Every finding on record at The Timbers of Cass County

This citation pertains to intakes #2998895 and #3000521.Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident sexual abuse for 1 resident (Resident #2) of 4 residents reviewed for abuse when Resident #4 who had a known history of sexual behaviors and who could propel her wheelchair throughout the facility touched Resident #2 sexually when he did not give consent, resulting in Resident #2 experiencing fear, wanting Resident #4 to stop coming to his room and wanting to discharge from the facility.Findings include: Review of the Facility Reported Incident (FRI) dated 4/15/2026 revealed .Incident Summary On 4/15 at 7:50p (PM), the administrator was notified that {Resident #4 (R4)}, a female resident, was inappropriately touching {Resident #2 (R2)} a male resident, in his room. Female resident stated she was checking to see if male resident was incontinent. Male resident denies asking resident to check him. Police were notified immediately after incident was reported. Residents were separated immediately upon discovery. (R2) when interviewed denies being fearful. He echoed the same sentiment to police. No injuries noted.Review of complaint filed by Anonymous Complainant (AC) EE on 4/15/2026 revealed Resident (R2) was given a gummy {gummy/gummie; edible cannabis products infused with tetrahydrocannabinol (THC) the compound responsible for marijuana's high} by a resident (R4) before she proceeded to sexually assault him. Facility did nothing about (R4) drugging him first in which we could not get him to wake up later. (R4) has touched/sexually assaulted many male residents in facility and I feel the residents are not safe with her present, this has went (sic) on for a long time.Upon further review, another FRI was noted and was reported to the State Agency on 2/3/2026. The FRI revealed On 2/4 at 10:55a (AM), (R4) came to the administrators office and told him that she needed to make a report. She proceeded to tell the administrator that she had been in (R2's) room on 2/3 in the evening. During her visit, she stated that (R2) put his hands on her legs and inner thigh, then proceeded to put his hands on her breasts. She stated that she was upset because she heard the resident that morning telling staff that he no longer wanted to see (R4) as she shows him her privates. When the administrator asked if the contact the previous night was consensual, she paused for several seconds before indicating that it was not. She stated that she had went to speak (sic) with (R2) right before reporting to the administrator what had transpired and asked him why he made the comments he did, to which he responded with we need to stay apart. (R4) expressed that this was a shock to her as she has assisted (R2) before with moving and other things. When discussing the allegations, (R2) stated that he did not touch (R4). When queried on their relationship status, he stated that they were not in a relationship. Discussing the investigation with the officer, the officer indicated that (R4) did not directly mention being touched on her breasts and instead focused her conversation on being hurt over the comments (R2) had made with regards to not wanting to see her anymore. (R4) approached the Administrator on 2/9 stating that she wanted to follow up on the previous incident. She told the administrator that she had gone to (R2) to apologize for blowing things out of proportion. She told the administrator that she had spent the weekend winding down at home and with friends. She told the administrator that she was upset over the comments. The police report associated with the FRI on 2/3/2026 revealed . (R2) does not want (R4) in this room anymore. (R4) said last night she overheard (R2) talking to one of the nurses and he stated he doesn't want to see that pussy. (R4) Showed great concern and frustration that (R2) did not want her in his room. I had asked (R4) if (R2) had touched her on her breast and she stated yes and it happened last night before (R2) stated he didn't want (R4) in his room. As I was speaking with (R4) I noticed that (R4) did not show any concern regarding being touched and only showed concern with not being allowed in (R2's) room. I would ask (R4) a question regarding the inappropriate touching and (R4) would answer the immediate question and then go back to talking about how she couldn't believe (R2) would say she can't come in his room. I went and spoke with (R2) And informed him the reason I was making contact. I asked (R2) if he had any sort of issue with (R4) and (R2) stated yes. I had asked (R2) if he had touched (R4) and he stated no. I told (R2) exactly what (R4) had told me and he said he never touched her in any way and stated why would he.I spoke with {Nursing Home Administrator (NHA) A }and informed him that (R4) showed no concern about touching of her breast and was only concerned about (R2) saying she can't be in his room.Resident # 2 (R2)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R2 admitted to the facility on [DATE] with pertinent diagnoses including bipolar disorder (chronic mental health condition characterized by severe shifts in mood, energy, activities and daily functioning), muscle weakness, reduced mobility, depression and PTSD (Post Traumatic Stress Disorder; mental health condition triggered by experiencing or witnessing a terrifying, life threatening event). Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which indicated R2's cognition was moderately impaired. Review of R2's current Care Plan revealed (R2) has been assessed upon admission for the presence of traumatic events in his history and found to have been a victim of trauma. Type or event physical assault with steak knife. Resulting in no triggers at this time. Problem Start date 11/19/2024. Review of R2's Progress Note dated 2/10/2026 revealed Spoke with resident regarding a recent allegation situation. Resident stated at this time he does not want the other resident involved in the situation to enter his room. Resident reports he has been trying to ignore her. Resident states he does not feel he is in any type of harm and did not verbalize any safety concerns at this time.Review of R2's Progress Note dated 4/15/2026 revealed . Resident is observed to be more stand-offish with talking about incident. Will talk this writer (sic) stating thank you for helping me with this situation. Resident has also stated I do not want her in my room or around me. Observed to be sad and scared after the police had left asking this writer if he's in trouble and he did want her (R4) to do that to him (touch him). Review of R2's Progress Note dated 4/16/2026 revealed Resident has been low in mood overnight following incident yesterday. Resident seems to have decreased appetite. Asked for a sandwich but did not eat it. Review of R2's Progress Note dated 4/16/2026 revealed Seen (R2) this am, he says he is doing ok. Little tired. Encouraged to go to an activity. He said he really did not feel like it. But maybe later.Review of R2's Progress Note dated 4/16/2026 revealed IDT (Interdisciplinary Team) reviewed incident between this resident and another resident on 4/15/26. Nurse observed this resident in his room being touched by another resident. Resident indicated that the touching was unwelcome and nurse intervened and removed other resident. Resident was assessed with no apparent injuries. Resident denies pain or discomfort. Resident stated that he felt safe and that he just didn't want her in his room anymore. Investigation initiated. Police notified and interviewed resident.Review of R2's Progress Note dated 4/16/2026 revealed Resident has been lethargic all day. Woke up occasionally when encouraged to eat meals. (physician name omitted) aware and verbally asked for resident to be monitored for changes. When aroused, resident is pleasant and cooperative. Vital signs obtained throughout the day and remained within normal limits for this resident. Currently lying in bed quietly with his eyes closed.Review of R2's Progress Note dated 4/17/2026 revealed . Prefers to stay in room. Observed to be more tired than normal does respond appropriately to questions.Review of R2's Progress Note dated 4/20/2026 revealed Talked to (R2) this am, he was lying in bed. Said he is ok, did not want to get up for breakfast, but said he would get up later and go for lunch. Resident #4 (R4 )Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R4 admitted to the facility on [DATE] with pertinent diagnoses including obesity, depression and epilepsy (neurological disorder characterized by recurrent unprovoked seizures caused by abnormal electrical activity in the brain) and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R4 was cognitively intact. Review of R4's Care Plan revealed no behavioral care plan related to sexual behaviors and no interventions that staff could use to help redirect sexual behavior when it was not welcome. Review of R4's Behavior Logs for February to April 2026 revealed only 1 sexual behavior in 3 months and nothing was recorded after 4/7/2026. Review of an outside psychiatric note for R4, dated 5/1/2026, revealed Chief Complaint: Inappropriate physical contact with another resident. Goals: Overall progress: Today's session focused on boundary exploration following an incident of inappropriate physical contact with another resident. The patient discussed her desire to help others which sometimes leads to boundary violations. We explored the distinction between appropriate ways to help versus care related tasks there are staff responsibilities. The patient demonstrated understanding of appropriate boundaries and stated she will not touch other residents. Judgement: Judgment is poor related to inappropriately touching another resident.Review of the Resident Council Minutes dated 4/14/2026 revealed that R4 attended the meeting and Ombudsman (O) Y was at the meeting. In the meeting notes R4 stated I have a friend of the opposite gender, I'm not allowed in this room. I'm not interested in men or women. I'm ok if they touch me. O Y responded Both parties have to consent. R4 responded with I had an affair. I had a shirt of his, stayed in his room no more than 10 minutes. His roommate called me a slut. Now this man says he never said that. O Y said Talk to me in private.Review of R4's chart revealed that R4 stayed in the room next to R2 from 1/2/2026 to 4/16/2026.Review of R4's Progress Note dated 2/10/2026 revealed Spoke with resident regarding a recent allegation involving another resident. (R4) stated she does not feel she is in harm and believes the other resident will not harm her, stating he is just an old man. Resident reports no safety concerns at this time. Review of R4's Progress Note dated 3/17/2026 revealed Went to see (R4). She recently was in a relationship which is now broken up. She says she is doing ok, but would like to talk to (psych services) will email them. Review of R4's Progress Note dated 3/23/2026 (Recorded as Late Entry on 03/24/2026) revealed Resident reports to this nurse that a resident in room [ROOM NUMBER]-1 (another room, not R2's room) verbally insulted her when she went to the room to visit resident in room [ROOM NUMBER]-5 (415-2). Resident states that as she left the room, resident in bed 1 hurled an insult and told her not to visit the room again. Staff instructed resident not to visit the room as of now until further instructions from the administrator. Resident denied any physical contact w/(with) the resident or any emotional distress at this time. Administrator was notified immediately and came to the building to handle the matter. Resident in her room throughout the rest of the shift w/o (without) concerns.Review of R4's Progress Note dated 3/24/2026 revealed Went and talked to (R4) about going in room [ROOM NUMBER]. I explained to her that neither gentlemen want her coming into their room anymore. She stated she understands and will not go in there anymore. Review of R4's Progress Note dated 3/30/2026 revealed Went to talk to (R4). We talked about her trying to visit the 2 gentlemen she has had recent relationships with. I explained to her they do not want her to visit them nor talk to them anymore. She said ok that's fine. She said she will try to not see them anymore.Review of R4's Progress Note dated 4/03/2026 revealed . Report given to this writer that resident was crying due to her not being able to go into gentleman rooms per gentleman's wish. Resident educated on respecting their privacy/wish of not going into their rooms without permission, resident continued upset and crying showing her discontent, however, resident observed being calmer and more cooperative. Review of R4's Progress Note dated 4/05/2026 revealed .observed resident attempting to propel herself to gentlemen's room this morning after breakfast, asked resident to come get her vitals taken, this nurse asked where she was going, resident stated she was headed to gentlemen's room on 200 hall, resident educated on his wishes of privacy and not going into his room, explained to (R4) that once gentlemen is up and in hallway she can talk, resident became upset and argumentative, uncooperative with taking vitals, began to move wheelchair back and forth, asked resident to please stop, resident closed her eyes and began to lightly tremble arms and eyes, after completing vital signs, resident opened her eyes and propelled herself back towards 100 hall. Review of R4's Progress Note dated 4/07/2026 revealed . Resident becoming more and more argumentative and non-compliant since parameters were set regarding resident entering other residents (sic) rooms without invite or permission from the residents of those rooms.Review of R4's Progress Note dated 4/16/2026 revealed Talked to husband about residents (sic) recent behaviors. He is going to take (R4) out for LOA (leave of Absence) till (until) Monday.Review of R4's Progress Note dated 4/16/2026 IDT (Interdisciplinary Team) reviewed incident that occurred on the evening of 4/15/26. Nurse observed this resident (R4) touching another resident (R2). Per resident, she was checking another resident's brief to see if he needed changed. Nurse intervened and separated residents. Resident informed that she should not attempt to provide care to other residents. In which, resident stated that she can do whatever she wants with anyone else. 1:1 precautions initiated out of caution in response to resident's behavior and disregard to being inappropriate. MD (Medical Director) notified. Resident's husband notified, after obtaining resident's consent.Review of R4's Progress Note dated 5/06/2026 revealed Resident was reviewed by the IDT regarding continued need for 1:1 observation status following a previous incident. At the time, resident stated she would do it again; however, staff assessment determined the statement was made out of anger and emotional escalation. Resident was reassessed on 5/5/2026. During discussion with staff, resident demonstrated remorse regarding the previous incident and stated she would not engage in similar behavior again. Resident was calm, cooperative, and able to verbalize understanding of expectations for appropriate interactions with peers. After IDT review, it was determined resident no longer meets criteria for continuous 1:1 observation. Resident will be discontinued from 1:1 status and transitioned to safety monitoring with 15-minute checks. Staff will continue to monitor behavior, provide support, and notify IDT of any further concerns or behavioral escalation.During an interview on 5/12/2026 at 11:49 AM, R2 sat in his wheelchair and had a flat affect and only nodded during the conversation at first. When discussing R4, R2 discussed a previous incident that occurred in his room several months back where R4 was in a wheelchair and went to his room and pulled her wheelchair next to his, she had her gown on for bedtime and she pulled it up and tried to get him to play with her privates and he told her No. R2 stated that she then parted her vagina and he kept saying No and then a nurse came in and he asked the nurse to get R4 out of his room and R4 left. R2 stated that he didn't touch her but she wanted him to touch her. R2 said she had a room next to him and she tried to come and see him and staff told her she couldn't come in and she kept trying. R2 said R4 would come to his door and say You have a big one and I want it and he told her that couldn't happen. When discussing the recent incident on 4/15/2026, R2 stated he was sitting in bed and R4 wheeled herself up to the bed, she was in her gown again and she pulled her gown up and pulled his cover back and put her hand under his pants and started playing with my penis and then the nurse came by and R4 stopped and the nurse took R4 out of the room. R2 stated that he wanted to go home after the incident because he didn't feel safe and was sad. R2 stated he doesn't want to go to the dining room and see anyone, especially R4 after the incident and staff keeps trying to get him to go. During an interview on 5/12/2026 at 11:38 AM, Certified Nursing Assistant (CNA) I stated R4 had sexual behaviors for a while now. CNA I said R2 didn't go down to the dining room for meals after the incident because he didn't want to run into R4. During an interview on 5/12/2026 at 12:24 PM, CNA S stated she worked on 4/15/2026 but was on break at the time of the incident. CNA S reported that she worked on the day of the incident on 2/3/2026 and R2 called her into his room and said he said didn't want R4 in room anymore because she showed him her privates. CNA S said that R2 was more depressed and sadder after the incident and didn't want to go to meals in the dining room or activities since he wants to avoid seeing R4. During an interview on 5/12/2026 at 12:42 PM, CNA L stated that she had seen R4 go into R2's room and make a pass at him but R4 wasn't allowed in his room anymore because he said he didn't want her in there but she would keep trying to get in his room sometimes. CNA L stated that R4 had spread her legs wide open and shown her privates to her (CNA L) when in the shower room. CNA L stated R4 had overly sexual behaviors. During an interview on 5/12/2026 at 1:30 PM, O Y stated that R4 brought up not being able to be in R2's room to her and that men are always on her radar and they don't want her in their room. O Y stated that she told R4 it was their right if they didn't want her in their room. O Y reported that this was an ongoing issue for months now and R4 wants to be with whoever she wants to whether he wants it or not. O Y stated that she had discussed that R4 would need consent from the other person if she wants a relationship with them. During an interview on 5/12/2026 at 2:10 PM, Licensed Practical Nurse (LPN) J stated on 4/15/2026 she was passing pills and came back up to R2's room and saw R4's hands underneath R2's pants and R2 mouthed help to her. LPN J said R4 was in her wheelchair facing R2 and R2 was sitting on his bed in front of her and she could only see that R4's hands were underneath his pants. LPN J stated that R4 tried talking to R2 and having a relationship with him and he didn't want that. LPN J stated that R2 always asked her to keep R4 away from him. After the incident, LPN J' said that R2 was more secluded and stayed in his room. LPN J reported that this had been going on for months before the incident on 4/15/2026. During an interview on 5/12/2026 at 2:45 PM, R4 stated on 4/15/2026 she was going by R2's room to say goodnight and R2 asked if she could get his water and put it on his tray table and he was trying to sit up in bed. Then, R4 said that R2 said would you do me a favor and see if my pants are wet? R4 said she did not put her hands down his pants and stated, that's ridiculous. When discussing gummies, R4 stated that she used to use gummies but she doesn't have any in her room.During an interview on 5/12/2026 at 3:05 PM, CNA FF stated that R4 was hard to keep an eye on and keep track of during peak hours because she moved throughout the facility. CNA FF reported that R4 was on 1:1 observation for a little bit after the incident on 4/15/2026 and was now on 15-minute checks and said that wasn't enough to keep an eye on her since a lot can happen in 15 minutes especially when they are busy in rooms taking care of residents. CNA FF said R4 went into R2's room a lot and R2 asked her to get out. CNA FF said that R4 should still be on 1:1 observation. When discussing interventions to help with R4's behaviors, CNA FF reported that there weren't any that she knew of besides 15-minute checks. During an observation on 5/12/2026 at 3:15 PM, R4 was self-propelling down the hallway without difficulty. During an interview on 5/12/2026 at 3:44 PM, R2 reported that on 4/15/2026 R4 came to his room and gave him gummies to take and then stroked his genitals. When asked how he knew it was gummies with THC, R2 said that he knew what it looked like and R4 told him what they were. R2 stated that the whole next day was the worst that he ever felt. Then, R2 asked this surveyor again if he could go home where he felt safe.During an interview on 5/13/2026 at 8:27 AM, LPN R stated that R2 told her about R4 going into his room months ago and spreading her legs and he didn't want to see it and she thought she charted it. LPN R said that R4 tried to get into R2's room and if you stopped her, she would get angry. LPN R reported that the next day after the incident on 4/16/2026, R2 was lethargic and he looked like he was drunk and R2 also told her that he felt like he was drunk. LPN R stated that R2 told her that the day before R4 gave him 4 gummies and he took it before she stroked him inappropriately. LPN R said she told Director of Nursing (DON) B and she wasn't sure what happened afterwards and she was told to continue to monitor R2. LPN R also said that even though R4 was on 15 minutes check now, she moves around the facility and it was hard to keep an eye on her since in 15 minutes R4 could get out of her sight and it was hard to know what she was doing. LPN R stated that management should find better inventions since that intervention wasn't enough and they weren't on the floor to know what was going on. After the incident, LPN R said R2 was more reserved. LPN R stated that she feels like (R4) is a perpetrator and since she was alert and oriented, she knew what she was doing. During an interview on 5/13/2026 at 8:47 AM, CNA G stated that 15-minute checks on R4 was the only intervention that she knew of and she didn't think that was enough to keep an eye on R4. During an interview on 5/13/2026 at 9:20 AM, Registered Nurse (RN) H stated that R2 asked her to make sure that R4 didn't get in his room before the incident on 4/15/2026. RN H said that R2 stayed in his room more since the incident. During an interview on 5/13/2026 at 11:47 AM, CNA K stated that staff didn't have good direction from management about R4 going into rooms and how they should handle it and what interventions they could use. During an interview on 5/13/2026 at 2:31 PM, CNA E stated that he worked on the day of the incident on 4/15/2026 but he did not see anything. CNA E said there was another incident where R4 showed her vagina to R2 and he said no and he didn't want her in his room. After the incident on 4/15/2026, CNA E reported that R4 wheeled herself up to him and was upset that she couldn't stay in R2's room and stated, I can touch any man anytime I want to and then proceeded to touch CNA E's thigh and he said he was cornered and felt uncomfortable. CNA E stated that R4's 15 min checks were not adequate since you are taking care of your residents and then have to find R4 and leave those residents, plus R4 moves quick and a lot can happen in 15 minutes. CNA E said the 15-minute checks weren't enough and they needed other inventions. During email correspondence on 5/13/2026 at 2:35 PM, NHA A mentioned that R4 started on 1:1 observation on 4/15/2026 after the incident involving R2, and it ended on 5/5/2026, at which point supervision of R4 was changed to 15-minute checks.During an interview on 5/13/2026 at 3:42 PM, Registered Nurse who was also the Social Worker (SW) Q stated that she just started in the role of SW recently since the previous SW left. SW Q said she was told about the incident on 4/15/2026 and had to interview staff and R2 and R4. SW Q wasn't aware of other incidents and said that R2 seemed fine when she saw him from the hallway. SW Q stated that she was told R4 gave R2 gummies and he took them, was out of it and didn't feel good the next day. When discussing a specific care plan for R4's specific sexual behaviors and interventions before and after the incident on 4/15/2026, SW Q stated that R4 went from 1:1 observation to 15-minute checks and wasn't aware of any other interventions. SW Q said they have been trying to get other placement for R4 for a long time. During an interview on 5/13/2026 at 4:20 PM, NHA A, DON B and Regional Director of Operations (RDO) X were in the room when discussing the incident between R4 and R2 and R2 feeling unsafe in the facility. NHA A stated that he was unaware that R2 felt unsafe in the facility. When asked about the gummies that R2 stated he took, NHA A said there were no gummies and stated that R2 was generally lethargic and he was told R2 and R4 shared a package of cookies not gummies. When discussing that there wasn't a sexual behavior care plan for R4 and asked what interventions were put in place after the incident on 2/3/2026 to help protect R2, NHA A stated that everything was in his FRI report and to read what the report said. When discussing interventions after the incident on 4/15/2026, NHA A stated that R4 was put on 1:1 observation and then it was changed to 15-minute checks since they decided as an IDT that R4 was doing well. RDO X stated that he was caught off guard with my information. During an interview on 5/14/2026 at 10:24 AM, R2 was lying in bed and said he wanted to leave again. R2 said that he wants R4 to stay away from him and not have her come to his room. R2 said after the incident when her hands were down his pants and stroking him, R4 had tried to see him a few times since then. When clarifying what R4 gave him before stroking him, R2 stated it was gummies, and when I asked if it was cookies, he said No and when asked how many gummies he took, he showed 4 fingers. During an interview on 5/14/2026 at 10:42 AM SW Q stated after our conversation the day before, she discussed with DON B R4's care plan and how there wasn't anything about R4's sexual behaviors and interventions for staff to use to help deal with it and they were working on it. SW Q wasn't sure what interventions were put in place after the incident on 2/3/2026 since she wasn't in the SW role at that time.During an interview on 5/14/2026 at 11:43 AM, DON B was asked about R2 and his lethargy on 4/16/2026 and she said that R2 took time to wake him up and arouse in the morning and wasn't sure why he was worse that time. When discussing that R2 told staff (LPN R) about the gummies and then she (LPN R) told DON B about it and asked what she did about it, DON B stated that since they couldn't confirm that R2 was given gummies, the physician told her to tell staff to monitor him like for any other situation. DON B reported that they did not do a THC test. DON B stated she was working on a sexual behaviors care plan for R4 and when asked about interventions put in on the care plan after the incident on 2/3/2026 when R4 showed R2 her privates and R2 mentioned several times he did not want R4 in his room, she stated she would have to look back because it happened after hours and NHA A was at the building.During another interview on 5/14/2026 at 1:55 PM, DON B stated after the incident on 2/3/2026, R4 went on a leave of absence with her husband and she was fine when she came back so they continued with the current plan and did not need to be on 1:1 observations or 15-minute checks at that time. Review of the Abuse Prevention Program Policy and Procedure with a review date of 1/2024 revealed . Sexual abuse, is defined as non-consensual sexual contact of any type with a resident. Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual or perineal area. Situations where a resident is sedated, is temporarily unconscious, or is in a coma that cannot give consent. VI. PROTECTION Residents are protected from physical and psychosocial harm during and after the investigation. This include: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; and Providing emotional support and counseling to the resident during and after the investigation, as needed. Revising 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.Review of the Comprehensive Resident Care Plan Policy with a review date of 1/2025 revealed . Social Service will incorporate residents mental and psychosocial well-being and related social needs into each resident's person centered plan of care.3. Each resident's comprehensive care plan is designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; . identify the professional services that are responsible for each element of care.6. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of their problem areas, rather than addressing all these symptoms or triggers.7. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage a task in isolation. The resident's physician (or Primary Health Care Provider) is integral to this process.17. Social services will review and update each resident's care plan quarterly, and as changes occur in the resident's care needs.

