENTED BUT CONFUSED. HE STAYED UP IN HIS WHEELCHAIR UNTIL CNA #6 TOOK HIM TO THE BATHROOM AND LAYED HIM IN BED AT 1:45 AM. CNA #6 WENT TO CHART IN THE COMPUTER STATION OUT IN THE HALLWAY WHEN AT AROUND 2:10 AM HEARD A LOUD BOOM. CNA #6 admitted THAT "NO ONE WITNESSED THE FALL". HE WAS FOUND LAYING ON THE FLOOR AND THE WHEELCHAIR HAD TIPPED OVER THE RESIDENT'S (#101) LEGS. HE COMPLAINED TO THE NURSE OF HAVING NECK PAIN AND BACK PAIN WHEN PUT BACK IN HIS WHEELCHAIR. THIS WAS THE SECOND TIME HE fell . THE FIRST TIME WAS IN APRIL ( [DATE]) WHERE HE HIT HIS FOREHEAD. THE SECOND TIME HE fell ([DATE]) HE BUSTED HIS HEAD AGAIN WITH 2 CUTS ON THE SAME AREA. HE WAS COMPLAINING OF "HEADACHE AND DIZZINESS." THIS TIME (REFERRING TO THE SECOND FALL OCCURRENCE) CNA #6 EXPLAINED: "HE DID NOT HAVE A BED ALARM, JUST CHAIR ALARM BUT THAT NIGHT HE WAS VERY HARD TO REDIRECT AND HE WAS ATTEMPTING TO GET OUT OF HIS WHEELCHAIR. HE WAS UNSTABLE WITH AMBULATION. HE USES THE WHEELCHAIR. LPN (LICENSE PRACTICE NURSE) # 7 ON [DATE] AT 2:30 PM, RECALLED THAT CNA #6 CALLED HER ATTENTION THAT RESIDENT #101 WAS ON THE FLOOR. HE WAS A HIGH RISK FOR FALL AND HE WAS ORIENTED BUT CONFUSED. THE FALL WAS UNWITNESSED. RESIDENT #101 WAS OBSERVED ON THE FLOOR WITH HIS FACE DOWN ON THE FLOOR. THERE WAS BLOOD ON HIS LEFT SIDE OF HIS FACE. AFTER ROM ASSESSMENT, RESIDENT WAS PUT BACK IN HIS WHEELCHAIR AND WAS PUT BY THE NURSES STATION FOR MORE DIRECT VISUAL SUPERVISION. RESIDENT #101 COMPLAINED OF HEADACHE, DIZZINESS AND NECK PAIN AFTER THE FALL. PRIOR TO THE FALL, LPN #7 RECALLED RESIDENT #101 WAS CLOSELY MONITORED DUE TO ATTEMPTING TO GET UP TO AMBULATE AND HE WAS UP AND DOWN THE HALLWAY IN HIS WHEELCHAIR. WE USUALLY PUT HIM BY THE NURSES STATION TO WATCH HIM BUT CNA #6 PUT HIM BACK IN BED AND LEFT TO DO HER COMPUTER CHARTING. WE DID NOT KNOW HOW HE fell . RESIDENT #101 STAYED SITTING BY THE NURSES STATION FROM 2:15 AM UP TO 7:00 DURING THE CHANGE OF SHIFT. ACCORDING TO LPN #7, SHE INFORMED THE ONCALL DOCTOR AFTER THE INCIDENT. THE DOCTOR DID NOT ORDER ANYTHING EXCEPT TO MONITOR THE RESIDENT, APPLY DRESSING TO THE FORHEAD LACERATION AND TO CALL IF THERE ARE SIGNIFICANT CHANGES. LPN #7 STATED SHE DID THE NEUROCHECK BUT COULD NOT LOCATE WERE SHE PUT THE DOCUMENTATION. THERE WERE NO DOCUMENTATION FOUND IN THE NURSES NOTES REGARDING POST FALL. LPN #7 admitted THAT SHE DID NOT GIVE PAIN RELIEF FOR HEADACHE, BACK AND NECK PAIN. ACCORDING TO THE DON (DIRECTOR OF NURSING) ON [DATE] AT 11:30 AM, NEUROCHECKS ARE STANDARD ASSESSMENT FOR ANY UNWITNESSED FALLS, CONTUSION TO HEAD OR FOR RESIDENTS WITH MENTAL STATUS CHANGE. DURING THE OBSERVATION CONDUCTED BY SURVEYOR , RESIDENT #101 ON [DATE] AT 11:30 AM, WAS IN THE ROOM SITTING OFF THE EDGE OF THE BED WITH NO CLOTHES OR GOWN ON, AND NO SOCKS , WAS ATTEMPTING TO GET OUT OF BED BUT NO SENSOR ALARM WAS GOING OFF. RESIDENT #101 HAD A DRIED UP BLOOD ON THE LEFT FOREHEAD (NO DRESSING ON AND WAS WEARING A CERVICAL COLLAR. THE 3RD FLOOR NURSE MANAGER COULD NOT EXPLAIN TO THE SURVEYOR WHY THE SENSOR ALARM WAS NOT SOUNDING OFF AT THAT TIME. CARE PLAN UPDATED [DATE], FOR RESIDENT #101 SPECIFIED: RESIDENT DOES NOT USE CALL LIGHT. ANTICIPATE NEEDS. SAFETY CARE PLAN UPDATED [DATE] , NOTED SENSOR ALARM TO BED. RESIDENT #103: INCIDENT REPORT DATED [DATE] AT 3:35 AM, RESIDENT #103 WAS FOUND LYING ON THE FLOOR NEXT TO HIS BED. THE FALL INCIDENT WAS UNWITNESSED. AFTER ASSESSMENT, RESIDENT #103 SHOWED NO INJURIES. RESIDENT WAS PLACED BACK IN BED BY 3 NURSING STAFF USING A HOYER LIFT. THE INCIDENT/ACCIDENT REPORT INVESTIGATION'S OVERALL CONCLUSION: "RESIDENT #103 WAS ASLEEP AND ROLLED OUT OF BED ONTO THE FLOOR." EMS (AMBULANCE) RUN SHEET DATED [DATE], WAS REVIEWED. DISPATCH CALL WAS RECEIVED AT 3:16 PM. RESIDENT #103 ARRIVED THE emergency room AT 3:34 PM. HOSPITAL RECORD OBTAINED ON [DATE], SHOWED THAT ACCORDING TO THE emergency room HISTORY AND PHYSICAL DATED [DATE], "NURSING HOME STAFF FOUND PATIENT ON THE FLOOR AT 3:00 AM. THEY PUT HIM BACK IN BED...PATIENT SPEAKING INCOHERENTLY, REPEATING WORDS... PATIENT HAS DRY ORAL MUCOSA. DRIED BLOOD ON HIS LIPS AND TEETH... DISPOSITION: admitted TO ICU (INTENSIVE CARE UNIT). RESIDENT #103 DUE TO COMORBIDITY UNRELATED TO THE FALL RESIDENT WAS THEN admitted TO HOSPICE AND expired on [DATE] UNDER HOSPICE CARE. RESIDENT #103 WAS admitted to the facility on [DATE], AND WAS ASSESSED HIGH RISK FOR FALL ON [DATE]. DIETARY ORDER LIST DATED [DATE], RESIDENT WEIGH= 391.10 LBS. ADL (ACTIVITIES OF DAILY LIVING) FUNCTIONAL/RESTORATIVE assessment dated [DATE], REVEALED RESIDENT #103 REQUIRED TOTAL ASSIST WITH 2 PERSON ASSISTANCE IN TOILETING AND TRANSFERS AND OTHER ADL'S. HISTORY AND PHYSICAL DATED [DATE], NOTED THAT RESIDENT #103 WAS admitted TO HOSPITAL AFTER FALL. RESIDENT HAS HEPATIC [DIAGNOSES REDACTED], HEPATITIS C, CONGESTIVE HEART FAILURE AND DEBILITY IN ADDITION TO OTHER DIAGNOSES. MDS dated [DATE], SHOWED RESIDENT #103 SCORED ,[DATE]. HE REQUIRED EXTENSIVE ASSISTANCE WITH ALL ADLS. HE REQUIRED 2 PERSON ASSISTANCE WITH BED MOBILITY, TRANSFERS, AND TOILET USE. REQUIRING 2 PERSON ASSISTANCE. RESIDENT DID NOT AMBULATE. PHYSICAL THERAPY EVALUATION AND INITIAL PLAN OF CARE REQUIRED RESIDENT #103 FOR FALL PRECAUTION DUE TO HISTORY OF FALL. REVIEW OF RESIDENT #103'S CLINICAL RECORDS SHOWED: RESIDENT #103 DID NOT HAVE SAFETY/ FALL CAREPLAN INITIATED DESPITE ASSESSED AS A HIGH RISK FOR FALL DATED [DATE] AND INITIAL PT EVALUATION FALL PRECAUTION RECOMMENDATION. SELF CARE DEFICIT CARE PLAN DATED [DATE], SPECIFIED: 1. OBSERVE DURING STAFF ROUNDS AND WHILE PROVIDING RESIDENT CARE RESIDENT'S POSITION WHILE IN BED. MAINTAIN RESIDENT AT MIDLINE OF BED AND AWAY FROM EDGES OF BED. 2. ASSIST, ENCOURAGE, CUE WITH FREQUENT POSITIONING WHILE IN BED. 3. ASSESS FOR SIGNS AND SYMPTOMS OF HEPATIC [DIAGNOSES REDACTED], PERIODS OF CONFUSION... DIMINISHED RESPONSIVENESS TO VERBAL STIMULI, HYPERACTIVE DEEP TENDON REFLEXES. ACCORDING TO THE NURSE MANAGER#8 ON [DATE] AT 12:00 PM, "RESIDENT HAS TO FALL 2 TIMES WITHIN 30 DAYS BEFORE ONE CAN BE CONSIDERED IN THE A FALLING STAR PROGRAM. THEN THE FALL TEAM WILL START INTERVENTIONS AND CAREPLAN." NURSE MANAGER #8 DENIED FINDING RESIDENT #103'S CAREPLAN FOR FALL/SAFETY INTERVENTIONS. REGISTERED NURSE #5 STATED ON [DATE] AT 10:30 AM, RESIDENT #103 AT AROUND 3:00 AM WAS HEARD CALLING FOR HELP AND WAS FOUND BY THE CNA # 9 ON THE FLOOR. HE WAS "TOO BIG" SO WE USED THE HOYER LIFT TO TRANSFER HIM BACK TO BED AFTER HE WAS ASSESSED. HE DENIED ANY PAIN. THERE WAS NO COMPLAINT OR NO OBVIOUS INJURY SO THE DOCTOR WAS NOT CALLED TO NOTIFY HIM OF THE FALL. RESIDENT MAY HAVE ROLLED OVER AND OUT OF BED. THE FALL WAS UNWITNESSED. RN #5 DENIED DOING NEUROCHECKS PER PROTOCOL BECAUSE HE WAS SLEEPING. SEVERAL ATTEMPTS TO REACH CNA (NURSE AIDE) #9 ON [DATE] AND [DATE] BUT BOTH PHONE NUMBERS PROVIDED BY THE FACILITY WAS NOT A WORKING NUMBER. ALTHOUGH CNA#9 STILL IS EMPLOYED AND WORKING AT THE FACILITY, NO WORKING NUMBER WAS PROVIDED TO THE SURVEYOR. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED MAINTAIN FUNCTIONING TAB ALARMS FOR TWO (#504 AND #521) OF 14 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 25, RESULTING IN FALLS WITH FACIAL BRUISING AND FALLS REQUIRING TRANSFER TO THE HOSPITAL FOR SUTURES. FINDINGS INCLUDE: ON 8/29/12 AT 8:40 A.M., RESIDENT #504 WAS OBSERVED IN A GERI CHAIR (RECLINER) WITH A TRAY TABLE RESTRAINT. RESIDENT #504 WAS ALERT, BUT DID NOT RESPOND TO VERBAL DIALOG. ON 8/31/12 AT 10:40 A.M., RECORD REVIEW REVEALED THAT RESIDENT #504 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED RESIDENT #504 HAD SEVERE COGNITIVE IMPAIRMENT, DID NOT WALK, NEEDED EXTENSIVE STAFF ASSISTANCE FOR MOBILITY IN BED, TRANSFER, EATING, AND WAS DEPENDENT ON STAFF FOR TOILETING AND HYGIENE. RESIDENT #504 WAS INCONTINENT OF BOWEL AND BLADDER AND HAD UNSTEADY BALANCE. THE MDS DOCUMENTED THAT RESIDENT #504 HAD A RESTRAINT, "CHAIR PREVENTS RISING", AND HAD FALLEN WHILE IN THE FACILITY. REVIEW OF A FACILITY "REHABILITATION SCREENING" DATED 6/24/12, REVEALED THE RESIDENT HAD, "IMPAIRED SAFETY AWARENESS, MEMORY, AND AMBULATION." REVIEW OF A NURSING CARE PLAN ENTITLED, "FALLS", DATED 6/25/12 REVEALED, "RESIDENT HAS PERSONAL HISTORY OF FALLS. DIAGNOSIS (DX) OF DEMENTIA AND IMPAIRED COGNITION, GENERALIZED WEAKNESS AND POOR SAFETY AWARENESS." INTERVENTIONS INCLUDED, "SENSOR ALARM TO BED" AND "BED IN LOWEST POSITION", IMPLEMENTED ON 4/3/12. REVIEW OF FACILITY ACCIDENT AND INCIDENT REPORTS (I&A) FOR RESIDENT #504 REVEALED THE RESIDENT HAD FALLEN IN THE FACILITY FIVE TIMES SINCE DECEMBER OF 2011. REVIEW OF I&AS DATED 12/17/11, AND 2/20/12 DOCUMENTED RESIDENT #504 HAD PERSONAL SAFETY ALARMS ON THE BED AND A LOW BED AT THE TIME OF THESE TWO FALLS. REVIEW OF I&AS DATED 2/20/12 AND 4/25/12 DOCUMENTED RESIDENT #504 "fell WHILE ATTEMPTING TO GET UP WITHOUT ASSISTANCE." REVIEW OF AN I&A DATED 7/14/12 AT 10:00 P.M., REVEALED, "RESIDENT WAS OBSERVED BY CERTIFIED NURSING ASSISTANT (CENA) WALKING OUT OF HER ROOM. CENA STATES THAT SHE WAS HUNCHED OVER AND DROPPED TO HER KNEES. LARGE LACERATION TO LEFT KNEE, LARGE AMOUNT OF BLOOD NOTED. EMERGENCY MEDICAL SERVICE (EMS) CALLED FOR TRANSFER TO (HOSPITAL)." REVIEW OF A NURSING NOTE DATED 7/15/12 AT 6:20 A.M., REVEALED, "RESIDENT ARRIVED FROM HOSPITAL. 