This citation pertains to intake #2735635Based on interview and record review, the facility failed to provide 30-day notification of discharge and implement appropriate discharge processes for 2 (Resident #100 and Resident #101) of 4 residents reviewed for facility-initiated discharge resulting in a lack of resident education related to care needs, lack of medical supplies needed for care at home, and the unapproved discharge of both residents.Findings include:Resident #100Review of an admission Record revealed Resident #100 was an [AGE] year old male who was originally admitted to the facility on [DATE] with pertinent diagnoses which included: traumatic ischemia of muscle(insufficient blood supply to muscle tissue caused by severe physical injury), fall on same level from slipping, tripping.muscle weakness, need for assistance with personal care, neuromuscular dysfunction of the bladder (nerve damage that disrupts between the brain, spinal cord, and bladder muscles causing underactive bladder function), diabetes mellitus(chronic metabolic disease characterized by high blood sugar levels), and encephalopathy(broad term for any disease, damage, or malfunction of the brain that alters mental state).Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 1/29/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 /15, which indicated the resident was cognitively intact. Section H revealed Resident #100 had an indwelling urinary catheter (flexible tube inserted into the bladder to continuously drain urine, held in place by a balloon) Section I revealed Resident #100 had an active diagnosis of malnutrition or was at risk for malnutrition.Review of a Care Plan for Resident #100 with a reference date of 8/29/25 revealed the following problems/goals/interventions: 1. Problem: Resident admitted to facility with foley catheter after hospitalization related to diagnosis of urinary retention. Goal: Resident will have toileting needs met without complications.2. Potential for episode(s) of hypo-hyper glycemia (excessively low or high blood sugar levels), r/t DX (diagnosis) of diabetes. Goal: Early recognition of s/s (signs and symptoms) of hypo/hyperglycemia with timely interventions. Approaches: (name of device omitted) blood sugar checks as ordered, administer diabetic medication(s) as ordered, observe for signs of hyperglycemia.observe for signs of hypoglycemia.3. Problem: Resident's ADL (activity of daily living) functional abilities.vary and fluctuate.4. (Resident #100) experiences incontinence of bowel on occasion.Approach: provide incontinence care after each incontinent episode.5. Problem: (Resident #100) is to discharge from the facility. Goal: Resident will be discharged to possible assisted living.obtain needed equipment and supplies.In an interview on 2/18/26 at 11:55am, Resident #100 reported he discharged from the facility on 1/20/26, one day after he met with Nursing Home Administrator (NHA) A who told him he had to leave because he had met all his goals. Resident #100 reported he was upset about leaving because his home was uninhabitable, he had never cared for his urinary catheter before, and he had no food. Resident #100 reported he felt he had no choice, and the facility bribed him by paying for a hotel for 10 days. Resident reported he did not receive information about his right to appeal his discharge. Resident #100 also reported he was discharged with no glucometer (device for checking his blood sugar level).In an interview on 2/18/26 at 1:50pm, Certified Nursing Assistant (CNA) C reported she was working the day Resident #100 discharged from the facility. CNA C reported she was concerned when she learned Resident #100 was being discharged to a hotel because he sometimes needed help with managing his bowel incontinence and catheter. CNA C reported she spoke with Resident #100 who voiced concern about his lack of food and told her he wished he had some oatmeal and milk he could take with him.In an interview on 2/18/26 at 2:52pm, former Social Worker (SW) J reported Resident #100 was discharged to a hotel but was hesitant about leaving the facility because he knew it was unlikely his home would be repaired enough to be in a livable condition within 10 days. SW J reported the facility pushed Resident #100 to discharge because of his outstanding balance with the organization. SW J reported she was concerned about Resident #100's wellbeing at the hotel due to a lack of transportation options, lack of food, and his need for support with catheter care.In an interview on 2/18/26 at 3:39pm, former Social Services Assistant (SSA) J reported she was pressured by NHA A to get the residents who had high bills out of the facility. SSA J reported part of the discharge process should include ensuring a resident has the medical supplies they need and referrals for other resources, including food if needed. SSA J confirmed Resident #100 was not referred for assistance with obtaining food.In an interview on 2/18/26 at 4:43pm former Social Worker (SW) L reported NHA A pressured Resident #100 to leave the facility on a daily basis due to the resident's outstanding balance and failure to pay. SW L reported Adult Protective Services (APS) deemed Resident #100's home as unsafe and uninhabitable but NHA A continued to pressure the resident to go home. SW L reported she was present when APS caseworker (APS/CW) O showed Resident #100 pictures of the inside of his home and at that time, Resident #100 reported he did not feel safe living in those conditions.In an interview on 2/19/26 at 3:12pm, APS/CW O reported with permission she inspected Resident #100's home and brought him pictures of the condition of the inside of his home. APS/CW O reported upon seeing the pictures Resident #100 confirmed he could not discharge back to his home until it was cleaned out and repaired. APS/CW O reported the home barely had a walking path through the interior, tripping hazards were present everywhere, it needed repairs to the utilities, had no running water, and front door had been kicked open. APS/CW O reported Resident #100 had friends that would help him repair his home, but repairs would likely take months, and Resident #100 frequently waffled on allowing others to help him.In an interview on 2/18/26 at 3:12pm, Durable Power of Attorney (DPOA) H reported she and Resident #100 met with NHA A approximately 2 weeks prior to Resident #100 being discharged , at which time NHA A told her Resident #100 could not afford to stay at the facility. When further queried, DPOA H reported she was not informed Resident #100 had an option to stay at the facility and/or to appeal being discharged . DPOA H expressed concern that Resident #100 was discharged without her knowledge and was not sent with a glucometer. DPOA H reported when the home health nurse made her initial visit 6 days after the discharge, the nurse evaluated him and sent him to the emergency room for further treatment.In an interview on 2/19/26 at 2:17pm, Registered Nurse (RN) R reported prior to discharge residents must be offered training for any nursing care they will complete for themselves. RN R reported the training should be documented in a progress note. RN R also reported any resident who requires blood sugar monitoring should be discharged with a glucometer and that should also be documented.In an interview on 2/19/26 at 2:51pm, RN Q reported Resident #100 relied on staff to complete catheter care and blood sugar checks.Review of a Emergency Department Provider Note for Resident #100, with a reference date of 1/26/26 revealed (Resident #100) is an 86 y.o.(sic) (year old) male patient presenting to emergency department with diarrhea and dark stools. States stools have been dark on and off for the past week.does have nearly black stool in brief.does state he recently came from (Skilled Nursing Facility) and was moved to a motel which he has for 10 days. He states he feels like he is having difficulty caring for himself at home.prescribed glucometer with test strips and lancets as he does not have a way to check glucose at home.DPOA called and expressed concerns about safety of discharge. States patient is relying on friends for food.is unable to leave his hotel room due to weakness. Patient is agreeable to permanent placement as he feels he cannot safely care for himself.HISTORY OF PRESENT ILLNESS.states he was referred here today by his home health nurse.Per EMS (Emergency Medical Services), home health care nurse called because he was covered in feces.Issues Requiring Follow Up: Patient has been taking (anticoagulant).dose reduced to 2.5mg (milligrams).Patient would likely benefit from Geri-psych referral.there are some signs of developing cognitive impairment.In an interview on 2/19/26 at 3:51pm, Director of Nursing (DON) B reported she could not locate documentation of Resident #100 receiving catheter care training or a blood glucose monitor prior to being discharged .In an interview, Business Office Manager (BOM) U confirmed Resident #100 owed the facility a substantial amount of money and had refused to apply for Medicaid or make any payments toward the balance. BOM U reported she tried many times to work with Resident #100 to resolve the issue and when she had no success, she asked NHA A to step in and attempt to resolve the situation. BOM U reported NHA A was responsible for issuing a 30-day notice of discharge.In an interview on 2/19/26 at 12:30pm, NHA A reported he had talked with Resident #100 on multiple occasions about his financial balance and about discharging from the facility. NHA A reported Resident #100 refused to apply for Medicaid because he did not want to have a portion of his income go toward his patient pay amount. NHA A reported Resident #100 was discharged to a motel with home health services. NHA A reported Resident #100 never mentioned wanting assistance with resources for food so the facility honored his wishes and did not pursue it.Resident #101Review of an admission Record revealed Resident # 101was a [AGE] year old male who was originally admitted to the facility on [DATE] with pertinent diagnoses which included: malignant neoplasm of colon (disease in which cells in the large intestine's inner lining grow uncontrollably, forming tumors), alcohol dependence with delirium( a sudden, temporary, and usually reversible state of confusion), and perforation(tearing) of the intestine.Review of a Minimum Data Set (MDS) assessment for Resident #101with a reference date of 1/13/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 5 /15, which indicated the resident was severely cognitively impaired. Section GG revealed Resident #100 was independent for wiping the opening of his ostomy (surgically created opening in the abdomen). Section H revealed Resident #101 had a colostomy (surgical procedure that creates an opening in the abdominal wall, connecting the colon to the outside of the body to divert waste into a replaceable bag).Review of a Care Plan for Resident # 101 with a reference date of 11/24/25 revealed the following problem/goal/approaches: Problem: (Resident #101) has impaired cognition AEB (as evidenced by) BIM's 5 severe impairment. Goal: (Resident #101) will be able to make safe.decisions with staff supervision. Approach: .reorient PRN (as needed), when resident is trying to remember something, do not rush.Review of a Social Services Progress Note for Resident #101 with a reference date of 1/7/26 revealed Resident is discharging tomorrow 1/8/26.Resident is being discharged to home.In an interview on 2/19/26 at 10:45am, DPOA M reported Resident #101 was notified on 1/7/26 that he would need to discharge on [DATE]. DPOA M reported she spoke with NHA A and told him there was no safe place for Resident #101 to go and no one to care for him. DPOA A reported NHA A said he'd look into options for Resident #101 but kept saying he did not want Resident #101 to build up medical debt. DPOA M reported ultimately, she picked Resident #101 up on 1/8/26 because an unknown staff member told her if Resident #101 was not picked up by midnight, he would be escorted outside the main door with the door locked behind him. DPOA M reported no one at the facility discussed the resident's right for a 30-day notice of discharge or his right to appeal the discharge. DPOA M reported Resident #101 initially said he did not want to discharge but after he was repeatedly approached by staff, who asked when his ride was coming, he agreed. DPOA M reported Resident #101 was not safe in his home, where he currently resides alone. DPOA M reported Resident #101 had never previously cared for his colostomy on his own, had poor short-term memory and reduced mobility following his lengthy hospitalization. DPOA M reported Resident #101 walked with a wheeled walker now that did not fit through the door to his bathroom, and he had fallen several times at home since his discharge. DPOA M reported Resident #101 was discharged with a referral to a local social services organization, but he has not received any homecare yet.In an interview on 2/19/26 at Certified Occupational Therapy Assistant (COTA) V reported Resident #101 should have received training on colostomy care from nursing prior to his discharge. COTA V reported Resident #101 was discharged with a wheeled walker for use in his home but a home evaluation to determine if the resident could safely use the device in his home was not completed. When further queried, COTA V reported with Resident #101's type of insurance, therapy does not have time to do home evaluations. COTA V reported due to Resident #101's cognition, he would need repetition in training to be successful with new tasks. COTA V also reported Resident #101 displayed impulsivity (tendency to act with no consideration of consequences) with unfamiliar tasks.In an interview on 2/19/26 at 3:51pm, DON B reported the facility could not provide any documentation of Resident #101 receiving training for colostomy care prior to his discharge.Review of an electronic communication received from NHA A on 2/18/26 at 9:59am revealed all discharges were voluntary, in reference to the discharge of Resident #100 and Resident #101.In an interview on 2/19/26 at 4:00pm, NHA A reported Resident #101's DPOA said they did not want him to discharge from the facility on 1/8/26 but they ultimately took him to his home. NHA A stated I'm not forcing people out.if they had said they weren't leaving they could have stayed. When queried, NHA A confirmed the facility did not provide Resident #100 or Resident #101 with written notice of discharge or right to appeal document.In a follow-up interview on 2/19/26 at 4:50pm, NHA A confirmed the facility was reluctant to initiate the involuntary discharge process.Review of electronic communications from the governing body on 2/19/26 8:38am, revealed the facility did not submit the required Notice of Involuntary Transfer or Discharge and Facility Initiated Discharge and Appeal Form form (ITD 100) for Resident #100 or Resident #101.Review of a Resident Transfers and Discharge policy with a reference date of 4/2020 revealed Facility -initiated transfer or discharge-Involuntary discharge: A transfer or discharge which the resident objects to; or did not originate though a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences.The facility provide written notice in a language the resident or the resident's representative can understand.Written notice will be given at least 30 days before the proposed discharge.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: On 1/6/26 at 10:42AM, three boxes of nutritional supplements (chocolate, vanilla, strawberry) were found in the walk-in cooler with each box containing 24 to 36 cartons. Further review of the boxes found the strawberry box with a facility date of 11/18/25 and the chocolate and vanilla boxes with a facility date of 12/17/25. An interview at this time with Dietary Supervisor (DS) Q found that the dates on the boxes are usually the date the boxes are pulled from the freezer. When asked how long the items are good for, Kitchen Supervisor (KS) G stated the cartons are listed with an expiration date. A review of the cartons found the expiration date listed is for the product while frozen, and the cartons state the product is only good 14 days from Thaw. A further review of the walk-in cooler found an open package of hot dogs with no date to indicate discard. On 1/6/26 at 12:23 PM, observation of the Birch Pantry with DS Q, found three open containers of thickened juice, in the refrigeration unit, were found with no date to indicate discard. A review of the containers stated the juice was good up to 7 days under refrigeration. An interview with DS Q found that dietary staff date the items when they bring them down, but nursing should be dating these when they open them. Further review of the refrigeration unit found an open container of soup dated 12/27/25. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use by date based on FOOD safety .According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .On 1/6/26 at 11:05 AM, observation of the stand-up mixer found a clear plastic bag covering the mixer. An interview with DS Q found that the large mixer is only used three or four times a month, and that the bag helps keep it clean between uses. Observation of the mixer, once the bag was removed, found heavy accumulation of stuck on white debris encasing the back shield of the unit. On 1/6/26 at 11:10 AM, observation of the inside ceiling of the kitchen microwave found an increased accumulation of dried splatter debris. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 1/6/26 at 3:46 PM, a follow up tour of the walk-in cooler found a large zip lock bag, sealed shut, with shredded pork loin leftover from lunch service. An interview with KS G found that lunch service ended around 12:30 PM and after the pork set out to cool, it was placed in the zip lock bag and put into the walk-in cooler around 1:00 PM. When asked if there was ever a temperature taken of the product to see where it was in the cooling process, KS G stated no. At this time, KS G and the surveyor each took the temperature of the pork roast and found it to be 90F-95F.According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include:On 1/6/26 at 1:25 PM, an interview with Maintenance Supervisor C, regarding the facilities Water Management Plan, found that the facility flushes water fixtures weekly to help remove stagnant water. When asked if the facility measures disinfection levels in the water, MS C stated he has a water strip test he does monthly that indicates levels of free chlorine and other factors within the water. When asked if the facility had control limits (minimums / maximums) for maintaining free chlorine or other factors on the water strip, MS C was unsure. On 1/6/25 at 1:38 PM, observation of the water softener salt room found two uncapped water lines behind the large water softener system. When asked if he was aware of these fixtures and if they are flushed regularly. MS C stated he was not aware of the hidden fixtures and will add them to his list for flushing. A record review of monthly logs submitted, dated April - November, found seven water quality parameters listed on each monthly chart with no clear distinction of acceptable ranges representing control limits. Multiple missing entries were noted with two of eight months showing 0 parts per million free chlorine residual, with no corrective action noted.A record review of the facility provided Water Management Plan (WMP), reviewed a document entitled Water Pathogen Risk Reduction, not dated, found that an interdisciplinary Water Management Team should meet at least quarterly. The plan goes on to state, The team shall review the plan at least annually to verify that the plan is being followed and to validate the monitoring and control methods. Further review of the WMP found a section where meeting minutes would be stored, with templates for taking minutes, but not completed forms or documentation of an active Water Management Team or annual review.

Based on observation and interview, the facility failed to maintain a clean and homelike environment for 4 residents (R91, R45, R5, and R14) of 4 residents reviewed for a safe, clean, and homelike environment resulting in a loud oxygen concentrator, unclean bed linens and wheelchair cushion, and holes in bed sheets, with the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self-esteem. Findings include:R91 Review of R91's Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact with a BIMS (Brief Interview Mental Status) score of 15/15. Section B- revealed R91's hearing was adequate. During an observation and interview on 1/6/2026 at 11:29 AM R91 stated his roommate (R45) had an oxygen concentrator that was very loud. It was so loud R91 and his roommate had to turn up the volume on their television to hear the television. Observed the oxygen concentrator in R91's room belonging to his roommate (R45) located at the foot of R45's bed and at the head of R91's bed. The concentrator was loud enough to be heard out in the hall with the door to the room closed. During an observation and interview on 1/7/2026 at 1:37 PM R91 stated he wanted to know why the oxygen concentrator was still in the room and a new quieter one had not been obtained yet. During an observation and interview on 1/7/26 at 1:43 PM, R91 stated he wished his roommate's oxygen concentrator could be changed out to a quieter one. The original one his roommate (R45) had was much quieter and easier to live with. The one currently in the room was very loud and interfered with watching television and sleeping. R91 stated he saw the oxygen supply company bringing in a new one for another resident and asked why his roommate had not gotten a quieter one yet. During an interview on 1/8/25 9:50 AM CNA (certified nursing assistant) J reported R91 had complained about the concentrator numerous times. R45 Review of R45's Minimum Data Set (MDS) dated [DATE], the resident was cognitively intact as indicated by a score of 15/15 on his BIMS (Brief Interview Mental Status). Section O revealed R45 received oxygen therapy and diagnoses included acute respiratory failure with hypoxia (lungs cannot get enough oxygen into the blood causing low blood oxygen levels), COPD (chronic obstructive pulmonary disease, and impaired vision. Review of R45's Physician's Order Summary, dated 6/25/25, revealed, Oxygen per nasal cannula at 2 liters continuous. During the observation on 1/06/2026 at 11:43 AM, R45 was sitting in a wheelchair next to his bed waiting for a new portable oxygen tank. The resident stated he needed oxygen from smoking for many years and wished he could get the original oxygen concentrator he had that was quieter than the current one he used. He had asked for a quieter oxygen concentrator from staff and was still waiting for one. R45 agreed that the oxygen concentrator was noisy and that it bothered both him and his roommate (R91). Further observation R45's living area exposed the resident's bed had blood stains and holes on his fitted sheets, and blood on his flat bed sheet and the pillow in his wheelchair. One hole in the fitted sheet was the size of a pencil eraser and the other approximately the size of a nickel. R45 stated he had a bloody nose the other day from his blood thinner medication and the blood was probably from that. He stated today, 1/6/25, was his shower day and the CNA had made his bed but had not changed his bed linens. During an observation and interview on 1/6/2026 at 11:59 AM, Licensed Practical Nurse (LPN) Y looked at R45's sheets and noticed the blood and holes, stating she would expect either the CNA or the shower aide to change R45's sheets when he went for a shower, when blood was first noted, and upon observing the holes. During an observation and interview on 1/7/26 at 1:43 PM, R45 was sitting in his wheelchair in his room wearing oxygen connected to an oxygen concentrator. The concentrator was loud enough to be heard in the hall through the R45's closed door. R45 said he and his roommate (R91) were told by staff they were going to check with (name of oxygen supply company) about a new and/or quieter oxygen concentrator but had not heard back from staff. R45 stated he was legally blind and couldn't see the blood or holes in his sheets and expected the facility to provide clean and intact bedding for him. He further stated he would not have lived at his home with blood or holes in his bedding. During an interview on 1/8/26 at 10:00 AM, Unit Manager (UM) E reported regarding R45 with R91 living in bed 1 and R45 in bed 2. Outlets in the room limited the location of the concentrator and the two residents liked the way the room was set up. Due to the oxygen concentrator noise level, the machine had been switched out twice before. R5 Review of R5's Minimum Data Set (MDS) dated [DATE], the resident was cognitively intact indicative by a score of 14/15 on her BIMS (Brief Interview Mental Status). Section GG-Functional Abilities revealed R5 was dependent for all cares, with diagnoses including nontraumatic intracranial hemorrhage (type of stroke affecting left non-dominant side), lack of coordination, contracture of muscle, and weakness. During an observation on 1/06/2026 at 2:01 PM, R5 had holes in her fitted bed sheets by her head. There were four holes between the size of a dime and nickel with many others smaller in size. During an observation on 1/7/26 at 9:15 AM, R5 had holes in her fitted bed sheets by her head. There were four holes between the size of a dime and nickel with many others smaller in size. During an observation and interview on 1/7/26 at 2:00 PM, R5 had holes in her fitted bed sheets by her head. There were four holes between the size of a dime and nickel with many others smaller in size. R5 stated she couldn't see them but would like to have sheets that were not raggedy. During an interview on 1/8/26 at 8:05 AM, Laundry Aide K stated, Any stained towels, wash cloths, pillowcases, sheets, or blankets that are seen in laundry are pulled, counted, and replaced. A lot of the older sheets are getting worn and are getting holes. These stained or worn linens should not be on the floor for resident use. During an observation and interview on 1/8/26 at 8:25 AM, Registered Nurse (RN) PP observed R5 in bed. RN observed holes in fitted sheet and stated, Aides (Certified Nursing Assistant-CNA) should take care of that. During an interview on 1/8/26 at 8:40 AM, CNA F stated, I am assigned to (R5) today. If I notice holes in resident sheets, I'll change them. I haven't noticed holes in (R5's) sheets today. I worked with (R5) on Monday but not the last two days. During an interview and record review on 1/8/26 at 8:31 AM, Occupational Therapy (OT) CC stated, Linens with holes should be removed. The bloody sheets should be changed out as well. Sheets should be changed on resident's shower day and if they are soiled or torn. Resident #14 Review of an admission Record revealed Resident #14 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (progressive disease that impacts cognitive skills) and major depressive disorder (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #14 with a reference date of 10/20/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Review of a Care Plan for Resident #14 with a reference date of 3/22/14 revealed the following problem/goal/approaches: Problem: Alteration in ADLs (activities of daily living) Goal: (Resident #14) will be clean, well-groomed daily and will participate in cares to her fullest ability. Approaches: .involve resident in care and decision making as much as possible. During an observation and interview on 1/6/26 at 1:18pm, Resident #14 sat in a chair in her room. The sheets on her bed had large areas of reddish discoloration across the entire surface of the fitted sheet. A yellow and tan circular stain, approximately 12 inches in diameter, was noted in the center of her pillowcase. When queried, Resident #14 reported she was very displeased with the condition of her sheets and pillowcase and felt they were filthy and had not been changed for weeks. During an observation on 1/8/26 at 11:14am, Resident #14 slept in her bed. The stains on her pillowcase and bed sheets remained as described during the observation on 1/6/26. In an interview on 1/8/26 at 12:17pm, Certified Nursing Assistant (CNA) SS reported Resident #14 was independent with cares and she was not assisted unless she asked for something. CNA SS reported Resident #14 would allow staff to change her bed linens as needed and those should be changed on the residents' shower days. In an interview on 1/8/26 at 12:29pm, Resident #14 reported her bed linens remained soiled. Resident #14 stated You see my pillowcase, it's filthy. I feel like asking them (staff) if they'd like to sleep on that. I shouldn't have to ask them to change my pillowcase and sheets when they're dirty. It's disgusting.

Based on interview and record review, the facility failed to ensure medications were administered per the physician's order for 1(Resident #60) of 1 resident reviewed for significant medication errors, resulting in the potential for adverse effects of the administration of digoxin without checking the resident's pulse and/or administering the medication if below the parameter of <60 beats per minute as outlined in the physician order. Findings include: Review of the [NAME]'s Drug Guide revealed, Digoxin (antiarrhythmic medication)-High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error .Monitor apical (heartbeat heard at the bottom tip of the heart, located on the left side of the chest, it is a more accurate heart rate measure than peripheral pulses, showing actual heart contractions, with a normal adult rate of 60-100 bpm (beats per minute) pulse for 1 full minute before administering. Withhold dose and notify health care professionals if pulse rate is < (less than) 60 bpm (beats per minute) in an adult. [NAME], [NAME], et al. Digoxin. [NAME]'s Drug Guide, 16th ed., F.A. [NAME] Company, 2019. Nursing Central, nursing.unboundmedicine.com/nursingcentral/view/[NAME]-Drug-Guide/51218/all/digoxin.Resident #60: Review of an admission Record revealed Resident #60 was a male with pertinent diagnoses which included congestive heart failure, stroke, mitral valve insufficiency (mitral valve located between the heart's upper and lower left chambers does not close tightly causing blood to leak backward into the left atrium instead of flowing forward), irregular heartbeat, tricuspid valve insufficiency (tricuspid valve between the right atrium and ventricle doesn't close tightly letting blood leak backward), and cardiomyopathy (disease of the heart muscle that makes it harder to pump blood, causing the heart to become enlarged, thickened, or stiff).Review of Resident #60's Orders dated 5/24/23, revealed, .Digoxin tablet, 125 mcg (microgram) (0.125mg); once a day upon rising; AFIB (atrial fibrillation). Hold if APICAL PULSE IS <60. Review of Resident #60's Medication Administration Record (MAR) for 12/8/25 to 1/7/26 revealed, .Digoxin tablet was administered on 12/17/25, pulse was 53; 12/23/25, pulse was 58; 12/30/25, pulse was 58, 12/31/25, pulse was 52; 1/7/25, pulse was 54. Review of Resident #60's Medication Administration Record (MAR) for 11/1/25 to 11/30/25 revealed, .Digoxin tablet was administered on 11/13/25, pulse was 56; 11/26/25, no pulse rate was noted.In an interview on 1/8/26 at 11:45 AM, Director of Nursing (DON) B reported Digoxin was for arrythmia, the nurse would check the pulse prior to giving as if it was not taken it could happen to cause the pulse to lower which would cause death in extreme cases or become unresponsive. DON B reported the therapeutic level should be monitored per the lab guidance the BMP and digoxin level every 6 months. DON B reported the Digoxin should not be given if the nurse had not taken the pulse, and if the pulse was below 60 it should be held. In an interview on 01/08/2026 at 2:59 PM, Pharmacist EE reported the digoxin level should be checked every 6 months. Resident #60 last had his done on 6/20/25. Pharmacist EE reported the digoxin was checked to ensure it was not at a toxic level, and the lab test would be done more frequently for residents who had history of higher levels of digoxin to ensure no toxicity develops.

Based on observation, interview, and record review, the facility failed to provide care to prevent bowel incontinence for a continent resident in 1 (Resident #31) of 1 resident reviewed for bowel incontinence, resulting in delay of treatment for diarrhea and the potential for dehydration. Findings include:Resident #31: Review of an admission Record revealed Resident #31 was a female with pertinent diagnoses which included disorders of bone density and structure, fall on same level from slipping, tripping, and stumbling, osteoarthritis (degenerative joint disease where protective cartilage wears down causing pain, stiffness, and swelling). This writer observed on 01/06/26 at 1:30 PM, Certified Nursing Assistant (CNA) W report to Licensed Practical Nurse (LPN) S Resident #31 had been having diarrhea with no control of her bowels. In an interview on 01/06/2026 1:48 PM, CNA W reported Resident #31 had not been here long and her bowel movements had not been normal every time she had taken care of her. CNA W reported she had informed the nurse a few days after she had admitted (12/16/25) of the concern with diarrhea, but as far as she was aware nothing had been done for Resident #31. CNA W reported nothing was staying in and almost as soon as Resident #31 had finished eating it was coming right out. CNA W reported she would take her to the restroom and would begin to wash her up and Resident #31 would tell her she needed to sit back down on the toilet. Review of Critical admission Assessment completed on 12/16/25 revealed, Resident #31 was continent of bowel with use of toilet. Review of Orders dated 12/19/25 revealed, .Document BM's Q (every) shift, Every Shift 10:30 PM - 06:30 AM, 06:30 AM - 02:30 PM, 02:30 PM - 10:30 PM.Review of Vitals Report dated 12/7/25 to 1/7/26 revealed, multiple instances of incontinence with loose, liquid stool documented by the CNAs assigned to care for Resident #31. Review of Progress Note dated 12/27/2025 at 09:57 PM, .Resident alert and oriented. Has been continent of bladder, but c/o (complaints of) of not having much sensation and knowing when she has been incontinent of stool. Bed mobility and toileting required 1 assist throughout the day and evening shifts. Lower back pain managed with prn (as needed) Tylenol and repositioning. Appetite 100% for all meals.Vital signs: 97.6-80-16; BP 110/59. Note: There was no documented follow up on this concern. Review of Orders for Resident #31 since admission revealed she was not prescribed any medications to address diarrhea. Review of Progress Notes dated 1/6/26 at 1:52 PM, revealed, .Resident is alert and oriented X 3-4. Resident is able to verbalize needs.Resident is a 1 assist.Resident is continent of urine, incontinent of bowel.No c/o (complaints of) pain or distress noted at this time. Note: this note was entered after LPN S was notified of the concern for continuous diarrhea for Resident #31 from CNA W.Review of medical record for Resident #31 on 1/7/25 following CNA W informing LPN S on 1/6/26 of the concern for diarrhea revealed no orders, no assessments, no progress notes of provider contact to address the concern. In an interview on 1/7/26 at 12:48 PM, Registered Nurse (RN) U reported he would the ask the CNA if the resident had been having the loose stools and would review resident's chart to determine if resident was taking a stool softener, if so, he would place the stool softener on hold due to the condition. RN U reported he would verify if the resident had an anti-diarrheal prescribed as a standing order, if not, he would reach out to the provider to see about adding one, if so, he would reactivate it. RN U reported he would enter a progress note and have staff monitor the resident's bowel movements regularly. In an interview and record review on 1/7/25 at 12:53 PM, Unit Manager (UM) E reported the CNAs have an area in the medical record where they would document their resident's bowel movements under vitals. UM E reported the CNA would notify the nurse if the resident was having loose stool, the nurse would contact the provider to determine if the provider would like to prescribe something to address the diarrhea. UM E reported the nurse would complete a progress note for the resident's condition. UM E reported some residents have standing orders and some don't, for a new resident and a new concern the provider would need to be contacted. UM E reported for a resident who had had diarrhea for a continuous duration, lab work should have been conducted. UM E reviewed Resident #31's medical record and reported there had been no labs completed since Resident #31 had been admitted . UM E reported the concern for Resident #31 should have been added to the doctor's book for the doctor or nurse practitioner to see the resident when in the building. UM E reported the CNAs had been educated they could add a comment for a concern as well as come to the unit managers and notify them of the concernReview of Progress Notes dated 01/07/2026 at 01:31 PM, .Writer (UM E) was informed that resident was having frequent loose stools. Writer spoke with resident about her eating/drinking habits and her bowel habits at home. Resident reported that she drinks coffee with almost every meal. However, she reported that she did not typically drink coffee at home unless someone brought her one when they visited. Writer educated resident on the effects coffee may have on her bowels. Resident stated she didn't know that and would try something different at the next meal. Writer also let resident known that the NP (Nurse Practitioner) was in the facility and writer would inform her of the loose stools she has been having. Writer will update resident with any new orders.Review of Progress Notes dated 01/07/2026 at 02:35 PM, . Writer spoke with NP regarding residents' loose stools. Order received for Imodium 2mg Q (every) 4 hours PRN (as needed) for loose stools. Orders also received to have CBC, CMP, Liver Function Test, TSH (Thyroid), and Lipid (Cholesterol) done on Friday. Order noted and resident notified.