12 STITCHES/SUTURES IN LEFT KNEE." REVIEW OF A NURSING NOTE DATED 7/20/12 (NO TIME NOTED) REVEALED, "LATE ENTRY. SKIN LACERATION 12 CENTIMETERS (CM) LONG FROM 7/14/12." REVIEW OF A FACILITY I&A INVESTIGATION DATED 7/14/12 REVEALED THE FOLLOWING, "ALARM WAS NOT ON. CENA STATED SHE DIDN'T KNOW SHE HAD AN ALARM." THE OVERALL CONCLUSION WAS NOTED AS, "RESIDENT GOT OUT OF BED UNASSISTED AND AMBULATED TO DOORWAY. RESIDENT HAS IMPAIRED MEMORY AND DECREASED SAFETY AWARENESS AND DOES NOT ASK FOR ASSISTANCE." "PLAN OF ACTION" WAS DOCUMENTED AS, "ONE TO ONE INSERVICE WITH CENA REGARDING SAFETY INTERVENTIONS." ON 8/31/12 AT 10:40 A.M., THE ADMINISTRATOR WAS INTERVIEWED REGARDING RESIDENT #504'S FALL WITH INJURY ON 7/14/12, AND REPORTED THE CENA ASSIGNED TO RESIDENT #504'S CARE AT THE TIME OF THE FALL WAS NO LONGER EMPLOYED AT THE FACILITY, AND COULD NOT BE CONTACTED. WHEN ASKED HOW THE CENA WAS INFORMED OF SAFETY INTERVENTIONS NEEDED BEFORE CARING FOR RESIDENT #504, THE ADMINISTRATOR STATED THE CENA SHOULD HAVE SIGNED IN TO "THE DAILY CARE GUIDE" AT THE START OF THE SHIFT, WHICH LISTED THE SAFETY INTERVENTIONS AND DEVICES NEEDED BY THE RESIDENT." ( ) ON 8/30/12 AT 10:05 A.M., RESIDENT #521 WAS OBSERVED IN A LOW BED WITH AN ALARM ATTACHED TO THE BED. THE RESIDENT HAD A LEFT BLACK EYE, SWOLLEN LOWER LIP WITH DRIED DARK BLOOD AND THE LEFT SIDE OF THE FACE WAS SWOLLEN AND BLACK AND BLUE. NURSE "U" WAS ASKED WHAT HAPPENED TO RESIDENT #521. NURSE "U' STATED "SHE (THE RESIDENT) fell YESTERDAY, KNOWING HER SHE WAS TRYING TO GO THE TOILET AND DIDN'T ASK FOR HELP." ON 8/31/12 AT 9:00 A.M., REVIEW OF THE ADMISSION FACE SHEET INDICATED RESIDENT #521 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THE RESIDENT WAS SEVERELY COGNITIVELY IMPAIRED, NOT STABLE TO TRANSFER FROM SURFACE TO SURFACE AND REQUIRED EXTENSIVE ASSISTANCE WITH TOILETING. ON 4/23/12 , THE RESIDENT WAS PLACED ON THE FALLING STAR PROGRAM (INDICATION THE RESIDENT IS HIGH RISK FOR FALLS). AN UPDATED FALL CAREPLAN, DATED 7/9/12 LISTED SENSOR ALARM TO BED AND WHEELCHAIR INTERVENTIONS. REVIEW OF RESIDENT #521'S NURSING NOTES DATED 6/27/12 TO 7/3/12 DOCUMENTED THE FOLLOWING "RESIDENT CONTINUES TO BE ATTEMPT SELF TRANSFERS WITHOUT ASSISTANCE... REMINDED TO USE CALL LIGHT." REVIEW OF INCIDENT/ACCIDENT REPORTS DOCUMENTED THE FOLLOWING, ON 6/27/12 " RESIDENT SITTING ON MAT NEXT TO BED. I HAVE TO GO TO BATHROOM." ON 7/10/12 " TRYING TO GO TO THE BATHROOM. OBSERVED KNEELING ON FLOOR NEXT TO BED." STEPS TAKEN TO AVOID IMMEDIATE REPETITION: "REMIND TO USE CALL LIGHT AND WAIT FOR ASSISTANCE." AT 9:50 A.M. , UNIT MANAGER "T" WAS QUERIED CONCERNING THE RECENT FALL WITH INJURY FOR RESIDENT #521. UNIT MANAGER "T" STATED " SHE (THE RESIDENT) fell YESTERDAY AFTERNOON. SHE WAS IN THE MIDDLE OF THE ROOM AND TRIED TO GET UP . THE ALARM DID NOT SOUND, THE NURSE JUST HAPPENED TO BE NEAR HER ROOM DOOR. WHEN WE CHECKED THE ALARM, AT FIRST IT WENT OFF, THEN THE NEXT TIME WE CHECKED IT DIDN'T. WE FOUND IT ( THE ALARM) HAD A SHORT IN IT. I HAD THE CERTIFIED NURSING ASSISTANT GO AND GET ANOTHER ALARM." WHEN ASKED IF SAFETY ALARMS ARE SUPPOSED TO BE CHECKED. UNIT MANAGER "T" RESPONDED "ALARMS ARE CHECKED EACH SHIFT." THE INCIDENT/ACCIDENT REPORT DATED 8/29/12 WAS REVIEWED WITH UNIT MANAGER "T ". THE REPORT DOCUMENTED RESIDENT #521 AS "UNSTEADY GAIT, CONFUSION ABOUT WHAT HAPPENED. " STEPS TAKEN TO AVOID IMMEDIATE REPETITION: "NEW SENSOR ALARM TO CHAIR." REVIEW OF THE FACILITY FALLS PREVENTION POLICY REVEALED NO INSTRUCTIONS REQUIRING CENA'S TO CHECK THE CARE GUIDE FOR SAFETY DEVICES AND INTERVENTIONS, AND NO NOTATIONS REGARDING ENSURING THAT CARE PLANNED SAFETY DEVICES AND INTERVENTIONS ARE IMPLEMENTED AND FUNCTIONING.( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 250. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW PRIMARY CARE PROVIDER'S (PCP) ORDERS TO UTILIZE A BI-PAP BREATHING DEVICE AT NIGHT FOR 1 OF 4 SAMPLED RESIDENTS (#104), FROM A TOTAL OF 5 RESIDENTS SAMPLED, RESULTING IN THE RESIDENT EXPERIENCING [MEDICAL CONDITION], hospitalization , INTUBATION (INSERTION OF A BREATHING TUBE), AND PLACEMENT ON A VENTILATOR IN THE INTENSIVE CARE UNIT. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #104 WAS A [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ORDERS FROM THE HOSPITAL TRANSFERRING RESIDENT #104 TO THE FACILITY, DATED 3/16/2012 (UNTIMED), SPECIFIED THE RESIDENT WAS TO UTILIZE A BI-LEVEL POSITIVE AIRWAY PRESSURE ([MEDICAL CONDITION]; USE OF MACHINE TO HELP A PERSON, WHO HAS SLEEP APNEA OR [MEDICAL CONDITION], BREATHE MORE EASILY DURING SLEEP) AT NIGHT. THE PHYSICIAN ORDERS [REDACTED]. DURING AN INTERVIEW ON 4/24/2012 AT 1:25 P.M., RESIDENT #104'S ATTENDING PHYSICIAN (#22) SAID, "I ORDERED [MEDICAL CONDITION] FOR THE RESIDENT ON RE-ADMISSION TO THE FACILITY 3/16/2012. SHE HAD VERY BAD LUNGS. SHE HAD ADVANCED [MEDICAL CONDITION] AND [MEDICAL CONDITION]. SHE NEEDED THE [MEDICAL CONDITION], BUT I WAS TOLD BY FACILITY STAFF THE RESIDENT WASN'T PUT ON IT BECAUSE STAFF SAID THEY HAD NO ORDERS FOR SETTINGS. I SHOULD'VE BEEN PAGED FOR THE SETTINGS NEEDED. THEY DIDN'T FOLLOW MY ORDER FOR NIGHT TIME USE OF [MEDICAL CONDITION]. I WAS NOTIFIED ON 3/18/2012 BY STAFF THAT THE RESIDENT'S CONDITION HAD CHANGED; A MENTAL STATUS CHANGE. FOR HER THAT USUALLY MEANT A CARBON [MEDICATION NAME] RETENTION ISSUE. SHE ENDED UP WITH [MEDICAL CONDITION] AND ON A VENTILATOR IN THE HOSPITAL, AND PNEUMONIA TOO. [MEDICAL CONDITION] WOULD HAVE HELPED PREVENT THE INTUBATION (PASSAGE OF A BREATHING TUBE INTO THE AIRWAY, WITH CONNECTION MADE TO A VENTILATOR)." DURING AN INTERVIEW ON 4/24/2012 AT 2:25 P.M., REGISTERED NURSE (RN) #21 SAID ON 3/17/2012, DURING THE EVENING SHIFT (IDENTIFIED AS 3:00 P.M. TO 11:00 P.M.) SHE CHECKED ORDERS FOR RESIDENT #104 AND FOUND an order for [REDACTED].