Based on observation, interview and record review, the facility failed to ensure residents were assessed for risk of entrapment and informed consent was obtained prior to installation of bedrails for 1 (Resident #78) of 1 resident reviewed for bed rails, resulting in the risk for entrapment and injury.Findings include:Review of Clinical Guidance for the Assessment and Implementation of Bed Rails, www.fda.gov, 2003, revealed .National surveys of patient death occurring in the bed environment demonstrate the risk of entrapment.when the patient becomes entrapped in the bed rail itself. The population at risk for entrapment are patients who are frail or elderly.or those who have.agitation, confusion.hypoxia (low blood oxygen level).use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team.any decision regarding bed rail use.should be made with the framework of an individual patient assessment.bed rail use.should be accompanied by a care plan that presents clear directions.Resident #78Review of an admission Record revealed Resident #78 was originally admitted to the facility on [DATE] with pertinent diagnoses that included: chronic obstructive pulmonary disease (progressive lung disease resulting in decreased ability to maintain blood oxygen levels) and hallucinations (false sensory perception, making someone see, hear, smell, taste or feel thing that aren't actually there, but seem real).Review of a Minimum Data Set (MDS) assessment for Resident #78 with a reference date of 12/6/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 8/15, which indicated the resident was moderately cognitively impaired. During an observation on 1/6/26 at 12:50pm, Resident #78 slept with her head at the foot of her bed. The resident's feet protruded through the bars of a half-length (approximately 36 inches length) bedrail that was raised and locked in place on her bed.Review of a Care Plan for Resident #78 on 1/6/26 revealed no care plan for use of a bedrail.Review of the Observations section of Resident #78's medical record on 1/6/26 revealed no Interdisciplinary Physical Restraint Assessment related to the use of a bedrail.Review of the Physician Orders for Resident #78 on 1/6/26, revealed no orders for use of a bedrail.During an observation on 1/7/26 at 3:12pm, Resident #78 sat in a recliner in her room. The half-length bedrail remained raised and locked in place on her bed.In an interview, Certified Nursing Assistant (CNA) P reported Resident #78 had used the half-length bedrail for a long time. When further queried, CNA P reported Resident #78's bedrail had been in use for at least a month, based on the fact that she had it prior to moving to her current room.Review of a Census Report revealed Resident #78 moved to her current room on 12/15/25.In an interview on 1/8/26 at 11:20am, Resident #78 reported she did not like the bedrail because she regularly bumped her feet on it.Review of a Bed/Side Rail Use policy with a reference date of 1/25 revealed .if a bed or side rail is used the facility must.assess the resident for risk of entrapment.review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.Procedure: 1. The IDT Enabler/Physical Restraint Assessment will be completed prior to application.2. The physician will be contacted, an order obtained for the type of enabler or restraint 4. Enabler/Physical Restraint Consent form will be completed.6. Maintenance staff will install according to manufacturer's recommendations.

Based on observation, interview and record review, the facility failed to implement interventions for positioning and contractures for 2 of 2 residents (R5 and R41) reviewed for range of motion, resulting in the potential for worsening of contracture and developing skin breakdown. Findings include: R5 Review of R5's Minimum Data Set (MDS) dated [DATE], the resident was cognitively intact indicative by a score of 14/15 on her BIMS (Brief Interview Mental Status). Section GG-Functional Abilities revealed R5 was dependent for all cares, with diagnoses including nontraumatic intracranial hemorrhage (type of stroke affecting left non-dominant side), lack of coordination, contracture of muscle, and weakness. During an observation and record review on 1/6/2026 at 2:01 PM, R5 had hand-written instructions that were highlighted, placed on the wall above the resident's head of bed. Place pillow under left forearm and hand to elevate for edema management. Place rolled washcloth in left hand for contracture management. Observed R5 for implementation of these devices and saw no rolled washcloth in left hand or a pillow under left forearm or hand. Observed two blue wedges on the floor in corner of room. No washcloths were visible in the resident's room. A second hand-written note was on the wall above R5's head of bed stating For Staff starting 1st shift; place rolled wash cloth in left hand at beginning shift. Remove at end of shift. It was noted to not be at the end of 1st shift. During an observation and interview on 1/7/26 at 9:15 AM, R5 stated she did not have a washcloth in her left hand because it would fall out because her hand moved. Staff told her they were going to get her a brace or something that would stay in her hand, but one had not been used yet. R5 stated there were no wedges or pillows under her left arm/hand or side. When staff moved her not too long ago her leg hurt and staff had not put anything under her hips to off-load the pressure on either side of her hips. R5 reported she did get uncomfortable at times and needed to move around but she could not move herself and needed staff to help her. She was hoping to be moved around a bit in her bed that day. During an observation and interview on 1/8/26 at 8:25 AM, Registered Nurse (RN) PP observed R5 in bed. RN PP observed left hand to not have a rolled washcloth, or a pillow/wedge under sheet to resident's left side. RN PP stated, (R5) will sometimes get the washcloth out of her hand or not let staff put the wedge under her left side. It should be documented when she refuses, and the unit manager is the one that updates the care plan if residents do not want something done or refuses. During an interview and record review on 1/8/26 at 8:31 AM, Occupational Therapy (OT) CC stated, (R5) is to have a washcloth in her left hand for contracture prevention and skin breakdown and is to be done by the care givers. Pillow or blue wedge under her left side under sheet to prevent resident's arm from falling off side of bed and is to be done by care givers. If a resident refuses this care, it should be documented either in nursing notes or behavior logs. Review of R5's OT Recert, Progress Report, & Updated Therapy Plan for certification period: 10/26/2025-11/24/2025 revealed, Start of Care: 9/26/2025.Long Term Goal #2.0 patient will compliant with using hand roll for 4 hours per day to decrease contracture.10/16/25 patient using only when therapy places; poor CNA follow up.10/26/25 patient using only when therapy places; poor CNA follow up.Short Term Goal #5.0 caregivers will complete daily positioning of LUE (left upper extremity (arm)) in elevation using pillows, wedges, and place rolled cloth in hand to manage joint and skin integrity.10/16/2025, 10/16/2025 education to be initiated/continued.10/26/2025 education continuing to CNA; follow up minimal. It was noted CNAs had poor follow up providing hand rolls for R5 and that there was no care plan in R5's medical chart for nursing staff to implement interventions recommended by Occupational Therapy. During an interview on 1/8/26 at 8:40 AM, Certified Nursing Assistant (CNA) F stated, A washcloth and wedge were frequently refused by (R5). I report it to her nurse. CNAs are to document in the behavioral log when a resident refuses treatments or cares. I don't remember if I chart her refusals. Review of R5's Behavioral Log Flow Sheet for October 2025 and November 2025 noted no documentation of any kind of behaviors had been done for either month. Review of R5's Behavioral Log Flow Sheet dated December 2025 indicated on 12/30 at 9:25 AM, the resident was 1 (refuses care with no specific details), 2 (Frustration/escalating behavior with no specific details), and 3 (argumentative) during ADL (activities-of-daily-living). It was noted no specific details on what kind of ADLs attempted to be done for the resident or if the behaviors were directed towards positioning or use of washcloth. It was noted the Behavioral Log Flow Sheet required specific details for refusals and the staff that documented failed to do so. Review of R5's Behavioral Log Flow Sheet on 1/8/26 at 8:49 AM for January 2026 noted no documentation of any kind of behaviors had been done from 1/1/26 to 1/8/26 at 8:49 AM. During an interview and record review 1/8/26 9:46 AM, Unit Manager (UM) E stated, I do not see an order for (R5) to have a washcloth in her left hand or the wedge under her left side. CNAs document in their charting or the resident's behavior log book and notify the nurse. If the nurse does not chart in their nurse's notes it should be in the behavior log book and if it becomes a regular refusal, depending on what the resident is refusing it is up to the myself for resident specific concerns to make a care plan specific to the refusals. I am the Unit Manager for (R5). I do see OT (Occupational Therapy) notes for (R5) to use hand rolls for 4 hours a day to decrease contractures. This was dated 10/26/25. It does say patient use only when therapy places the hand rolls. The OT notes also say (R5) is reluctant to reposition but (R5) is pretty good at allowing repositioning. The pillow is used for left upper extremity (left arm) to manage joint and skin integrity. The OT note does not specifically say who places the pillow and that CNAs are to receive ongoing education and nursing should be placing it 10/26/25. If a resident is refusing these cares/treatments, they should be documented in behavior log by CNAs and if the resident continually refuses it should be reevaluated by the nursing staff. I would be one of the staff that would put the refusals in the care plan. There is not a care plan for what the OT has recommended for (R5). Review of R5's Care Plan, Skin Integrity, start date 10/27/2022, revealed, .Skin Integrity (R5) is at risk for skin breakdown related to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.decreased mobility/dependent with self-care and mobility. Goal (R5) skin will remain intact. Interventions: 10/27/2022 Encourage and assist as needed with turning and repositioning as (R5) will allow. It was noted there was not a comprehensive resident-specific care plan with interventions for R5 pertaining to the implementation of rolled washcloth for the left hand, pillow to elevate left arm and hand for edema management, or a pillow/wedge under sheet to left side to keep arm from falling off bed. Resident #41: Review of an admission Record revealed Resident #41 was a male with pertinent diagnoses which included stroke, muscle weakness, contracture (permanent tightening or stiffening of muscles, tendons, skin leading to limited range of motion and potential deformity) of multiple sites, left elbow, left hand, need for assistance with personal care, bed confinement, paralysis affecting left dominant side, diabetes, and abnormal posture. Review of current Care Plan for Resident #41, revised on 11/20/21, revealed the focus, .(Resident #41) is at risk for skin breakdown r/t (related to) left sided weakness, impaired mobility. with the intervention .CNA (Certified Nursing Assistant) to observe skin integrity during daily cares. Note: Care plan not updated to include the use of the washcloth. Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section GG: Functional Limitation in Range of Motion: Impairment on one side, Upper extremity. In an interview and observation on 1/7/25 at 1:25 PM, Resident #41 was in his room lying in his bed. Resident #41 allowed this writer to observe his left hand as it was under the blanket on his bed. Resident #41's hand was in a loose fist, with no washcloth in his hand. There was a sign on the wall behind the head of his bed which indicated a washcloth should be placed in his left hand very morning. This left hand was under the blanket, and it was in a loose fist, with no washcloth in his hand. Sign on the wall indicated that a washcloth should be placed in his left hand every morning. Resident #41 indicated he couldn't remember if the washcloth was placed in his hand every day but agreed the washcloth was not in place today. During an observation on 01/08/2026 at 9:26 AM, Resident #41 was in his room lying in his bed. head of the bed was approximately 45 degrees. When queried if he had the washcloth in his left hand today, Resident #41 indicated he did not have the washcloth in his hand. In an interview on 1/8/26 at 10:04 AM, Certified Occupational Therapist (COTA) UU reported the hand roll was placed in his hand to keep his hand dry, keep nails from digging in his palm. COTA TT reported the nursing staff were to complete passive range of motion (PROM) with Resident #41. COTA TT reported the communication form was completed and the nursing staff were educated on his care for PROM, ensuring hand hygiene was completed daily as well as a skin check before and after donning of cloth roll and nursing staff signed off on the education sign in sheet they had been educated on the care. COTA UU queried if a sign was still on the wall in his room to remind staff, this writer confirmed the placement of the sign above Resident #41's head of his bed. Review of Occupational Therapy Discharge Summary dated 2/11/25, revealed, .left and roll to be placed during first shift of day.caregivers to completed LUE (left upper extremity) passive range of motion with daily care, sin check daily.

Based on observation, interview, and record review, the facility failed to ensure treatment and care to maintain foot health in 1 (Resident #36) of 1 resident reviewed for foot care, resulting in delay of treatment for podiatry concerns and pain/discomfort of Resident #36's feet. Findings include: Resident #36: Review of an admission Record revealed Resident #36 was a female with pertinent diagnoses which included rheumatoid arthritis (chronic autoimmune disease where the immune system attacks healthy joint tissue causing pain, warm, swollen joints), cellulitis of right and left lower limbs (bacterial skin infection causing red, swollen, painful, and warm skin, can spread and become serious), chronic pain, weakness, heart failure, and need for assistance with personal care. Review of current Care Plan for Resident #36, revised on 6/20/24, revealed the focus, .(Resident #36) has potential for /actual pain r/t (related to) rheumatoid arthritis and poly arthritis. with the intervention .Administer pain medications as ordered .Observe for nonverbal signs of pain; grimacing, moaning, increased vital signs, guarding area(s).Pain assessment every shift. In an interview on 1/6/26 at 1:18 PM, Resident #36 reported her feet hurt as well as she reported something blue under her toenails and would like to soak her feet. Resident #36 reported she thought maybe it was the lotion the nurse applied to her feet. She said she had seen the podiatrist before and he cut her toenails because they were crooked but he doesn't address the concern she had with the lotion and under her toenails turning blue. In an interview on 1/6/2026 at 1:26 PM. Licensed Practical Nurse (LPN) S reported Resident #36 liked Bio Freeze (topical pain reliever using menthol to provide for temporary relief) and Aquaphor (healing ointment to restore and soothe dry, cracked, or irritated skin) on her feet, but she had not mentioned the concern with under her toenails being blue. LPN S reported she would bring it up to the doctor by calling them to come and examine Resident #36's feet. LPN S reported she would go in to examine Resident #36's feet. LPN S reported the cream was a white color, so she was unsure why Resident #36 thought she had blue under her toenails. In an interview on 1/6/2026 at 1:35 PM, when queried LPN S reported she thought it was fungus underneath her toenails as she had big horned toenails (severely thickened, overgrown, and curved toenails resembling a ram's horn due to uneven keratin growth causing pain) on her feet and she would contact the doctor for some cream for it.In an interview on 1/7/26 at 1:21 PM, Resident #36 reported he feet hurt and wanted to have some relief. Resident #36 indicated she reported the pain to the nurse, and she was hoping it was not going to be long before she came and put the cream on her feet. In an interview on 1/7/26 at 1:36 PM, LPN S reported she thought it was a fungus, reported the doctor had been in to see the resident, and LPN S said she had placed Resident #36 on the list to see the podiatrist. When queried if she saw the doctor examine the patient, LPN S reported no, the doctor was standing outside the resident's door in the hallway, and nothing had been prescribed for Resident #36. When queried when the podiatrist was going to be in the building next, LPN S reported she did not know when. In an interview on 1/7/26 at 3:18 PM, Resident #36 reported the nurse had not come and applied the lotion to her feet and her feet really hurt. In an interview on 1/7/26 at 3:33 PM, Registered Nurse (RN) M reported if there was a concern for fungus or other concerns expressed by the resident, she would contact the doctor depending on the concern, and/or document in the doctor book for them to be seen during rounding. In an interview on 1/7/26 at 3:40 PM, UM E reported the MD/NP (Medical Doctor/Nurse Practitioner) were here today. UM E reported she had rounded with them; Resident #36 was not on the list and was not seen by the doctor today. UM E reported the doctor was not here yesterday as she had not been feeling well and came today instead. UM E reviewed the doctor's book to verify if Resident #36 was on the list and she verified she was not. UM E reported if there was a concern for a resident the nurse would place the resident's name in the doctor book, and the concern would get communicated to her as she rounded with the doctor. UM E reported the doctor was in the facility on Tuesdays and Thursdays and the Nurse Practitioner was in the facility on Wednesdays and Fridays. During an observation and interview on 1/7/26 at 3:48 PM, Unit Manager (UM) E reviewed Resident #36's orders which revealed, she was prescribed Voltaren (cream or gel which treats arthritis pain by targeting pain directly at the source to deliver clinically-proven nonsteroid anti-inflammatory medicine) for her fingers and toes, BID (twice a day) between 06:00 - 2:00 PM and 03:00 PM - 10:00 PM. This writer asked UM E to review the medication administration record (MAR), and she reported it was documented in Resident #36's medical record she had received the Voltaren treatment during first shift, 06:00 - 02:00 PM. UM E was informed to speak to Resident #36 to verify the treatment had been provided. In an interview on 1/7/26 at 4:15 PM, MDS Nurse X reported Resident #36 was having her Voltaren cream applied at this time by the Unit Manager.

Based on observation, interview, and record review the facility failed to provide resident centered activities designed to support leisure needs for 3 (Resident #70, Resident #60 and Resident #75) of 4 residents reviewed for activities, resulting in feelings of boredom and the potential for worsening symptoms of depression, as well as a decline in physical and cognitive well-being.Findings include:Resident #70: Review of an admission Record revealed Resident #70 was a female with pertinent diagnoses which included dementia, cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language), need for assistance with personal care, aphasia (language disorder from brain damage that impairs speaking, understanding, reading, or writing), and depression. Review of current Care Plan for Resident #70, revised on 11/7/2022, revealed the focus, .(Resident #70) prefers activities that identify with prior lifestyle. She likes to listen to music, watch tv, look at magazines, and she enjoys animals, as well as going outside . with the intervention .Provide activities that resemble the resident's prior lifestyle; Musical entertainment, special events, socials, religious activities .Provide materials of interest: Tv, magazine, word search, puzzles .Inform resident of upcoming activities by: provide activity calendar, verbal reminders, escort, encouragement . Review of Social Services note dated 11/24/25 at 8:30 AM, revealed, .Annual MDS (Minimum Data Set) assessments completed. Resident received a 2/15 BIMS (Brief Mental Status) . Note: Score of 2 indicated resident was seriously cognitively impaired. Review of MDS dated [DATE], revealed, a staff assessment was completed which indicated Resident #70's activity preferences were listening to music, being around animals such as pets, spending time away from nursing home, and spending time outside. Review of Progress Note dated 01/01/2026 at 11:10 PM, .Resident likes to do her own independent activities and attends activities of choice. No signs or symptoms of distress noted. Resident A & O (alert & oriented) to person, place, time. Resident up at nurses' station for most of shift, went to cafeteria for supper. Went to room for nighttime care .is able to make her needs known to staff . During an observation on 01/06/2026 at 1:14 PM, Resident #70 was seated across from the nurse's station along the wall by the entrance to the 300 hallway. In an interview and observation on 1/6/26 at 2:28 PM, Certified Nursing Assistant (CNA) W reported Resident #70 didn't want to go to Bingo this afternoon and she preferred to talk to her stuff animals in her room and that kept her busy. Resident #70 was observed seated across from nurse's station after lunch, head down, eyes closed, and legs crossed. During an observation on 1/7/25 at 1:15 PM, Resident #70 was observed seated across from the nurse's station and her eyes were closed. During an observation on 1/7/25 at 2:36 PM, Resident #70 was observed seated across from the nurse's station in her wheelchair. She was not speaking or talking with any residents or staff. During an observation on 1/7/25 at 3:32 PM, Resident #70 was seated up at the nurse's station, and the music was unable to be heard as this writer stood along the wall and was unable to hear the music which was at the other end of the wall closer to the entrance to the hallway and the area was quiet at the time. During an observation on 1/7/25 at 3:55 PM, Resident #70 was seated in the same location as the previous observation this time Resident #70 had her eyes closed. During an observation on 01/08/2026 at 9:20 AM, Resident #70 was observed in her room talking to her stuffed animals while she was lying in her bed. During an observation on 01/08/2026 at 1:15 PM, Resident #70 was seated the nurse's station in her wheelchair, she had her left hand on her head, and had her eyes closed. This writer had attempted to speak to Resident #70 who was pleasantly confused. When spoke to and asked questions, the resident made eye contact but did not provide meaningful or purposeful answers to question. Resident #70 was not observed participating in any scheduled activities during the duration of the survey. Review of Activities Charting Report for Resident #70 revealed, November 2025 Resident #70 participated in 4 group activities; for December she participated in 10 group activities. Resident #60: Review of an admission Record revealed Resident #60 was a male with pertinent diagnoses which included stroke, speech disturbance, and dementia, Review of current Care Plan for Resident #60, revised on 11/08/21, revealed the focus, .(Resident #60) prefers activities that identify with prior lifestyle. He enjoys listening to country music, watching tv, being outdoors, and people watching . with the intervention .Inform resident of upcoming activities by provide activity calendar, verbal reminders, escort, encouragement .Provide materials of interest: TV, movies, magazines, Provide occasional visits with resident for socialization and companionship, Provide pet visits as able, Provide activities that resemble the resident's prior lifestyle: outdoor, socials, special events, musical entertainment, exercise . Review of Social Services note dated 12/22/2025 at 10:45 AM, .Quarterly MDS and psychosocial assessments completed. Resident received a 0/15 BIMS, which indicates severe cognitive impairment . Review of Activities assessment dated [DATE], revealed, .Previous Occupation: Farmer/Mailman .Cognitive and/or Sensory Deficit Programming: Does resident require special programming - No, skip rest of section .continue current plan of care . During an observation on 01/06/2026 at 10:35 AM, Resident #60 was seated in his wheelchair directly across from the nurse's station. This writer attempted to speak with Resident #60 and the resident made eye contact but did not provide meaningful or purposeful answers to question. During an observation on 01/06/2026 at 2:27 PM, Resident #60 was observed seated next to Resident #70 and he was seated towards the end of his wheelchair seat, leaning forward with his eyes closed. During an observation on 1/7/25 at 2:42 PM, Resident #60 was observed seated in his wheelchair in his room, he had his water cup by him on his rolling bedside table. He has his head down, and his hands clasped. Eyes were closed. During an observation on 1/7/25 at 3:32 PM, Resident #60 was observed seated in his wheelchair in his room, he had his water cup by him on his rolling bedside table. He has his head down, and his hands clasped. Eyes were closed. During an observation on 01/08/2026 at 9:17 AM, Resident #60 was seated at the nurse's station, his eyes were closed and he had his head down. During an observation on 01/08/2026 at 1:17 PM, Resident #60 was seated at the nurse's station in his wheelchair on the corner, couldn't hear the music as another resident was humming along. He could barely keep his eyes open and his head was tilted forward. Review of Activities Charting Report for Resident #60 revealed, November 2025 Resident #60 participated in 11 group activities, 1 family visit; for December he participated in 19 group activities, 1 family visit. In an interview on 01/06/2026 at 11:28 AM, Activity Director (AD) N reported she had developed an activity called healthy hands which was a sensory activity and she would provide residents with a washcloth to wash their hands prior to meals, she reported it was difficult to schedule an evening activity as dinner was not being served at a consistent time and the activity aide competed the last activity for the day at 5:00 PM. AD N reported she had concerns with residents being placed at the nurse's station listening to music which wasn't age appropriate for those residents aged in their 70s, 80s, and 90s, that the music was more modern like 90s and 2000s. In an interview on 1/8/26 at 1:49 PM, AD N reported when she had started at the facility staff were documenting on hard copies of various forms of paper, not a specific document. AD N reported she was having Activities Aide (AA) JJ sorting through loose papers to sort the documentation into months to later be entered into the medical record. AD N reported she had educated the activities staff on documenting one to one room visits with residents. Review of the Activity Calendar for January 6 - January 8th revealed, .1/6/26: 8:30 Daily Agenda, Reminders of Daily programs; 10:00 AM Daily Chronicles, Today's menu and Exercise; 10:30 National Bean Day, Healthy Hands; 2:00 PM Bingo; 3:30 PM Unit specific in room Hand Care Cart; 5:00 PM Air Hockey in the game room .1/7/26: Waffle Wednesday: Chocolate Chip Waffles; 10:00 AM, Daily Chronicles, Today's menu, and Exercise; 10:30 AM Calendar Committee, Health Hands; 2:00 PM January Birthday Celebration - Cake, Punch, and a Birthday game .1/8/26: 8:30 Daily Agenda, Reminders of Daily programs; 10:00 AM Daily Chronicles, Today's menu and Exercise; 10:30 Happy Birthday Elvis - Song quiz, Facts & The King Trivia; Healthy Hands; 2:00 PM Laura's Creations; 3:15 PM Bible Study led by Volunteer (First Name); 5:00 PM Penny Pitching . Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems. Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings. Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier. When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience.research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory — and the more variety the better. Other studies are providing new information about ways that creative activities, such as music or dance, can help older adults with memory problems or dementia. Resident #75 Review of an admission Record revealed Resident #75 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: multiple strokes (sudden loss of blood flow to an area of the brain causing symptoms like numbness, loss of movement, confusion or vision/speech deficits), major depressive disorder (persistent sad mood resulting in loss of interest, affecting daily functioning). Review of a Minimum Data Set (MDS) assessment for Resident #75 with a reference date of 12/14/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #75 had little interest or pleasure in doing things and felt down, depressed, or hopeless nearly every day of the 14-day assessment period. Review of a Care Plan for Resident #75 with a reference date of 6/23/25 revealed the following problem/goal/approaches: (Resident #75) lacks sense of initiative/involvement as evidenced by R/T (related to) little interest or pleasure in doing things. Goal: Resident will not exhibit signs of isolation. Approaches: .attempt to involve resident with individuals who seem to bring out a more positive optimistic side of the resident, encourage resident to establish social role in the facility.involve resident with those who have shared interests, provide opportunity for resident's expression of individuality (e.g. what gave sense of satisfaction in earlier life). During an observation and interview on 01/06/2026 at 11:40 AM, Resident #75 sat at the edge of his bed. His room was quiet; the television was off. Resident #75 reported he was not interested in the types of activities offered at the facility, frequently felt bored and realized the lack of activity could worsen the symptoms of his depression. Resident #75 reported he worried about his mood worsening, but he could not do the types of leisure activities he used to enjoy and needed support to occupy his free time. In an interview on 1/8/26 at 9:41am, Activity Assistant (AA) OO reported Resident #75 did not attend any group activities at the facility and spent most of his time alone in his room. Review of an Activities Charting Report with a reference date of 12/25/25 revealed Resident #75 participated in 1 activity, Healthy Hands. Additional documentation of any group or 1:1 activity involvement for Resident #75 was requested but no additional documentation was provided prior to the conclusion of the survey. In an interview on 1/8/26 at 11:24am, Activities Director (AD) N reported she accepted her position a few months prior to this date and had not been able to evaluate Resident #75 to determine his leisure needs and interests. AD N reported the facility was working on developing a 1:1 visit program for residents who preferred to remain in their rooms, but visits were not being consistently offered yet. In a follow up interview on 1/8/26 at 12:13pm, AD N reported following an evaluation on this date, she determined Resident #75 was agreeable to support with pursuing his leisure interests which included birdwatching, playing cards, and visiting with like peers. AD N reported she searched for Resident #75's activity participation records/1:1 visit documentation and could not find any additional record of his involvement. Review of an Activity Programming policy with a reference date of 6/17 revealed Policy: Activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are person-appropriate to the individual resident.

Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 3 of 4 residents (Resident #31, #36, and #41) and nail care for 1 (Resident #41) of 4 residents reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for decreased self-esteem. Findings include: Resident #31: Review of an admission Record revealed Resident #31 was admitted to the facility on [DATE]. In an interview on 1/6/26 at 1:07 PM, Resident #31 reported she had not had a shower since she had been admitted to the facility. Review of Orders dated 12/19/25 revealed, .Bath/Shower on Once A Day on Mon, Wed 06:30 AM - 02:30 PM.Review of Skin Monitoring - CNA/STNA Shower Review documents completed on 12/16/25, refused and signed by nurse (note Resident was admitted 11:45 AM), 12/18/25 signed by staff member, no nurse signature, and 12/23/25 refused three times but not signed by nurse. No other documented shower sheets in record. No progress notes in the record to support the refusals. Note: No care plan implemented which would support refusing showers. Review of Behavior Logs for October, November, and December 2025 revealed, no behaviors noted for refusal of care. Resident #36: Review of an admission Record revealed Resident #36 was a female with pertinent diagnoses which included rheumatoid arthritis (chronic autoimmune disease where the immune system attacks healthy joint tissue causing pain, warm, swollen joints), cellulitis of right and left lower limbs (bacterial skin infection causing red, swollen, painful, and warm skin, can spread and become serious), chronic pain, weakness, and need for assistance with personal care. Review of current Care Plan for Resident #36, revised on 6/20/24, revealed the focus, .Alteration in ADLs (Activities of Daily Living) - self-care and functional mobility may fluctuate r/t (related to) weakness, heart failure, rheumatoid arthritis. with the intervention .Allow resident time to perform and complete ADLs as able. Staff to provide assistance for completion of tasks as needed.In an interview on 1/6/26 at 1:18 PM, Resident #36 reported she would like to get her showers as expected as she was not receiving them as she should. Resident #36 reported she felt the facility needed more staff so she could get showers twice a week. Resident #36 reported she does get one a week, but they needed to be done more.Review of Orders revealed Resident #36 was to be provided with a shower every Tuesday and Friday, 6:00 AM to 5:00 PM. Review of Skin Monitoring - CNA/STNA Shower Review documents for Resident #36 revealed 11/4/25, refused and not signed by nurse, 11/18/25, refused and not signed by nurse, 12/12/25 not signed by nurse, 12/16/25, refused and not signed by nurse, 12/19/25, refused and not signed by nurse. Note: no other documented showers or refusals were in the medical record. No progress notes entered in the medical record for the refusals per policy. Review of Behavior Logs for October, November, and December 2025 revealed no behaviors documented for refusal of care. Resident #41: Review of an admission Record revealed Resident #41 was a male with pertinent diagnoses which included stroke, contracture (permanent tightening or stiffening of muscles, tendons, skin leading to limited range of motion and potential deformity) of multiple sites, left elbow, left hand, need for assistance with personal care, bed confinement, paralysis affecting left dominant side, diabetes, and abnormal posture. During an observation on 1/7/26 at 1:25 PM, Resident #41 was in his room lying in his bed, his fingernails were long, jagged, with black debris under them on his right hand. During an observation on 1/8/2026 at 9:20 AM, Resident #41's fingernails were jagged, long and had black dirt and debris in the nail. In an interview on 1/7/26 at 3:33 PM, Registered Nurse (RN) M reported the nurse's cut the resident's nail who have diabetes, when completing weekly routine skin assessments and would look to see if the nails were jagged, not sharp which could increase chances of scratches, open areas on the skin. RN would clean the nails if there were dirt and debris in the nails. RN G reported the CNAs (Certified Nursing Assistant) or Shower Aides would notify the nurse on shower days if the resident's nails would need trimming. Review of Skin Monitoring - CNA/STNA Shower Review documents completed on 10/1/25 refused, 10/3 refused, 10/10 refused, 10/22 refused and not signed by nurse, 10/24 refused, 10/29 refused, 11/7 no nurse signature, 11/12 refused and not signed by nurse, 11/14 refused and not signed by nurse, 11/21 refused, 12/5 refused, 12/12 refused, 12/19 refused. Note: No other shower sheets provided for the residents. Review of Progress Notes for Resident #41 revealed no documentation supporting the refusals for showers/baths. Review of Behavior Logs for October, November, and December 2025 revealed no behaviors documented for refusal of care. In an interview on 1/7/26 at 12:41 PM, CNA MM reported when she provided a shower to the resident, a shower sheet was completed, and the nurse would sign it. If a resident refused the shower, the staff would attempt to offer the shower again, if not, then refused was documented on the shower sheet and signed by the nurse. In an interview on 1/7/26 at 3:03 PM, Shower Aide SS reported when a resident refused a shower she would reapproach them three times and if the resident still refused, she would let the CNA assigned to the resident know, let the nurse for the resident know, document on the shower sheet the resident refused and have the nurse sign it. Shower Aide B reported for care refusals it would be logged in the behavior book for behaviors. In an interview on 1/7/26 at 12:46 PM, RN U reported first he would find out why the resident refused the shower, maybe they wanted the shower later in the day or by another staff member who had a better rapport with the resident. RN U reported if the shower was refused three times, it would be documented in the behavior log by the CNA, and the nurse would document in a progress note the refusal.

This citation pertains to MI00149672, MI00150373, MI00150362, MI00150996 Based on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom, isolation, and a lack of person-centered activities. This citation has the potential to impact any resident who relies on the activities program to support their leisure involvement. Findings include: Review of certification standards of the National Certification Council for Activity Professionals revealed ADC (Activity Director Certified) Certification ensures an individual has the knowledge and skills to lead and direct an activities and life enrichment department. ADC Certification validates the competencies necessary to be an Activity Director including leadership, management, advocacy, care planning and documentation. Review of Participating in Activities You Enjoy as You Age, published by the National Institute on Aging, 3/28/22, revealed: Research has shown that older adults with an active lifestyle: Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer . Studies looking at people's outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Studies suggest that older adults who participate in activities they find meaningful, .say they feel happier and healthier . When people feel happier and healthier, they are more likely to be resilient .Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience .research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory - and the more variety the better. Review of a General Orientation Activity Department facility policy with a reference date of 9/2016 revealed Policy: The facility will be staffed with qualified activities personnel .Procedure: The Activities Director will be qualified according to federal and state regulation (certification as an Activity Director or consultant by the National Certification Council for Activity Professionals, NCCAP, or certification as a Therapeutic Recreation Specialist by the National Council for Therapeutic Recreation Certification, NCTRC, or has two years full time experience in a Geriatric activity program within the last five years, or has completed a state approved basic activity director's course or the 90-hour MEPAP course and the 90 hour internship). Review of an anonymous complaint received on 2/24/25 revealed I am a concerned son who is writing to formally report concerns regarding the lack of activities being conducted for the residents at (facility name omitted) in relation to the duties of the activity manager. It's been observed by my mother . that the activity manager has not been implementing or overseeing planned recreational and therapeutic activities in accordance with .facility policy. There has been a notable lack of structured activities planned or implemented by activity managers . my mother is upset and dissatisfied with the absence of activities . Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke), major depressive disorder (persistent sad mood impacting daily living), and hemiplegia (paralysis or loss of movement one side of the body). Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 1/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #103 was cognitively intact. Section F of the MDS revealed Resident #103 reported it was very important to her to pursue her favorite activities. Review of a Care Plan for Resident #103 with a reference date of 2/21/18, revealed a problem/goal/approaches of: Problem: (Resident #103) prefers activities that identify with prior lifestyle. Goal: Resident will not exhibit boredom/isolation as evidenced by doing her own independent activities and groups as interested. Approaches: Allow resident to do therapeutic chores. She is a resident volunteer for the activity store and likes to keep an eye on the merchandise and make sure people pay .encourage resident to become involved with .musical entertainment, special events, arts and crafts .bingo .socials, trivia, resident council . In an interview on 3/11/25, at 3:14pm, Resident #103 reported the number of activities available had significantly declined in the last 9 months, fewer activities were offered on the weekends, and no evening activities were provided. Resident #103 reported on the weekends she spent time self-propelling her wheelchair around the facility because she was bored. Resident #103 reported seeing more residents sitting in their rooms unengaged. Resident #103 reported several residents expressed feeling bored due to the lack of activities. Resident #103 reported she no longer volunteered with the activity store because the store was nearly empty, and she missed the sense of purpose she felt when she had volunteered for it. Resident #103 voiced frustration with the current activities program provided and described it as nearly wrecked. In an interview on 3/12/25 at 11:03am, Activities Director (AD) C reported she assumed the responsibility for the role of Activity Director approximately 9 months ago. When asked about the types of activities her program provided for residents who were dependent for leisure involvement, AD C stated I go around and talk to them. AD C did not report any other therapeutic activities the facility provided for those that could not or chose not to participate in traditional activities. AD C confirmed some residents were dependent on the provision of structured leisure activities to meet their needs. When queried about the potential for negative outcomes due to a lack of support for activity involvement, AD C stated isolation could happen if activities weren't' provided based on each resident's needs and preferences. AD C reported the last structured activity of the day began no later than 3:15pm each day.AD C reported she knew some residents preferred to pursue leisure interests in the evenings, but she did not have a record of each resident's preferences that referred to when planning programs. AD C reported she relied on use of section F of the MDS to gather all information about a resident's leisure preferences and needs. When asked if she used the facility's initial activity assessment or annual activity assessment form, AD C indicated she was not aware of those forms. In an interview on 3/12/25 at 11:49am, Activity Assistant (AA) Q reported AD C did not provide her with any information about each resident's preferences or needs. AA Q stated, I can't provide individualized activities without knowing their information. In an interview on 3/12/25 at 3:17pm, Nursing Home Administrator (NHA) A reported the facility strived to provide an individualized activities program for each resident and to do so, the Activities Director was expected to have or obtain a certification. NHA A reported AD C did not have a certification as an Activities Director but was hired with the understanding that she would obtain the certification. NHA A reported upon her hire, AD C was expected to obtain a certification as an activity professional but had not been held accountable to ensure she achieved this requirement. NHA A confirmed AD C had not conducted activity assessments as they should have been done and that assessments served as the foundation for individualized care. When further queried, NHA A reported the facility could not provide official verification that AD C had worked full time in a therapeutic activities program for 2 years.