#18) DURING REPORT, TELLING HIM TO USE THE RESIDENT'S PREVIOUS SETTINGS. RN #21 SAID SHE DID NO FURTHER FOLLOW UP TO THE [MEDICAL CONDITION] ORDER WITH THE RESIDENT'S ATTENDING PHYSICIAN. RN #21 SAID THE RESIDENT'S [MEDICAL CONDITION] MACHINE REMAINED IN HER ROOM DURING A RECENT ADMISSION TO THE HOSPITAL. RN #21 SAID RN # 18 ONLY NEEDED TO TURN THE [MEDICAL CONDITION] MACHINE ON FOR USE BY THE RESIDENT. DURING AN INTERVIEW ON 4/25/2012 AT 9:45 A.M., RN #18 SAID HE HAD PREVIOUSLY BEEN ASSIGNED TO THE CARE OF RESIDENT #104, AND WAS AWARE SHE HAD SLEEP APNEA, AND THAT IT COULD BE FATAL. HE SAID HE HAD BEEN ASSIGNED TO RESIDENT #104, ON 3/17/2012, AS MANDATORY OVERTIME, ON THE NIGHT SHIFT (IDENTIFIED AS 11:00 A.M. TO 7:00 A.M.). HE SAID HE DID NOT PROVIDE USE OF THE [MEDICAL CONDITION] MACHINE TO THE RESIDENT AS ORDERED BY HER ATTENDING PHYSICIAN; HE SAID HE WASN'T AWARE THE MACHINE WAS IN THE RESIDENT'S ROOM. THE NURSE SAID HE WAS SUMMONED TO THE RESIDENT'S ROOM AT APPROXIMATELY 10:10 A.M. ON 3/18/2012, BY HER DAUGHTER - A PHYSICIAN, WHO REPORTED THE RESIDENT WAS UNRESPONSIVE, BREATHING, BUT BLUE IN COLOR. HE SAID A NON-REBREATHER MASK WAS PLACED ON THE RESIDENT (WHOSE PULSE OXIMETER WAS 79 PER CENT; ACCEPTED MINIMUM FOR A [MEDICAL CONDITION] RESIDENT WAS IDENTIFIED AS 90 PER CENT), HER VITAL SIGNS OBTAINED, AND HER PHYSICIAN NOTIFIED BY PHONE. THE RESIDENT WAS SUBSEQUENTLY SENT TO A LOCAL HOSPITAL FOR EVALUATION. ACCORDING TO THE EMERGENCY DEPARTMENT REPORT DATED 3/18/2012 (UNTIMED), RESIDENT #104 WAS admitted TO THE hospital on [DATE] AT 12:13 P.M. UNRESPONSIVE WITH "ACUTE [MEDICAL CONDITION], REQUIRING RAPID SEQUENCE INTUBATION." THE RESIDENT WAS REPORTED AS SUBSEQUENTLY TRANSFERRED TO THE INTENSIVE CARE UNIT WITH PLACEMENT ON A VENTILATOR. DURING A PHONE INTERVIEW ON 4/26/2012 AT 9:00 A.M., A CUSTOMER REPRESENTATIVE FROM THE COMPANY WHO SUPPLIED THE [MEDICAL CONDITION] MACHINE , FOR USE BY RESIDENT #104, SAID IT HAD BEEN DELIVERED to the facility on [DATE], AND WAS REMOVED FROM THE FACILITY ON 3/27/2012; 9 DAYS AFTER THE RESIDENT EXPERIENCED EMERGENT TRANSFER FROM THE FACILITY TO A LOCAL HOSPITAL. THE REPRESENTATIVE SAID THE THERE WAS NO NEED FOR FACILITY STAFF TO OBTAIN SETTING ORDERS FOR THE [MEDICAL CONDITION] MACHINE AS SETTINGS WERE AUTO-SET; SETTINGS ADJUSTED TO THE RESIDENT'S BREATHING. THE REPRESENTATIVE SAID STAFF ONLY NEEDED TO BE SURE THE MACHINE WAS PLUGGED INTO AN ELECTRICAL OUTLET AND WAS FUNCTIONING. DURING AN INTERVIEW ON 4/25/2012 AT 3:25 P.M., THE NURSING HOME ADMINISTRATOR SAID IT WAS HER EXPECTATION PHYSICIAN ORDERS [REDACTED].

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 783 AND MI 801. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION FOR 1 OF 5 SAMPLED RESIDENTS (RESIDENT #101) , FROM A TOTAL SAMPLE OF 11 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #101,WHO had a history of [REDACTED]. THIS DEFICIENT PRACTICE PLACES 28 ADDITIONAL RESIDENTS WHO HAD BEEN ASSESSED AS "FEEDERS" AND/OR LEGALLY BLIND AT RISK FOR SERIOUS HARM OR INJURY. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #101 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS, DATED 10/18/2011, IDENTIFIED THAT RESIDENT #101 REQUIRED EXTENSIVE ASSISTANCE DURING MEALS, WITH ASSIST FROM ONE PERSON. THE NUTRITION CARE PLAN INITIATED 7/12/2011, SPECIFIED "FEED RESIDENT (#101) AT MEALS." THE NURSE AIDE'S INFORMATION SHEET (UNDATED) SPECIFIED RESIDENT #101 WAS A "FEEDER" AND SHE ALSO REQUIRED "SET UP" (OPENING CARTONS, POSITIONING FOOD AND BEVERAGES, ETC.). THE INFORMATION SHEET REVEALED RESIDENT #101 WAS LEGALLY BLIND, AND WAS ALSO TOTALLY DEPENDENT ON STAFF FOR ACTIVITIES OF DAILY LIVING (ADL'S). ACCORDING TO THE INCIDENT/ACCIDENT REPORT, DATED 12/20/2011 (UNTIMED), RESIDENT #101 EXPERIENCED BURNS TO HER INNER THIGHS, WITH A SMALL BLISTER NOTED OF HER RIGHT INNER THIGH, AFTER HOT TEA WAS SPILLED. THE RESIDENT WAS REPORTED TO HAVE BEEN ASSESSED BY A PHYSICIAN, AND TREATMENT ORDERED. DURING AN INTERVIEW ON 12/22/2011 AT 9:45 A.M., RESIDENT #101 SAID SHE HAD REQUESTED AND RECEIVED A CUP OF TEA FROM A CERTIFIED NURSING ASSISTANT (CNA) #4, WHO SET THE CUP ON A TABLE NEXT TO HER IN HER ROOM ON 12/19/2011 AT 2:30 P.M. "I COULDN'T SEE IT; I HAD TO FEEL FOR THE CUP. I REACHED BACK TO PUT IT ON THE TABLE