Based on observation, interview, and record review the facility failed to implement transmission-based precautions for 1 (Resident #104) of 3 residents reviewed for isolation precautions, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: Review of CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, published 4/12/24 by the Centers for Disease Control and Prevention revealed: Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered .core practices include: clean and disinfect .frequently touched surfaces .ensure proper use of personal protective equipment .implement additional precautions (i.e., Transmission-Based Precautions) . Resident #104 Review of an Admission Record revealed Resident #104 was admitted to the facility on [DATE] with pertinent diagnosis that included: unspecified dementia (progressive condition of decline in cognitive skills). Review of a Nursing Progress Note for Resident #104 with a reference date of 3/12/25 at 10:46am, revealed Resident A/Ox3-4 (alert and oriented to person, place, time, situation) .Resident c/o (complained of) severe sore throat, moist nonproductive cough noted as well .wheezing heard on auscultation (act of listening to heart and lungs) .PA (Physician Assistant) notified of change of condition .check for Influenza A and B .Resident notified of new orders . During an observation on 3/12/25 at 1:50pm, no signage for isolation precautions was present on or near Resident #104's room door. Two housekeeping staff were present in her room, steam cleaning the carpet of the room. The housekeeping staff wore KN95 masks but no other personal protective equipment (PPE). The staff did not perform hand hygiene upon leaving the room. The staff did not remove their face protection, continued down the hall wearing the same mask. During an observation on 3/12/25 at 1:51pm, Activities Director (AD) C entered Resident #104's room while wearing an KN95 mask but no other PPE and invited the resident to attend a large group activity in the dining room. AD C did not perform hand hygiene upon leaving the room. AD C did not remove face protection, continued down the hall wearing the same mask. During an interview on 3/12/25 at 1:53pm, Resident #104 reported she hadn't felt well all day and was told she should stay in her room at this time. During an interview on 3/12/25 at 2:07pm, Registered Nurse (RN) I reported Resident #104 tested positive for the flu and RN I had requested isolation signage and a PPE cart from housekeeping. During an interview on 3/12/25 at 2:10pm, Director of Nursing/Infection Preventionist (DON) B reported when a resident becomes symptomatic of a suspected contagious illness, isolation precautions should be implemented at the onset of the symptoms. Review of an Isolation-Categories of Transmission-Based Precautions facility policy with no reference date revealed In addition to Standard Precautions, implement Droplet Precautions for individual documented or suspected to be infected with microorganisms transmitted by droplets .examples of infections requiring Droplet Precautions include .Influenza. Review of a Center for Disease Control droplet precautions signage revealed Everyone must clean their hands before entering and when leaving the room .Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit.

This citation pertains to intakes MI00150362 & MI00149672. Based on interview, and record review, the facility failed to maintain complete and accurate medical records for 1 resident (Resident #103) of 3 residents reviewed for complete and accurate medical records, resulting in the lack of proper documentation of involvement in activities programs. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Resident #103 Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 1/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #103 was cognitively intact. Section F of the MDS revealed Resident #103 reported it was very important to her to pursue her favorite activities. Review of an Activity Participation Record for Resident #103 revealed the following activity participation was recorded: 3/7/25 Movie, 3/10/25 Social Hour, and 3/11/25 Resident Council. In an interview on 3/12/25 at 2:43pm, Resident #103 reported she was certain she did not watch the facility movie that was provided on 3/7/25. Resident #103 added that she did not attend a social hour or any other social gathering on 3/10/25 because she was showering at that time. Resident #103 reported she specifically recalled not attending the Resident Council meeting documented on 3/11/25. In an interview on 3/12/25 at 2:51pm, Certified Nursing Assistant (CNA) M reported she regularly cared for Resident #103 and was confident the resident consistently recalled information accurately from day to day. CNA M described Resident #103 as cognitively intact. In an interview on 3/12/25 at 11:03am, Activities Director (AD) C reported the facility maintained documentation of each resident's activity participation on a daily basis. AD C reported she reviewed the records and summarized the resident's attendance at care conference meetings. In an interview on 3/12/25 at 11:49am, Activity Assistant (AA) Q reported she noted discrepancies in resident activity participation records at times. In an interview on 3/12/25 at 11:56am, AA F reported she often waits until the end of the day to document resident activity attendance and sometimes it's difficult to remember who came to each activity.

This citation pertains to MI00149672, MI00150373, MI00150362, MI00150546 Based on observation, interview, and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 4 of 4 Residents (Resident #100, Resident #101, Resident #102, and Resident#103) reviewed for activities, resulting in a potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being. Findings include: Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities revealed: Despite resident's cognitive status, their activity involvement was significantly related to better scores on care relationship, positive affect, restless tense behavior, social relations .Conclusion: Activity involvement seems to a small yet important contributor to higher well-being in long-term care residents at all stages of dementia . [NAME] D, de [NAME] J, Willemse B, Twisk J, Pot AM. Aging Ment Health. 2016;20(1):100-9. doi: 10.1080/13607863.2015.1049116. Epub 2015 Jun 2. PMID: 26032736. Review of an anonymous complaint received on 2/24/25 revealed I am a concerned son who is writing to formally report concerns regarding the lack of activities being conducted for the residents at (facility name omitted) in relation to the duties of the activity manager. It's been observed by my mother . that the activity manager has not been implementing or overseeing planned recreational and therapeutic activities in accordance with .facility policy. There has been a notable lack of structured activities planned or implemented by activity managers . my mother is upset and dissatisfied with the absence of activities Resident #100 Review of an Admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia (paralysis or loss of movement on one side of the body), legal blindness, reduced mobility and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 12/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #100 was moderately cognitively impaired. Section F of the MDS revealed Resident #100 reported it was very important for him to listen to the music he likes. Review of a Care Plan for Resident # 100 with a reference date of 2/25/21, revealed a problem/goal/approaches of: Problem: (Resident #100) is blind and prefers activities that identify with prior lifestyle .enjoys listening to old time rock and roll music and using (device name omitted) (cloud based voice activated smart device). During an observation on 3/11/25 at 10:17am, Resident #100 was in bed, appeared to be asleep. In an observation/interview on 3/11/25, at 11:32am, Resident #100 was lying in bed upon approach and when greeted stated Where am I? Resident appeared anxious, rolling back and forth in bed. When informed he was in his room, resident stated I got so mixed up being here by myself, I wasn't sure where I was. Resident #100 reported he normally liked to attend several group activities per week but had not been feeling well and was getting really bored in his room. Resident #100 confirmed he had a cloud based smart device that would allow him to listen to music. However, it was observed that the device did not activate when the resident attempted several times to play his music. Resident #100 reported he had been trying to listen to music but could not do so. In an interview on 3/12/25 at 10:59am, Resident #100 reported his cloud based smart device was still not working. Resident #100 reported he was worried about his ongoing health issues and wanted something to distract himself. Resident #101 Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (condition in which there is a progressive decline in cognitive abilities), muscle weakness and major depressive disorder (persistent sad mood impacting daily living). Review of a Minimum Data Set (MDS) assessment for Resident #101 with a reference date of 2/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #101 was severely cognitively impaired. Section F of the MDS revealed Resident #101 reported it was very important to her to read, listen to music of her choosing and participate in religious services. Review of a Care Plan for Resident #101 with a reference date of 9/21/22, revealed a problem/goal/approaches of: (Resident #103) prefers activities that identify with prior lifestyle. She likes to listen to music and watch TV. During an observation on 3/11/25 at 8:49 am, Resident #101 sat in the Evergreen lounge staring ahead blankly. The television was playing quietly. No staff were present, all residents in the lounge sat quietly and did not speak when spoken to. During an observation on 3/11/25 at 10:04 am, Resident #101 sat in the Evergreen lounge with her eyes closed. The television was playing quietly. No staff were present and all residents in the lounge sat quietly, did not speak when spoken to. During an observation on 3/11/25 at 10:17am, Resident #101 was in her bed. Her room was quiet and dark. During an observation on 3/11/25 at 3:00 pm, Resident #101 was asleep in her bed. During an observation on 3/12/25 at 8:43 am, Resident #101 sat in the Evergreen lounge with her eyes cast toward the window. The television was on but not audible, several other residents sat nearby. None spoke when spoken to. During an observation on 3/12/25 at 8:58 am, Activities Director (AD) C entered the Evergreen lounge, said good morning to each resident and exited the room at 9:00 am. In an interview on 3/11/25, at 11:11 am, Family Member (FM) R reported she visited Resident #101 daily. FM R reported most of the activities provided at the facilities were not within Resident #101's abilities due to her advanced dementia. FM R reported one of the remaining leisure activities that Resident #101 could still enjoy was music, but the facility did not make that available to her on a regular basis. FM R reported the facility offered live music occasionally but was scheduled in the afternoon, when Resident #101 preferred to lay down and rest. When queried about the types of activities the facility did provide to Resident #101, FM R stated They bring her popcorn and call that an activity. That's about it. Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: rhabdomyolysis (a breakdown of muscle tissues that releases damaging proteins into the blood). Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 1/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #102 was moderately cognitively impaired. Section F revealed Resident #102 reported listening to music and being outside were very important to her, attending group activities and religious services were somewhat important to her as was having pet visits. Review of a Care Plan for Resident #102 with a reference date of 1/28/25, revealed a problem/goal/approaches of: Problem: Resident prefers activities that identify with prior lifestyle such as watching tv and movies she does enjoy social visits. Goal: Resident will express satisfaction with daily routine and leisure activities. Approaches: Encourage resident to become involved with activities such as going for walks as well as bring thing (sic) to her room to do socializing, provide materials of interest such as a movie list as well as a radio to listen to music, provide setting in which activities preferred in her room. During an observation and interview on 3/11/25, at 9:11 am, Resident #102 sat in her bed in her room. No music or her television was playing in her room. Resident #102 was very talkative when approached. Resident #102 described herself as a [NAME] little girl who would talk to anybody. Resident #102 reported she had not been doing anything lately but looking out the window. During an observation on 3/11/25 at 12:09 pm, Resident #102 was in bed on her right side, turned toward her window. The television was on in her room but not in her line of sight. During an observation on 3/12/25 at 9:38 am, Resident #102 was laying in her bed. Her room was quiet. During an observation on 3/12/25 at 1:43 pm, Resident #102 was awake, sitting partially upright in bed, looking into the hallway. In an interview on 3/12/25 at 10:04 am, FM N reported the facility had not contacted her about Resident #102's previous leisure interests and she doubted the resident could accurately identify them herself. FM N reported she visited the resident daily and had not seen her involved in any activities. FM N reported she wanted the facility to provide additional mental stimulation to Resident #102 because she appeared to be becoming disconnected with her surroundings. FM N reported she noticed Resident #102 gazing out the window more and more and sitting unengaged. FM N reported Resident #102 never had pets, never attended organized religious services, was meticulous about cleaning her home, enjoyed watching birds at her birdfeeder prior to coming to the facility. FM N reported something as simple as a bird feeder would give Resident #102 additional stimulation and joy. Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke), major depressive disorder (persistent sad mood impacting daily living), and hemiplegia (paralysis or loss of movement one side of the body). Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 1/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #103 was cognitively intact. Section F of the MDS revealed Resident #103 reported it was very important to her to pursue her favorite activities. Review of a Care Plan for Resident #103 with a reference date of 2/21/18, revealed a problem/goal/approaches of: Problem: (Resident #103) prefers activities that identify with prior lifestyle. Goal: Resident will not exhibit boredom/isolation as evidenced by doing her own independent activities and groups as interested. Approaches: Allow resident to do therapeutic chores. She is a resident volunteer for the activity store and likes to keep an eye on the merchandise and make sure people pay .encourage resident to become involved with .musical entertainment, special events, arts and crafts .bingo .socials, trivia, resident council . In an interview on 3/11/25, at 3:14 pm, Resident #103 reported the number of activities available had significantly declined in the last 9 months, fewer activities were offered on the weekends, and no evening activities were provided. Resident #103 reported on the weekends she spent time self-propelling her wheelchair around the facility because she was bored. Resident #103 reported she no longer volunteered with the bingo store because the store was nearly empty, and she missed the sense of purpose she felt when she had volunteered. Resident #103 voiced frustration with the current activities program provided and described it as nearly wrecked. Review of an email received on 2/21/25 from Ombudsman S revealed I attended a resident council meeting on 1/28/25 and residents voiced complaints about the resident store. It used to be fully stocked with food items residents could purchase and it was nearly empty. In an interview on 3/12/25 at 2:51 pm, Certified Nursing Assistant (CNA) M reported Resident #103 used to really enjoy volunteering for the facility store but had lost the motivation to do so when the inventory was significantly reduced. In an interview on 3/12/25 at 9:03 am, CNA J reported residents complained about being bored, didn't like some of the activities because they seemed childish and that weekend activities were canceled frequently. CNA J reported she had not seen any activities being provided for resident's who had severe cognitive impairments and had not seen room visits happening regularly. In an interview on 3/12/25 at 9:40 am, Activity Assistant (AA) F reported there she relied on her interactions with the residents to learn what the resident's liked and were capable of participating in. AA F reported she felt there was a need to provide more activities for residents with severe cognitive impairments and she would sometimes just go sit with them on her breaks to provide some socialization. AA F when she provided room visits, she just checked in with anyone she hadn't seen in recent days and asked if they needed any leisure supplies. AA F said there was no formal structure for her to follow with provide 1:1visits. In an interview on 3/12/25 at 11:49 am, AA Q reported the facility offered fewer activities and residents were complaining. AA Q reported she felt the facility needed to provide more activities for the residents who had cognitive impairments, but she was unsure how to provide therapeutic activities for them. AA Q she struggled to provide activities to other residents as well because she had to learn their preferences on her own. AA Q reported AD C did not provide her with any information about each resident's preferences or needs. AA Q stated, I can't provide individualized activities without knowing their information. In an interview on 3/12/25 at 2:13 pm, CNA K reported the facility primarily offered bingo, and a few other activities in the afternoon. CNA K reported no activities were offered to residents after the evening meal and she noticed residents who were not able to provide activities for themselves became more restless in the evenings. CNA K reported several residents had complained to her about the reduced inventory in the bingo store. In an interview on 3/12/25 at 11:03 am, Activities Director (AD) C reported she assumed the responsibility for the role of Activity Director approximately 9 months ago. When asked about the types of activities her program provided for residents who were dependent for leisure involvement, AD C stated I go around and talk to them. AD C did not report any other therapeutic activities the facility provided for those that could not or chose not to participate in traditional activities. AD C confirmed some residents were dependent on the provision of structured leisure activities to meet their needs. When queried about the potential for negative outcomes due to a lack of support for activity involvement, AD C stated isolation could happen if activities weren't' provided based on each resident's needs and preferences. AD C reported the last structured activity of the day began no later than 3:15 pm each day. AD C reported she knew some residents preferred to pursue leisure interests in the evenings, but she did not have a record of each resident's preferences that referred to when planning programs. In an interview on 3/12/25 at 3:17 pm, Nursing Home Administrator (NHA) A reported the facility strived to provide an individualized activities program for each resident to support them remaining engaged in life. NHA A stated things are not the way they should be referring to the current activity program at the facility. NHA A reported he became aware activity assessments were not completed as they should be and confirmed the assessments should be used as a foundation for the care each resident receives. NHA A also confirmed the evening activity programming was not being provided as outlined in the facility policy and that the facility did not currently offer individualized 1:1 activity visits. Review of a Activity Programming facility policy with a reference date of 6/2017 revealed Policy: Activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are person-appropriate to the individual resident. Our activity program consists of individual and small and limited large group activities that are designed to meet the needs and interests of each resident and include, as a minimum .at least one evening activity is offered per week .7. Individualized and group activities provided will: reflect the schedules, choices and rights of the residents, are offered at hours convenient to the residents, including evenings .weekends .