AFTER I DRANK. I COULDN'T SEE THE TABLE AND I COULDN'T HOLD THE CUP ANY LONGER. I COULDN'T SEE THAT THE AREA OF THE CHAIR WASN'T THE TABLE. I PUT THE CUP ON THE BLANKET OVER ME, THINKING I'D PUT IT ON THE TABLE. IT SPILLED. THERE WAS NO ONE IN THE ROOM WITH ME; I WAS LEFT ALONE. I SCREAMED. I SCREAMED BLOODY MURDER. IT HURT SO BAD." DURING AN INTERVIEW ON 12/21/2011 AT 1:55 P.M., CNA #4 SAID, "I DIDN'T LOOK AT THE CARE GUIDE (IDENTIFIED AS THE NURSE AIDES' INFORMATION SHEET). THE CARE GUIDE SAID TO FEED HER (RESIDENT #101); I DIDN'T FEED HER. ON 12/19/2011, I GAVE HER A CUP OF TEA. THE WATER WAS HOT; I TOLD HER IT WAS HOT. I'D GOTTEN THE TEA FROM THE KITCHEN AND BROUGHT IT TO HER ROOM. I TOOK OFF THE LID ON THE MUG. SHE HAS BLURRED VISION. I LEFT THE TEA ON A SIDE TABLE. I DIDN'T ADD COLD WATER OR ICE CUBES TO THE HOT TEA. I DIDN'T STAY IN THE ROOM WITH HER; I LEFT." DURING AN INTERVIEW ON 12/21/2011 AT 2:25 P.M., RESTORATIVE AIDE #5 SAID, "I HEARD A SCREAM ON 12/19/2011 ABOUT 2:30 P.M. I RAN TO HER ROOM. SHE WAS ALONE. I REMOVED A WET BLANKET THAT WAS OVER HER. HER PANTS WERE WET IN THE GROIN AREA. SHE SAID THE WATER WAS BURNING HER. I RAN OUT TO FIND A NURSE (LICENSED PRACTICAL NURSE/LPN #3). HER CARE GUIDE SAID SHE WAS A FEEDER. SHE WAS SUPPOSED TO HAVE SOMEONE WITH HER AT ALL TIMES WHEN SHE ATE OR DRANK, BECAUSE SHE NEEDED ASSISTANCE. I DO RESTORATIVE WORK WITH HER (RESIDENT #101). SHE HAD A GREAT DEAL OF WEAKNESS. SHE WOULD STRUGGLE TO DO IT HERSELF. IT WOULDN'T BE SAFE TO LEAVE HER ALONE TO EAT OR DRINK." DURING AN INTERVIEW ON 12/21/2011 AT 2:50 P.M., LPN #5 SAID, "I'VE CARED FOR THE RESIDENT (#101) A LOT OF TIMES. SHE'S ALERT, BUT VERY CONFUSED. SHE WAS WEAK AND DEPENDENT FOR ADL'S. SHE HAD GOOD AND BAD DAYS, BUT NEEDED ASSISTANCE WITH FEEDINGS. OCCASIONALLY SHE HAD TREMORS OF HER HANDS. I WAS CALLED TO HER ROOM ON 12/19/2011 BY THE RESTORATIVE AIDE (#5). HER WET PANTS FROM HAVING SPILLED THE HOT TEA WERE STILL ON HER. I ASSESSED THE RESIDENT AND FOUND SHE HAD REDNESS OF HER THIGHS; HER RIGHT THIGH HAD A SMALL BLISTER. A DOCTOR WAS IN THE FACILITY AND CAME TO SEE HER. HER NURSE AIDE INFORMATION SHEET SAID SHE WS TO HAVE A FEEDER AT ALL TIMES. EVEN WHEN WE STAND BY AND LET HER FEED HERSELF, IN AN ATTEMPT TO INCREASE HER INDEPENDENCE, SOMEONE MUST STILL BE WITH HER AT ALL TIMES AND NOT LEAVE HER SIDE OR HER ROOM." DURING AN INTERVIEW ON 12/22/2011 AT 10:50 A.M., OCCUPATIONAL THERAPIST #11 SAID, "I KNEW SHE (RESIDENT #101) HAD VISUAL ISSUES. SHE WOULD ASK ME TO COME CLOSER TO HER SO SHE COULD SEE I WAS THERE. SHE COULD BRING FOOD AND DRINK TO HER MOUTH. HOWEVER, IT WAS NOT SAFE FOR HER TO BE SEATED IN A GERI CHAIR, WITH A TABLE NEXT TO HER, AND EXPECT HER TO REACH SAFELY FOR A HOT BEVERAGE, LIKE TEA. SHE HAD A SHOULDER ISSUE, AND HER SHOULDER RANGE WAS LIMITED. SHE WAS A FEEDER. FEEDERS CAN'T DO IT, DRINK HOT LIQUIDS BY HERSELF SAFELY. FEEDERS HAVE TO HAVE SOMEONE THERE TO FEED THEM, FOOD AND FLUIDS." ACCORDING TO THE EMERGENCY DEPARTMENT PHYSICIAN NOTES, DATED 12/19/2011 AT 7:13 P.M., RESIDENT #101 WAS diagnosed with [REDACTED]. THE RESIDENT WAS REPORTED TO CONTINUE CARE AT THE HOSPITAL FOR treatment of [REDACTED]. DURING INTERVIEWS ON 12/22/2011 AT 11:25 A.M. AND ON 1/6/2012 AT 1:15 P.M., THE DIRECTOR OF NURSING (DON) #2 SAID THE FACILITY HAD NO POLICY/PROCEDURES REGARDING RESIDENT'S ABILITY TO HANDLE HOT BEVERAGES, OR FOR FEEDERS. DON #2 SAID IT WAS EXPECTED THAT RESIDENTS WHO WERE LEGALLY BLIND SHOULD HAVE A FACILITY STAFF MEMBER WITH THEM AT ALL TIMES WHEN HOT BEVERAGES WERE CONSUMED. RESIDENTS IDENTIFIED AS FEEDERS WERE ALSO EXPECTED TO HAVE A FACILITY STAFF MEMBER WITH THEM AT ALL TIMES DURING CONSUMPTION OF HOT BEVERAGES. DURING AN INTERVIEW ON 1/6/2012 AT 1:50 P.M., THE NURSING HOME ADMINISTRATOR #1 SAID IT WAS EXPECTED THAT RESIDENTS WHO WERE LEGALLY BLIND SHOULD HAVE A FACILITY STAFF MEMBER WITH THEM AT ALL TIMES WHEN HOT BEVERAGES WERE CONSUMED. RESIDENTS IDENTIFIED AS FEEDERS WERE ALSO EXPECTED TO HAVE A FACILITY STAFF MEMBER WITH THEM AT ALL TIMES DURING CONSUMPTION OF HOT BEVERAGES. ON 12/22/2011 AT 5:20 P.M., THE ADMINISTRATOR (#1) WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 12/21/2011 AND BEGAN ON 12/19/2011 WHEN THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT RESIDENT #101 FROM EXPERIENCING A SECOND DEGREE BURN OF HER THIGHS. ON 12/27/2011, THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1) AS OF 12/27/2011, ALL 131 FACILITY RESIDENTS WERE ASSESSED UTILIZING THE RESIDENT HOT BEVERAGE SAFETY AUDIT 2) BEGINNING 12/22/2011, ALL NURSING STAFF/ACTIVITIES STAFF WERE INSERVICED ON THE NEWLY CREATED HOT BEVERAGE POLICY/PROCEDURE. THE INSERVICE INCLUDED THE EXPECTATION THAT CERTIFIED NURSE AIDES FOLLOW THE CNA CARE GUIDE. CNA #4 WAS TERMINATED. 