Based on observation and interview, the facility failed to: 1. Properly label/date and securely store food product once opened or prepared; 2. Discard expired food items; and 3. ensure cleanliness of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food/supplement from the kitchen and from nourishment room refrigerators/freezers. Findings include: An initial kitchen/food service tour was conducted on [DATE] beginning at 9:35 AM with Dietary Supervisor (DS) Z. The following observations were made: At 9:38 AM in the walk-in cooler: an opened, half empty container of nectar-thickened sweet tea with a manufacturer use by date of [DATE] and no label to indicate opened or discard dates; an opened bottle of nectar-thickened cranberry juice that was not labeled with opened or discard dates; and a pitcher of what DS Z reported was maple syrup that was not labeled for contents or opened or discard dates. At 9:45 AM in the reach-in cooler: two opened bottles of vegetable juice that were not labeled with opened or discard dates; and a storage container labeled apple juice with an opened date of ,d+[DATE] and a discard date of ,d+[DATE]. At 9:53 AM, the plate warmer located by the trayline (the area in the kitchen where resident meal trays were assembled) was turned on to warm the plates. The top plate of one of the stacks of plates in the warmer had dried caked food debris on the edges. When DS Z removed that plate from the warmer to be rewashed, the plate underneath was noted to be soiled with food crumbs and debris. There was a divided dish stacked on the opposite stack of plates that had dried food debris in the wells of the plate. At 10:02 AM in the Birch nourishment room: In the refrigerator, there was an opened container of nectar-thickened water that was not labeled with opened or discard dates; 2 containers of resident food (unidentifiable) items that were unlabeled and undated; a Styrofoam container of resident food (spaghetti and meat sauce) that was dated with a single date of [DATE]. In the freezer, there was a fast-food restaurant name omitted red beverage that was frozen that was not labeled or dated. At 10:07 AM in the Dogwood nourishment room: In the refrigerator, there was an opened container of nutrition supplement drink labeled with an opened date of ,d+[DATE] and a discard date of ,d+[DATE]; there were three clear carafe containers filled with milk, orange juice, and lemonade that were not labeled with opened or discard dates; an opened, half empty container of nectar-thickened sweet tea that was not labeled with opened or discard dates; and an opened, half empty container of honey-thickened cranberry juice that was not labeled with opened or discard dates. There was dried red spillage in the refrigerator and freezer on the doors and there was dirt and debris behind and under the drawers in the refrigerator. At 10:25 AM in the Evergreen nourishment room: In the refrigerator, there was a plastic grocery bag of resident food items that was not labeled or dated; two unlabeled sandwich bags of celery sticks that had become black at the ends and had areas of mold; an unlabeled, opened package of a log of cured snack meat, not securely covered and left opened to air, that was dried, shriveled, and black in color on the opened end; a bag of prepared tamales that was not labeled with prepared or discard dates; a scooped container of coleslaw that was not labeled with prepared or discard dates; an opened, three-fourths empty gallon of pasteurized apple cider that was not labeled with opened or discard dates; and an opened bottle of (brand name omitted) cream-based coffee drink that was not labeled with opened or discard dates. There was dried red spillage on the door of the refrigerator. In a follow-up interview on [DATE] at 11:26 AM, DS Z reported dietary staff were responsible for cleaning the nourishment room refrigerators and freezers. DS Z reported staff tried to clean them when they noticed they were dirty and then a deep scrub of the interior was done once a week. DS Z reported the expectation for food labeling and dating was that everything should be labeled and dated at the time it was opened, and resident food items should be labeled and dated by staff when they are brought in. DS Z reported opened drinks should be discarded after 5 days of being opened and prepared foods, including resident foods, should be discarded after 3 days from preparation. A follow-up kitchen/food service tour was conducted on [DATE] beginning at 11:30 AM with Dietary Assistant Supervisor (DAS) AA. The following observations were made: At 11:30 AM at the clean pan storage rack, noted 3 half pans that had been stacked together, on top of one another, such that the bottom of the stacked pan fit securely inside the next pan. When unstacked, it was noted that each of the pans was wet. DAS AA reported the pans should not have been put away wet because of the risk of bacterial growth. At 11:35 AM on the bottom shelf of a food preparation table, noted a stock pot that DAS AA reported as being clean and ready for use. Upon inspection, it was noted that the upper edge of interior of the pot had a small patch (the size of a dime) of caked, dried, granular substance that was yellowish in color. DAS AA reported it looked like dried powder from the dish machine and removed the pot to be rewashed. At 11:45 AM, the knife storage rack, on which 4 knives were being stored, was noted to be soiled with dust and debris on the top grates of the rack. During the follow-up kitchen/food service tour on [DATE], lunch meal service trayline that began at 11:45 AM was observed. During this observation, at approximately 11:52 AM, it was noted that Dietary [NAME] (DC) CC scooped a serving of gravy into a plastic (brand name omitted) bowl. There was what appeared to be a melted round ring around the interior of the bowl. This surveyor inquired to DC CC what the ring around the inside of the bowl was, to which DC CC reported it was just a stain from oatmeal and placed the bowl of gravy onto a resident meal tray which then went out to the care unit for delivery. DAS AA had stepped away momentarily and on her return, this surveyor queried her as to the process for damaged/stained dinnerware replacement. DAS AA reported when a staff member saw a bowl or other item that was in disrepair or stained, they were supposed to let her know to replace the item with a new one. DAS AA reported the facility had just gotten box of new bowls and the damaged/stained bowl should have been replaced and should not have been sent to a resident.

Based on interview, and record review, the facility failed to honor mealtime preferences for 3 anonymous residents (attending a resident council meeting) and Resident #78, resulting in expressed feelings of discontent and a potential for increased loneliness. Findings include: Resident #78 Review of an Admission Record revealed Resident #78, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (chronic condition in which blood flow to the brain is reduced causing impaired thinking, memory, and behavior), feeding difficulties, and major depressive disorder (serious mental health condition causing persistent low mood and loss of interests). Review of a Minimum Data Set (MDS) assessment for Resident #78, with a reference date of 09/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #78 was severely cognitively impaired. Section GG of the MDS revealed Resident #78 required supervision, verbal cueing and/or touching assistance for eating. Review of a MDS with a reference date of 9/27/23, section F revealed Resident #78 indicated being around groups of people was very important to her. Review of a Care Plan for Resident # 78, with a reference date of 10/5/22, revealed a problem/goal/approaches of: Problem: Alteration in ADLs (activity of daily living) .Goal: (Resident #78) will .participate in cares to her fullest ability. Approaches: Eating: Assist per 1 .offer resident choice in bathing, clothing, bedtime, etc. In an interview on 10/29/24 at 1:10pm, Family Member/Durable Power of Attorney (FM/DPOA) YY reported Resident #78 had not been given the opportunity to eat her evening meals or any weekend meals in the dining room for many months. FM/DPOA YY reported she visited Resident #78 daily in effort to provide the resident with socialization and support with eating. FM/DPOA YY reported she told the facility it was important for Resident #78 to eat all her meals in the communal dining room but was told the facility could not support this preference due to staffing concerns. FM/DPOA YY reported Resident #78 sat in her room most of the day unless she went to the dining room for her meals. FM/DPOA YY reported socialization was important to Resident #78 because she enjoyed being around people. FM/DPOA YY reported going to the dining room was also beneficial for Resident #78 because the setting cued her to initiate feeding herself. In an interview on 10/31/24 at 12:01pm, Certified Nursing Assistant (CNA) II reported the residents had not been given the option to eat their evening meals or any of the weekend meals in the dining room in nearly 2 years. CNA II reported she residents and family members complained several months ago about the resident having to eat their meals in their rooms, but nothing had changed. CNA II reported it was not always possible to ensure the residents had the assistance they needed for eating when they ate in their rooms. In an interview on 10/31/24 at 1:22pm, Director of Nursing (DON) B reported the facility opted to stop communal dining for the evening meal because of staffing issues. DON B reported he was not aware the residents were not being given the opportunity to eat any weekend meals in the dining room, and that it was important the residents were given an opportunity to gather for meals because some residents look forward to it. When further queried, DON B reported the facility was currently fully staffed but the dining restrictions had not been lifted. In a confidential meeting on 10/30/24 at 3:15pm, 4 of 9 resident reported they were frustrated that they were not able to eat in the dining room for their evening and weekend meals. The residents reported they enjoyed getting out of their rooms and socializing in the dining room during meals, and that they were more independent with feeding themselves when seated at a dining table. The residents reported the dining restrictions had been in place for several months. Review of a facility policy titled Self-Determination and Participation, with a reference date of 1/24, revealed: Policy: Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. 41982 In an interview on 10/29/24 at 10:20 AM, Dietary Supervisor (DS) Z reported the dining rooms were closed for the evening meal and that all the residents at in their rooms at that time. DS Z reported it had been like that for a while and she was not sure why they were closed; she had just been told by management that they were to be closed.

Based on interview and record review, the facility failed to develop comprehensive care plans for 2 (Resident #53 and Resident #90) of 20 residents reviewed for care planning resulting in the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Resident #53 Review of an Admission Record revealed Resident #53 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care. Review of Resident #53's Orders revealed, Empty left Nephrostomy (artificial opening in the skin to allow urine to drain from the kidney) bag every shift . Review of Resident #53's Care Plan revealed that Resident #53 did not have a care plan developed for his nephrostomy bag. During an interview on 10/31/24 at 12:16, MDS RN M reported that she was the staff member responsible for ensuring care plan orders were in place for residents. MDS RN M confirmed that Resident #53 did not have a care plan in place for his Nephrostomy bag, and this was missed. Resident #90 Review of an Admission Record revealed Resident # 90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes mellitus (a disease that results in too much sugar in the blood). Review of Resident #90 Orders indicated that Resident #90 had orders for Duloxetine (antidepressant medication), Eliquis (anticoagulant medication), and Olanzapine (antipsychotic medication). Review of Resident #90's Care Plan revealed that Resident #90 did not have a care plan developed for her diabetes diagnosis or anticoagulant and psychotropic medications. During an interview on 10/31/24 at 11:47 AM, MDS RN M reported that she was the staff member responsible for ensuring care plan orders were in place for residents. MDS RN M reported that Resident #90 should have had a care plan in place for her diabetes diagnosis, and use of anticoagulant and psychotropic medications and that this was missed.

Based on interview and record review, the facility failed to provide timely notification of exhaustion of Medicare Part A benefits in 1 (Resident #90) of 4 residents reviewed for beneficiary notification resulting in Resident #90 being unaware of changes in regard to financial liability, and frustration. Findings include: Resident #90 Review of an Admission Record revealed Resident # 90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #90, with a reference date of 10/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #90 was cognitively intact. During an interview on 10/29/24 at 11:41 AM, Resident #90 reported that she had just been informed by the facility that she did not have Medicare coverage, and that she could expect to receive a bill from the facility for an estimated amount of $10,000. Resident #90 reported that this was the first time the facility had made her aware that she did not have coverage to pay for the services she was receiving. Resident #90 was upset and crying and reported that she did not know how she would ever be able to afford the bill. During an interview on 10/31/24 at 12:28 PM, Business Office Manager (BOM) D reported that Resident #90 was admitted to the facility on [DATE] with only 7 days remaining of Medicare Part A coverage. BOM D reported that Resident #90 should have been informed by the admissions team that she only had 7 days of coverage. BOM D did not know if Resident #90 had been made aware that she only had 7 days of Medicare Part A coverage remaining. During an interview on 10/31/24 at 12:33 PM, Admission Director (AD) E reported she was not aware when Resident #90 admitted that she had 7 days of Medicare Part A coverage remaining and had learned that Resident #90 was changed to private pay. AD E confirmed that she did not inform Resident #90 that she had 7 days of coverage remaining, and that the facility had not given Resident #90 notice that her benefits were ending. During an interview on 10/31/24 at 2:09 PM, MDS RN M reported that she was the staff member that discovered that Resident #90 had exhausted her Medicare Part A benefits on 10/25/24. MDS RN M confirmed that Resident #90 should have received notice from the facility that her Medicare Part A benefits were exhausted 3 days before Resident #90's benefits were ending, but that the facility had missed this. MDS RN M reported that she was the staff member that would provide the notices to residents and confirmed that she had missed this because she was not aware that Resident #90 did not have Medicare Part A benefits remaining. MDS RN M confirmed that the admission team had missed communicating this to MDS RN M. MDS RN M confirmed that she had calculated an estimate of pending costs for Resident #90 and reported that she had told Resident #90 the bill was estimated to be around $10, 000.