3) NEWLY admitted RESIDENTS OF THE FACILITY WILL BE ASSESSED BY NURSING FOR LEVEL OF FEEDING ASSISTANCE REQUIRED UTILIZING THE RESIDENT HOT BEVERAGE SAFETY AUDIT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 12/27/2011, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED, AND SEVERITY OF HARM THAT IS NOT IMMEDIATE JEOPARDY, DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT AND TREAT PRESSURE ULCERS FOR ONE (#304) RESIDENT, (IDENTIFIED AS LOW RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS), OF FIVE RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 24 RESULTING IN A FACILITY ACQUIRED PRESSURE ULCERS TO THE LEFT FOOT AND THE LEFT ISCHIUM (HIP). FINDINGS INCLUDE: ON 11/15/11 AT 10:45 A.M., AND AT 3:00 P.M. AND ON 11/16/11 T 9:45 A.M., RESIDENT #304 WAS OBSERVED IN BED WITH HER EYES CLOSED. SHE WAS LAYING ON AN AIR PRESSURIZING MATTRESS POSITIONED ONTO THE RIGHT SIDE WITH BOTH HEELS RESTING WITH PRESSURE INTO THE MATTRESS OR PILLOW. THE HEELS WERE NOT FLOATING (HEELS NOT TOUCHING/RESTING ON ANY SURFACE). ON 11/16/11 AT 11:30 A.M., RESIDENT #304'S CLINICAL RECORD WAS REVIEWED. PER THE FACE SHEET, RESIDENT #304 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. PER THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE] AND THE QUARTERLY MDS dated [DATE], RESIDENT #304 REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY, DRESSING, EATING, HYGIENE AND BATHING AND REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATION. THE QUARTERLY MDS CODED THE RESIDENT AS SEVERELY IMPAIRED IN COGNITION. THE FACILITY ADMISSION "SKIN AND PAIN REPORT" DATED 4/25/11 DOCUMENTED THAT RESIDENT #304'S SKIN WAS INTACT. THE BRADEN SCALE (A TOOL USED TO PREDICT THE RISK OF DEVELOPING PRESSURE SORES) DATED 4/25/11 AND 8/4/11 SCORED RESIDENT #304 AT "15" AND "16" RESPECTIVELY. A TOTAL SCORE OF 15-18 INDICATES LOW RISK. THERE WAS NO SPECIFIC SKIN CARE PLAN FOR RESIDENT #304. REVIEW OF THE ACTIVITIES OF DAILY LIVING CARE PLAN DATED 5/17/11 REVEALED, "ASSESS SKIN DURING DAILY CARE FOR ANY REDNESS OR SKIN BREAKDOWN...INSPECT SKIN WITH DAILY CARE AND OBSERVE FOR BRUISING." RESIDENT #304'S "SKIN AND PAIN REPORT" SHEETS WERE REVIEWED. ON 8/12/11 A DARK BLUE AREA MEASURING AT 4 CM X 3 CM TO RESIDENT #304'S LEFT HEEL WAS DOCUMENTED. NURSE NOTES DATED 8/12/11 DOCUMENTED, "ELEVATE HEELS WHILE IN BED." THE "SKIN AND PAIN REPORT"S DATED ON 8/24/11, 8/26/11, 8/31/11 AND 9/7/11, WERE REVIEWED AND REVEALED THAT A BRUISE OR DISCOLORED AREA WAS DOCUMENTED BY THE CERTIFIED NURSING ASSISTANT (CNA) ASSIGNED TO SHOWER THE RESIDENT ON THESE DATES. HOWEVER, NO SKIN CARE PLAN WAS IMPLEMENTED ON ANY OF THESE DATES. A SKIN CARE PLAN WAS GENERATED ON 9/14/11 AND DOCUMENTED THE FOLLOWING, "LEFT ISCHIAL UNABLE TO DETERMINE PRESSURE ULCER 3.9 X 5.5 X UNABLE TO DETERMINE. SANTYL ORDERED EVERYDAY AND PRN (AS NECESSARY). DTI (DEEP TISSUE INJURY) ON LEFT HEEL 7 X 4 X UNABLE TO DETERMINE." INTERVENTIONS INCLUDED "AIR PRESSURIZING MATTRESS, TREATMENTS AS ORDERED, REPOSITION EVERY TWO HOURS, CUSHION ON WHEELCHAIR, FLOAT HEELS WHILE IN BED." A PHYSICIAN WOUND CARE SERVICE NOTE, DATED 9/22/11, DOCUMENTED THE FOLLOWING, "ONSET OF WOUNDS WAS AT THE FACILITY. HEEL WOUND BEGAN ONE MONTH AGO. THE LEFT ISCHIAL WOUND BEGAN TEN DAYS AGO." ON 11/16/11 AT 11:50 A.M., RESIDENT #304 WAS OBSERVED IN BED, LAYING ON HER BACK. SHE WAS ALERT BUT SLOW TO RESPOND WHEN SPOKEN TO. NURSE 'J' WAS OBSERVED TO PERFORM WOUND CARE. THE WOUND TO THE LEFT HIP REVEALED FULL THICKNESS TISSUE LOSS WITH EXPOSED MUSCLE. THERE WAS SOME GREEN-COLORED SLOUGH. THE WOUND MEASURED 2.5 CENTIMETERS (CM) BY 3.5 CM AND 1.1 CM IN DEPTH. NURSE 'J' SAID THAT THE WOUND TO THE LEFT ISCHIUM WAS "A STAGE FOUR." THE LEFT HEEL DRESSING WAS THEN REMOVED TO REVEAL AN AREA IRREGULARLY SHAPED WITH NECROTIC (BLACKENED, DEAD SKIN) TISSUE COVERING THE ENTIRE HEEL. THE WOUND MEASURED 7 CM BY 3 CM. NURSE 'J' DESCRIBED THE LEFT HEEL WOUND AS, "UNSTAGEABLE." ON 11/18/11 AT 10:25 A.M., RESIDENT #304 WAS OBSERVED IN BED, POSITIONED ONTO HER BACK WITH BOTH HEELS RESTING WITH PRESSURE INTO A PILLOW. ON 11/18/11 AT 12:00 P.M., THE CLINICAL CHART WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON), UNIT MANAGER (UM) 'H' AND THE REGISTERED DIETICIAN (RD). THE DON AND UM 'H' WERE QUERIED REGARDING A SKIN CARE PLAN. THE DEEP TISSUE INJURY WAS NOTED BY STAFF ON 8/12/11 AND THERE WAS NO CARE PLAN INITIATED. THE DON STATED, "THERE SHOULD HAVE BEEN A CARE PLAN IN PLACE. THE DON AND UM 'H' COULD NOT EXPLAIN WHY THE DEEP TISSUE INJURY WAS NOTED BY THE CNA'S AND THERE WERE NO INTERVENTIONS NOR A CARE PLAN IMPLEMENTED TO TREAT THE PRESSURE ULCER. WHEN ASKED WHY THERE WAS NO SKIN CARE PLAN PRIOR TO THE DEVELOPMENT OF PRESSURE ULCERS TO THE LEFT HEEL AND LEFT ISCHIUM, THE DON STATED, "RESIDENT #304 WAS NOT AT RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS AND A SKIN CARE PLAN DID NOT TRIGGER." WHEN ASKED IF THAT MEANT THAT THE RESIDENT DID NOT RECEIVE ANY PREVENTATIVE SKIN CARE, THE DON SAID THAT PREVENTIVE SKIN CARE MEASURES WERE IN PLACE. THE DON AND UM 'H' REVIEWED THE CLINICAL RECORD AND WERE NOT ABLE TO PROVIDE WRITTEN EVIDENCE THAT MEASURES TO PREVENT A PRESSURE ULCER WERE IN PLACE. WHEN ASKED IF RESIDENT #304'S PRESSURE ULCERS WERE UNAVOIDABLE, THE DON AND UM 'H' WERE UNABLE TO EXPLAIN OR PROVIDE ANY WRITTEN EVIDENCE THAT THE PRESSURE ULCERS THAT DEVELOPED ON RESIDENT #304'S LEFT HEEL AND LEFT ISCHIUM WERE NOT UNAVOIDABLE. THE MONTHLY VITAL SIGN SHEET REVEALED THAT RESIDENT #304 WEIGHED 126 POUNDS ON 9/5/11 ON 11/7/11 THE RESIDENT WAS NOTED TO WEIGH 109 POUNDS. THE RD WAS ASKED WHY THERE WERE NO DIETARY INTERVENTIONS INITIATED AT THE ONSET OF THE PRESSURE ULCERS TO THE LEFT HEEL (NOTED ON 8/12/11) AND THE LEFT ISCHIUM (NOTED ON 9/14/11) TO PREVENT A 15 POUND WEIGHT LOSS. THE RD STATED, "I WOULD HAVE ADDED SUPPLEMENTS RIGHT AWAY IF I KNEW ABOUT THE WOUNDS." REVIEW OF THE FACILITY POLICY ENTITLED "treatment of [REDACTED]. ( )

THIS CITATION PERTAINS TO INTAKE # MI 434 BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO ENSURE RESIDENTS REMAIN FREE FROM ACCIDENT HAZARDS IN 3 (#101, #107 AND #108) OF 9 RESIDENTS, 8 OF WHICH WERE SAMPLED FOR ACCIDENTS AND SUPERVISION, RESULTING IN CONTINUED FALLS FOR RESIDENT #101, AN UNSUPERVISED FALL CAUSING PAIN AND RIB FRACTURES FOR RESIDENT #107, AND A FALL WITH PAIN, SWELLING AND BRUISING TO THE RIGHT HAND OF RESIDENT #108. RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 10/07/2010, RESIDENT #101 WAS AN [AGE] year-old FEMALE LIVING AT THE FACILITY SINCE 03/16/2010, UNTIL HER DISCHARGE ON 10/29/2010. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 HAD MODERATELY IMPAIRED DECISION MAKING SKILLS WITH LONG AND SHORT-TERM MEMORY LOSS. SHE COULD NOT WALK AND REQUIRED EXTENSIVE STAFF ASSISTANCE WITH ALL BED MOBILITY, TRANSFERS, LOCOMOTION AND TOILET USE. SHE HAD FALLEN IN THE LAST 31 TO 180 DAYS. THE CARE PLAN DATED 4/5/2010, IDENTIFIED FALLS AS AN AREA OF CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ANTI-SKID PAD TO WHEELCHAIR, BED AND WHEELCHAIR ALARMS, AND EXTENSIVE ASSISTANCE WITH ALL TRANSFERS, AMBULATION AND TOILETING. ON 3/17/2010, PHYSICAL THERAPY ASSESSED RESIDENT #101. PHYSICAL THERAPY DESCRIBED HER BALANCE AS POOR. PHYSICAL THERAPY FOUND THAT SHE REQUIRED MAXIMUM ASSISTANCE FOR ALL TRANSFERS, WALKING AND BED MOBILITY. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS" BY OLGA DREEBEN PUBLISHED BY JONES & BARTLETT PUBLISHERS, 2006 MAXIMUM ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 75% OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 6/20/2010, AT 12:55 PM THE FACILITY FAILED TO PROVIDE TRANSFER AND AMBULATION ASSISTANCE AND STAFF FOUND RESIDENT #101 ON THE FLOOR BETWEEN A CHAIR AND A WHEELCHAIR. STEPS TAKEN TO AVOID IMMEDIATE REPETITION WERE " ...RESIDENT WAS TAKEN TO BED AND WENT TO SLEEP" , NO EVIDENCE COULD BE FOUND IN RESIDENT #101'S CHART TO INDICATE THERE WERE ANY CHANGES IN SUPERVISION OR ASSISTIVE DEVICES AFTER THE INCIDENT TO PREVENT THE REOCCURRENCE OFF ACCIDENTS FOR RESIDENT #101. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 6/26/2010, THE FACILITY AGAIN FAILED TO PROVIDE TRANSFER AND AMBULATION ASSISTANCE AND AT 7:00 PM WHILE TRANSFERRING FROM THE WHEELCHAIR TO THE BED AND RESIDENT #101 fell . A STEP TAKEN TO AVOID IMMEDIATE REPETITION WAS ANTI ROLLBACK BRAKES ADDED TO WHEELCHAIR. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 9/22/2010, AT 8:45 PM, THE FACILITY FAILED TO PROVIDE TRANSFER AND AMBULATION ASSISTANCE AND STAFF FOUND RESIDENT #101 ON THE FLOOR. STEPS TAKEN TO AVOID IMMEDIATE REPETITION WERE "...PLACE A NON-SKID PAD IN WHEELCHAIR ..." AN INTERVENTION STAFF ALREADY HAD PUT IN PLACE. NO EVIDENCE FOUND IN THE RESIDENT'S CHART INDICATED THE IMPLEMENTATION OF ANY SUPERVISION OR ASSISTIVE DEVICES AFTER THE INCIDENT TO PREVENT THE REOCCURRENCE OF ACCIDENTS FOR RESIDENT #101. ON 11/18/2010 AT 11:00 AM, THE DIRECTOR OF NURSING WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT #101'S CLINICAL RECORD INCLUDING THE INCIDENT AND ACCIDENT REPORTS. THE DIRECTOR OF NURSING WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #101 RECEIVED THE ASSISTANCE SHE REQUIRED TO PREVENT ACCIDENTS. RESIDENT #107 ACCORDING TO THE FACE SHEET DATED 11/15/2010, RESIDENT #107 WAS A [AGE] year-OLD-MALE LIVING AT THE FACILITY SINCE 10/06/2010. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MEDICAL RECORD, STAFF readmitted RESIDENT #107 to the facility on [DATE] AND SUBSEQUENTLY THERE WAS NO MINIMUM DATA SET AVAILABLE. THE REHABILITATION SCREENING DATED 10/8/2010 DEFINED RESIDENT #107 AS HAVING PROBLEMS WITH BED MOBILITY TRANSFERS, AMBULATION, TOILETING BALANCE AND FALLS. DESPITE THIS ASSESSMENT, THE CERTIFIED NURSE ASSISTANTS (CNA'S) PLANNED RESIDENT #107 TO BE INDEPENDENT WITH BED MOBILITY, TRANSFERS, AMBULATION AND TOILETING . NO CARE PLAN WAS DEVELOPED TO ENSURE RESIDENT #107'S SAFETY WHILE PERFORMING THESE NECESSARY PROBLEMATIC ACTIONS IDENTIFIED BY THE REHABILITATION DEPARTMENT. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 11/10/2010, AT 2:45 AM, THE FACILITY FAILED TO PROVIDE TRANSFER, AMBULATION AND TOILETING ASSISTANCE AND RESIDENT # 107 WAS FOUND ON THE FLOOR IN THE BATHROOM. RESIDENT #107 WAS SENT TO A LOCAL HOSPITAL FOR EVALUATION AND TREATMENT AS INDICATED. ACCORDING TO THE LOCAL HOSPITALS RADIOLOGY REPORT DATED 11/10/2010, RESIDENT #107 SUSTAINED MULTIPLE RIB FRACTURE FROM THIS FALL. ON 11/18/2010 AT 11:00 AM EMPLOYEE "B" THE UNIT MANAGER WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT #107'S CLINICAL RECORD INCLUDING THE INCIDENT AND ACCIDENT REPORTS. EMPLOYEE "B" SAID RESIDENT #107 HAD AN UNSTEADY GAIT, FREQUENTLY ATTEMPTED TO SELF-TRANSFER, AND REQUIRED THE USE OF ALARMS. EMPLOYEE "B" SAID THAT STAFF DISCONTINUED RESIDENT #107'S SAFETY ALARMS AT THE RESIDENT REQUEST, BUT THAT THE FACILITY FAILED TO TAKE OTHER ACTIONS TO ENSURE HIS SAFETY. EMPLOYEE "B" WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #107 RECEIVED THE ASSISTANCE HE REQUIRED TO PREVENT ACCIDENTS. ON 11/18/2010 AT 1:40 PM EMPLOYEE "H" THE THERAPY MANAGER WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT #107'S CLINICAL RECORD AND SAID THAT THE REHABILITATION SCREENING DATED 10/8/2010 DEFINED RESIDENT #107 AS HAVING PROBLEMS WITH BED MOBILITY TRANSFERS, AMBULATION, TOILETING BALANCE AND FALLS. EMPLOYEE "H" ALSO SAID THAT THE SCREENING WAS KEPT IN THE THERAPY DEPARTMENT AND WAS NOT PROVIDED TO THE NURSES FOR USE IN PLANNING THE CARE FOR AND ENSURING THE SAFETY OF RESIDENT #107. RESIDENT #108 ACCORDING TO THE FACE SHEET DATED 10/01/2010, RESIDENT #108 WAS A [AGE] year-old FEMALE LIVING AT THE FACILITY SINCE 09/08/2010. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #108 HAD SEVERELY IMPAIRED DECISION MAKING SKILLS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #108'S BALANCE WAS SO POOR THAT THE BALANCE TEST COULD NOT BE COMPLETED WITHOUT PHYSICAL HELP. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WITH BED MOBILITY, TRANSFERS, AND LOCOMOTION. RESIDENT #108 WAS UNABLE TO WALK AND HAD FALLEN IN THE PAST 30 DAYS. THE CARE PLAN DATED 9/21/2010, IDENTIFIED FALLS AS AN AREA OF CONCERN FOR RESIDENT #108 AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ANTICIPATE NEEDS AND A FLOOR MAT. WHILE IN HER WHEELCHAIR WHICH WAS SIZED SPECIFICALLY FOR RESIDENT #108, SHE REQUIRED ANTI SKID PADS, A PUMMEL CUSHION FOR POSITIONING, LAP BUDDY, WHEELCHAIR ALARMS AND PROPER NON-SKID FOOTWEAR. RESIDENT #108 REQUIRED THE EXTENSIVE ASSISTANCE OF TWO STAFF MEMBERS WITH ALL TRANSFERS AND AMBULATION. THE CARE PLAN ALSO IDENTIFIED THAT RESIDENT #108 WAS LIKELY TO ATTEMPT TO TRANSFER WITHOUT ASSISTANCE, IF NOT SUPERVISED. PHYSICIAN ORDERS [REDACTED].#108. ON 9/29/2010, PHYSICAL THERAPY ASSESSED RESIDENT #108. PHYSICAL THERAPY DESCRIBED HER AS HAVING POOR SAFETY AWARENESS. PHYSICAL THERAPY FOUND THAT SHE REQUIRED MINIMUM ASSISTANCE FOR ALL TRANSFERS AND BED MOBILITY. PHYSICAL THERAPY FOUND THAT WHILE WALKING SHE REQUIRED MINIMUM TO MODERATE ASSISTANCE WITH A ROLLING WALKER. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS" BY OLGA DREEBEN PUBLISHED BY JONES & BARTLETT PUBLISHERS, 2006 MINIMUM ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 25% OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. MODERATE ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 50% OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 11/11/2010, AT 7:15 PM, THE FACILITY FAILED TO PROVIDE TRANSFER AND AMBULATION ASSISTANCE AND RESIDENT #108 fell TO THE FLOOR IN HER ROOM. RESIDENT #108 SUSTAINED BRUISING AND SWELLING TO HER RIGHT HAND. STEPS TAKEN TO AVOID IMMEDIATE REPETITION WERE "...CHECK/MONITOR LAP BUDDY PLACEMENT ..." AN INTERVENTION STAFF ALREADY PUT IN PLACE. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY SUPERVISION OR ASSISTIVE DEVICES AFTER THE INCIDENT TO PREVENT THE REOCCURRENCE OF ACCIDENTS FOR RESIDENT #108. ON 11/19/2010 AT 11:00 AM, THE DIRECTOR OF NURSING WAS GIVEN THE OPPORTUNITY TO REVIEW RESIDENT #108'S CLINICAL RECORD INCLUDING THE INCIDENT AND ACCIDENT REPORTS. THE DIRECTOR OF NURSING WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #108 RECEIVED THE ASSISTANCE OR DEVICES SHE REQUIRED TO PREVENT ACCIDENTS. THE DIRECTOR OF NURSING SAID THAT ACCORDING TO THE FACILITY'S INTERNAL INVESTIGATION RESIDENT #108 HAD BEEN PLACED IN A WHEELCHAIR THAT WAS NOT APPROPRIATELY SIZED FOR RESIDENT #108. THE DIRECTOR OF NURSING SAID THAT THE WHEELCHAIR PROVIDED TO RESIDENT #108 ALSO DID NOT HAVE ALL OF THE APPROPRIATE SAFETY INTERVENTIONS IN PLACE AS REQUIRED IN THE PLAN OF CARE.