This citation pertains to intake #MI 829. Based on interview and record review, the facility failed to perform the [MEDICATION NAME] Maneuver per American Heart Association (AHA) standards prior to the arrival of Emergency Medical Services (EMS) personnel for 1 of 4 residents (Resident #37) reviewed for accidents and hazards, when Resident #37 was found by Certified Nursing Assistant (CNA) QQ gasping for air and assumed to be choking on [DATE] at approximately 5:55 P.M. This resulted in an Immediate Jeopardy when Resident #37 became non-responsive and Registered Nurse (RN) P, Director of Nursing (DON) B and Licensed Practical Nurse (LPN) S subsequently administered the [MEDICATION NAME] Maneuver inadequately without lowering Resident #37 to the ground or performing chest thrusts. Resident #37 was pronounced dead at 6:20 P.M. This deficient practice placed all 98 residents, at risk for serious harm, injury, and/or death. On [DATE], the Nursing Home Administrator A was notified of an Immediate Jeopardy that began on [DATE] when Resident #37, who was identified to be choking and unresponsive was not administered the [MEDICATION NAME] Maneuver per AHA standards, and staff were found to be not adequately trained per facility policy. Findings include: Review of the facility policy Medical Emergency Response Revision ,[DATE] revealed, Emergency Response Team: Consists of the highest level nurse supervisor in the building, the nurse assuming care of that resident for that day, at least one nursing assistant and one member to make the 911 call and coordinate other communications Training and Education: 1. All licensed nurses will remain current in AHA Basic Life Support (BLS) CPR (Cardiopulmonary Resuscitation) and AED (Automated External Defibrillator) for healthcare providers certification. Review of the facility policy CARDIOPULMONARY RESUSCITATION Revision ,[DATE] revealed, Purpose: The purpose of this policy and procedure is to ensure the facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with resident's physician orders, such as DNR (Do Not Resuscitate)/Full Code, and the resident's advance directives. The facility will provide consistent and appropriate response to emergency situations, to provide basic life support (BLS) that is consistent with acceptable practice standards held by the American Heart Association (AHA). AHA publishes guidelines every 5 years for CPR and Emergency Cardiovascular Care (ECC). These guidelines are evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs. This facility and facility staff will follow these guidelines .B. Certification / Training of Staff *Licensed Nurses providing direct resident care including supervision and/or delegation responsibilities will have a current and valid CPR certification from American Heart Association for healthcare providers upon hire. * The facility will track and monitor licensed nurse CPR certification annually with nurse licensure tracking. There is no grace period for expired CPR certification; nurses will be removed from the schedule until they obtain a current healthcare provider CPR certification. * (Company name eliminated) communities will consistently follow the American Heart Association (AHA) guidelines for Basic Life Support (BLS) or follow Emergency Cardiac Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations. According to National Center for Biotechnology Information-Abdominal Thrust Maneuver ([MEDICATION NAME]) last updated [DATE], .Today, the [MEDICATION NAME] maneuver is accepted and taught during BLS and ACLS for conscious adults, but backslaps are still recommended for infants and chest compressions are recommended for unconscious patients Although there are no absolute contraindications, the abdominal thrust maneuver is not recommended by the AHA for infants or unconscious patients .Cases of choking happen in mere seconds and unexpectedly, making preparation nearly impossible. As mentioned above, the [MEDICATION NAME] maneuver is taught during BLS for the conscious choking adult. According to American Heart Association-2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Originally published [DATE] (https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110XXX 9) Foreign-Body Airway Obstruction (Choking) FBAO is an uncommon, but preventable, cause of death. Most reported cases of FBAO occur in adults while they are eating. Most reported episodes of choking in infants and children occur during eating or play when parents or childcare providers are present. The choking event is therefore commonly witnessed, and the rescuer usually intervenes while the victim is still responsive. Treatment is usually successful, and survival rates can exceed 95%. Recognition of Foreign-Body Airway Obstruction Because recognition of FBAO is the key to successful outcome, it is important to distinguish this emergency from [MEDICAL CONDITIONS], or other conditions that may cause sudden respiratory distress, cyanosis (bluish or purplish discoloration of the skin or mucous membranes due to lack of oxygen), or loss of consciousness. Foreign bodies may cause either mild or severe airway obstruction. The rescuer should intervene if the choking victim shows signs of severe airway obstruction. These include signs of poor air exchange and increased breathing difficulty, such as a silent cough, cyanosis, or inability to speak or breathe . Relief of Foreign-Body Airway Obstruction When FBAO produces signs of severe airway obstruction, rescuers must act quickly to relieve the obstruction. If mild obstruction is present and the victim is coughing forcefully, do not interfere with the patient's spontaneous coughing and breathing efforts. Attempt to relieve the obstruction only if signs of severe obstruction develop: the cough becomes silent, respiratory difficulty increases and is accompanied by stridor (a high pitch, [MEDICATION NAME] sound heard when taking a breath), or the victim becomes unresponsive. Activate the EMS system quickly if the patient is having difficulty breathing. If more than one rescuer is present, one rescuer should phone 911 while the other rescuer attends to the choking victim .If the adult victim with FBAO becomes unresponsive, the rescuer should carefully support the patient to the ground, immediately activate (or send someone to activate) EMS, and then begin CPR. The healthcare provider should carefully lower the victim to the ground, send someone to activate the emergency response system and begin CPR (without a pulse check). After 2 minutes, if someone has not already done so, the healthcare provider should activate the emergency response system. A randomized trial of maneuvers to open the airway in cadavers and 2 prospective studies in anesthetized volunteers showed that higher sustained airway pressures can be generated using the chest thrust rather than the abdominal thrust. Each time the airway is opened during CPR, the rescuer should look for an object in the victim's mouth and if found, remove it. Simply looking into the mouth should not significantly increase the time needed to attempt the ventilations and proceed to the 30 chest compressions . Review of a Face Sheet revealed Resident #37 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Progress Note dated [DATE] at 06:42 P.M. revealed, (Resident #37) observed unresponsive with food particles in her mouth at 5.55pm. Resident had pulse at the time but not breathing. [MEDICATION NAME] maneuver procedure conducted immediately. Resident suctioned with a few food particles noted. Resident maintained a steady pulse throughout the procedure. Supplemental oxygen initiated concurrently. Staff called EMTs (Emergency medical Technician) who arrived at 6.10pm. The EMTs staff attempted to remove food particles and stated that the airway was clear with agonal (life threatening-abnormal) pulse rate. No CPR attempted d/t resident's DNR (Do Not Resuscitate) status. At 6.20pm, resident had no pulse and no respirations. This was confirmed by 3 RNs present at the time. Note that this document did not include vital signs or blood sugar levels. During an interview on [DATE] at 10:59 A.M., DON B recalling the events that led up to Resident #37's death on [DATE] reported, that it was supper time and Resident #37 was eating in her room when a CNA noticed that she was unresponsive, so the CNA called for a nurse. DON B then reported that they started doing the [MEDICATION NAME] Maneuver because they could see food and thought something was stuck in her throat. DON B reported that the nurses performed the [MEDICATION NAME] Maneuver and used the suction tool, but nothing came out. DON B reported that Resident #37 had a pulse, but was not breathing. DON B reported that EMS arrived and they did not see any obstruction. DON B reported that there was no progress report from EMS because they did not do anything. During an interview on [DATE] at 02:15 P.M., CNA QQ reported that on [DATE] she had brought Resident #37 her dinner meal and Resident #37 sat up in her bed to eat independently, then CNA QQ returned a couple minutes later with a drink, and found Resident #37 gasping for air, with her eyes wide open and face color bluish-purple. CNA QQ reported that she yelled down the hall for help and RN P came into the room and then RN P immediately left the room to page others to assist. CNA QQ reported that RN P and some other nurses sat Resident #37 up and did the [MEDICATION NAME] Maneuver, but were not successful at getting the food out. CNA QQ reported that EMS arrived a few minutes later and were able to remove the food, but it was too late. During an interview on [DATE] at 12:34 P.M., RN P reported that on [DATE] at 5:55 P.M. she was called into Resident #37's room in response to CNA QQ's call for help. RN P reported that Resident #37 was lying flat in her bed, her face was blue, eyes open and her mouth wide open (RN P demonstrated this expression). RN P reported that she could feel Resident #37's pulse at that time, but Resident #37 did not respond to her voice, therefore RN P immediately went into the hall to page all available nurses to come help. RN P recalling the events reported that she saw food in Resident #37's mouth and removed it with her fingers and then raised the head of the bed so that Resident #37 was in a sitting position. RN P reported that at that time Resident #37's body was limp and RN P was holding her up in a sitting position, patting her on the back and then stood behind Resident #37 and performed the [MEDICATION NAME] Maneuver (RN P demonstrated wrapping her arms around this surveyor and simulating abdominal thrusts.) RN P reported that Resident #37's head was hanging down limp during that time. RN P reported that several other staff arrived, and then we used the suction to remove food in Resident #37's mouth, held oxygen to her nose and did more abdominal thrusts in the sitting position. RN P reported that during these events Resident #37 remained unresponsive, in her bed in a sitting position, or held in a sitting position by staff. RN P then reported that EMS arrived and looked in Resident #37's mouth, said that it was clear but that her pulse was getting weak. RN P reported that EMS wasn't able to do anything else because Resident #37 was DNR. During an interview on [DATE] at 01:27 P.M., DON B reported that when he entered Resident #37's room on [DATE], RN P, LPN S, RN O and some CNA's were in the room already. DON B reported that Resident #37 was lying on her back in bed with the head of the bed raised and the nurses were suctioning Resident #37's mouth. DON B reported that using the suction tool after performing the [MEDICATION NAME] Maneuver, would be expected of the nurses, when they observe that a resident is eating and then starts gasping or stops breathing and the nurses suspect that food was caught in the airway. DON B reported that the [MEDICATION NAME] Maneuver was performed by several people .(LPN S) performed and I observed. DON B reported that Resident #37 was being held in a sitting position in her bed during the [MEDICATION NAME] Maneuver. DON B reported that EMS arrived and used a light to look down her throat and reported that it was clear. DON B reported that EMS did not administer breaths, that would be CPR, but they used the facility's Ambu Bag (a hand-held device used to provide positive pressure ventilation to patients who are not breathing) to verify that Resident #37's airway was clear. DON B reported that there was no incident report completed by the facility. DON B reported that there was no report indicating a timeline or measures that were taken leading up to Resident #37's death, stating we only do that when CPR is performed. During an interview on [DATE] at 02:24 P.M., LPN S reported that he entered Resident #37's room on [DATE] in response to RN P's overhead page for assistance, Resident #37 was lying on her back in bed with the head of the bed raised into a sitting position, LPN S stated Resident #37 did not look good, but she had a pulse. LPN S reported that first we checked her blood sugar level and when that was not concerning at 289, we thought blocked airway. LPN S reported that he did not see any food in her mouth, but the suctioning tool was used to see if there was any food back farther. LPN S reported that the suctioning tool was inserted down Resident #37's throat until it couldn't go further and only small particles of food were coming out. LPN S reported that DON B then entered the room and performed the [MEDICATION NAME] Maneuver to Resident #37 by standing behind her and administering abdominal thrusts, while LPN S and RN P were holding Resident #37 in a sitting position in her bed and using the suction tool in Resident #37's mouth. LPN S then reported that LPN S and DON B switched positions and LPN S performed the [MEDICATION NAME] Maneuver to Resident #37. LPN S reported that Resident #37 remained in a sitting position and did she not respond to the [MEDICATION NAME] Maneuver or the suctioning measures being performed. LPN S reported that they, hooked oxygen to the Ambu Bag and administered breaths to Resident #37, but did not observe rise and fall of her chest, and therefore suspected that there was still a blockage. LPN S reported EMS then arrived and laid Resident #37 completely flat in her bed, opened her mouth and used a laryngoscope (device used to view the throat), and were able to see a piece of food blocking her airway. LPN S reported that EMS used forceps (a handheld tool used for grasping objects) and the facility's suction tool and were able to retrieve a piece of hash brown. LPN S reported, then the Ambu bag was used again to deliver a couple of rescue breaths and Resident #37's chest did rise and fall, and her heart rate was faint. LPN S reported that no further measures were taken to resuscitate Resident #37's due to her code status of DNR. During an interview on [DATE] at 04:08 P.M., Family Member III reported that she was notified by the facility on [DATE] that Resident #37 had passed away after she was found choking. FM III reported that the facility explained to her that they had found food down deep in Resident #37's throat, and that Resident #37 was likely coughing while she was eating which lead to her choking to her death. FM III reported that Resident #37's death was a shock to the family because Resident #37 was in good health. Review of Resident #37's EMS Report dated [DATE] revealed, Dispatched to the local nursing home for a resident in [MEDICAL CONDITION]. Upon arrival to scene we find a [AGE] year-old female being held in a sitting position by facility staff. Report received was that the patient was found when her aide came to collect her dinner tray. Per report patient was found to be apnic (sic) (without breathing) with a pulse. Per report multiple attempts were made to clear the airway with the [MEDICATION NAME] maneuver that were unsuccessful. Exam found the patient in a sitting position with staff supporting her with her head all the way forward. Patient was placed into a reclined position and her head repositioned to facilitate proper airway positioning. No change in respiratory status after repositioning. Laryngoscope used to visualize the airway and a large piece of food was found to be occluding (obstructing) the vocal cords. With the use of the Magill forceps and suctioning the obstruction was removed. BVM (bag valve mask) ventilations (introduction of air) now successful with good chest rise noted. A valid DNR was presented and a four lead EKG (heart monitor) was obtained. Patient was found to be in agonal (life threatening-abnormal) rhythm at 25 BPM (beats per minute). Medical control contacted and advised of the situation, treatment rendered and the result of said treatments. Medical control also advised of DNR. Medical control also advised that the facility would handle the death of the resident in-house according to their SOP (standards operating procedure). Medical control advised that was acceptable. During an interview on [DATE] at 11:32 A.M., EMS MMM reported upon arrival on [DATE], staff had reported that Resident #37 had a blocked airway and they had tried the [MEDICATION NAME] Maneuver without success and Resident #37 was being held in a sitting position in the middle of her bed by staff with her head hanging down. EMS MMM reported that the first priority was to open the airway, therefore EMS MMM held Resident #37's head up and then positioned her in a reclined position on the bed. EMS MMM reported that a laryngoscope was used to visualize Resident #37's throat and a large piece of food was visualized obstructing the vocal cords. EMS MMM reported that by using forceps, the facility's suctioning tool, and the help of LPN S, the piece of food was removed. EMS MMM reported that the facility's Ambu Bag was used to deliver breaths and to confirm that the airway was now clear. EMS MMM reported that an heart monitor was attached to Resident #37 and showed an agonal rhythm. EMS MMM reported at that time, the facility presented a DNR order, then EMS MMM called the hospital to obtain further instruction and the hospital advised EMS MMM to not provide any further treatment for [REDACTED]. During an interview on [DATE] at 01:27 P.M., DON B reported that it is a requirement of the facility that all licensed nurses have a current certification for Basic Life Support including CPR and [MEDICATION NAME] Maneuver, but that some nurses may not have a current certification. DON B reported that this information is kept in a binder with the Human Resources department. During an interview on [DATE] at 8:55 A.M., Minimum Data Set Registered Nurse (MDS RN) H reported there were no current Basic Life Support (BLS) certifications for RN P, DON B, or RN O. During an interview on [DATE] at 10:10 A.M., DON B reported Basic Life Support (BLS) Certifications for the nursing staff are monitored by Staff Development Coordinator K. During an interview on [DATE] at 10:56 A.M., Staff Development Coordinator K reported DON B was responsible for monitoring nursing licenses and BLS Certifications for upcoming expiration dates. During an interview on [DATE] at 1:42 A.M., DON B reported there was no vital sign documentation for Resident #37 in [DATE]. DON B reported the blood sugar level obtained for Resident #37 during the choking incident on [DATE] should be documented in the progress notes. Review of Vital Signs for Resident #37 revealed, no documentation of vital signs for [DATE]. Review of Blood Sugar Results and Progress Notes for Resident #37 revealed, no documentation of blood sugar levels for [DATE] during the time of the facility's emergency response (approximately 5:55 P.M.) On [DATE], the survey team verified the facility completed the following to remove the Immediate Jeopardy. The facility immediately completed the following actions: * At 1:00 PM on [DATE] a review of all personnel records were reviewed to determine staff AHA 2010 CPR certification status * AT 1:30 PM on [DATE] the staffing schedule was updated to ensure 2010 AHA CPR certified staff are scheduled and available in the facility 24 hours a day * At 1:30 PM on [DATE] (Educator LLL) was contacted to schedule CPR training and certification for all licensed nurses in the facility. The training will meet 2010 American Heart Assoc. standards. * Training for CPR certification is scheduled for [DATE] for all uncertified Nurses to be certified. * On [DATE] the CNA's and Licensed Nurses who were working on shift were trained on the [MEDICATION NAME] maneuver, this included return demonstration and given a test, by (RN MMM). This training will meet 2010 American Heart Assoc. standard. * Ongoing, (UM Q), will train the CNA's and Licensed Nurses on the [MEDICATION NAME] maneuver, including a return demonstration and test, prior to working their next shift. * On [DATE] competencies were completed to ensure non-licensed nursing personnel were aware of their expected role in emergency response procedures and in the [MEDICATION NAME] maneuver in accordance with the 2010 American Heart Association standards and the facility policy. Attach: CPR Policy, Medical Emergency Response Policy The following will commence immediately on [DATE] and all dates forward: 1. CPR certified staff will be available in the facility 24 hours per day. 2. Licensed nurses will be required to submit a copy of CPR certification to the facility Human Resources Director to be kept in a CPR binder which will be tracked by (DON B) to ensure nurses remain current in CPR certification. 3. The facility Human Resources Director will maintain a tickler file on Licensed Nurses CPR Certifications and will notify them 1 month prior to their certification expiration. 4. Nurses who allow CPR certification to lapse will not be allowed to return to work until the certification is received by the facility. 5. Newly hired nurses will not be allowed to work until current CPR certification is received for placement and tracking in the CPR binder in the Human Resources office. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with a scope of isolate and severity of actual harm due to all nursing staff had not received training for CPR/[MEDICATION NAME] Maneuver and sustained compliance had not been verified by the state agency.

This citation pertains to intake number MI 696. Based on interview and record review, the facility failed to individualize and monitor an indwelling catheter in 1 of 2 sampled residents (Resident #51) reviewed with catheters, in a total sample of 8 residents, resulting in septic shock due to a urinary tract infection. Findings include: Nurses Progress Notes dated [DATE] revealed Resident #51 was readmitted to the facility following hospitalization for urosepsis (systemic infection in the blood that develops secondary to a urinary tract infection [MEDICAL CONDITION], and circulates throughout the body). physician progress notes [REDACTED].#51 had a history of [REDACTED]. Feeding Tube care plan dated [DATE] revealed Resident #51 had a percutaneous endoscopic gastrostomy (PEG, tube placed into stomach) for nutrition, medication and hydration needs. According to the progress notes dated [DATE], Resident #51 received nothing by mouth (NPO) and 2880 milliliters of total water from tube feeding and flushes per day. Case Information dated [DATE] revealed Resident #51 had a cystoscopy (exam of lining of your bladder and the tube that carries urine out of your body) on [DATE] with a postoperative [DIAGNOSES REDACTED]. A urology History and Physical note dated [DATE] revealed Resident #51 had a primary [DIAGNOSES REDACTED]. The same note indicated that it was suspected Foley catheter had not been changed in 2 months and (Resident #51) remained on an antibiotic for a urinary tract infection. The note revealed no recurrence of gross hematuria and Resident #51's catheter was changed and a discussion regarding the importance of regular catheter exchanges was documented. Urology Manager O was interviewed on [DATE] at 1:45 PM and stated Resident #51's catheter was last changed by their office on [DATE] and that he was scheduled for an appointment to change the catheter on [DATE], but the facility called and canceled the appointment. Urology Manager O stated that regular catheter exchanges were expected every month for Resident #51. A hospice noted titled Focused and Comprehensive Assessment dated [DATE] revealed under patient's immediate needs, unable to find in chart when the catheter was last changed, a note to the physician to please order a catheter change. The document indicated that a Licensed Practical Nurse at the facility reported that the catheter was changed in [DATE], but could not locate the date it was changed. In an interview on [DATE] at 11:00 AM, Nurse Practitioner (NP) N stated she saw Resident #51 on [DATE] and instructed staff to change Resident #51's catheter if appears to have a change in appearance or condition. NP N stated during the same interview that she did not consult Resident #51's urologist, that she wasn't aware he saw a urologist. According to the progress note dated [DATE] at 12:21 PM, Resident #51's urine was clear, yellow and non-odorous on this day. The Physician order [REDACTED]. The same report revealed a [DIAGNOSES REDACTED]. There was no evidence in the medical record that the Foley catheter was changed in [DATE]. The Indwelling Catheter care plan with goal target date of [DATE], revealed to change catheter as ordered. The hospice note titled Focused and Comprehensive Assessment dated [DATE], indicated the catheter was draining amber colored urine and Resident #51 was lethargic (sluggish, tired). A home health aide/ plan of care hospice note, dated [DATE] indicated Resident #51 had very dark urine that had a lot of sediment. According to a Healthline article titled Catheter Associated UTI (CAUTI) (Nall, R., February 29, 2016, retrieved from website at http://www.healthline.com/health/catheter-associated-uti#Overview1) A CAUTI has similar symptoms to a typical urinary tract infection [MEDICAL CONDITION]: cloudy urine; blood in the urine; strong urine odor; urine leakage around catheter; pressure, pain, or discomfort in lower back or stomach; chills; fever; unexplained fatigue; and vomiting. According to a 2006 Urology Nursing article Urologic Nursing Clinical Practice Guidelines. Care of the Patient With an Indwelling Catheter, A daily urinary output of 1,,[DATE],000 cc (,[DATE] ml/kg/24 hour) was recommended to keep urine dilute and help decrease catheter encrustation's. (retrieved from Medscape at http://www.medscape.com/viewarticle/ 5) The Physician order [REDACTED].#51. [DATE] Medication Administration Record [REDACTED]. [DATE] MAR indicated [REDACTED]. The same MAR, on [DATE] had no documented value for day shift output, had 575 cc output documented on evening shift, and 600 cc documented output on night shift. The same MAR indicated [REDACTED]. The [DATE] MAR indicated [REDACTED]. According to the Progress Note dated [DATE], orders were received to send Resident #51 to the hospital. In an interview on [DATE] at 9:00 AM, Director of Nursing (DON) B stated nurses were expected to write output from Resident #51's catheter every shift on the MAR. A Physician's Progress Note dated [DATE] indicated Resident #51 was having chills, increased confusion, low grade temperature, tenderness with touch to the bladder, and a large amount of purulent (puss) drainage after Foley catheter was removed that morning. The same note indicated plan to send Resident #51 to the emergency room for [MEDICAL CONDITION] (serious blood infection). The hospital History and Physical dated [DATE], indicated upon arriving to the emergency department, Resident #51 was found to be unresponsive with [MEDICAL CONDITION] (abnormally low blood pressure) with systolic blood pressure of 80, [MEDICAL CONDITION](increased heart rate) with heart rate of 114, tachypnea (increased respiratory rate) with respiratory rate of 28 and pale and dry mucous membranes. The same document indicated the principal problem was septic shock (last stage [MEDICAL CONDITION]:[MEDICAL CONDITION]- infection reaches the bloodstream and causes inflammation in the body. [MEDICAL CONDITION]- infection is severe enough to affect organ function. Septic shock occurs with a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death). Resident #51 returned from the hospital with Drain Care orders dated [DATE] to change the Foley catheter every 21 days. According to the Minimum Data Set assessment dated [DATE], Resident #51 was discharged from the facility following his death on [DATE]. ( )

Based on observation interview and record review the facility failed to monitor resident daily weight, report change in condition to physician and follow physician orders [REDACTED].#7 and #6) in 5 residents reviewed from a total sample of 22 residents, resulting in the residents care needs and highest practicable function not being met. Finding include: According to the facility policy Notification of Change, dated 1/08, under Notification: 1. Call the physician and document time in the nurse's notes .Introduction: The Residents physician .must be notified when .the resident experiences a change in condition .Notification Parameters: Condition/[MEDICAL CONDITION] .gradual onset that is nor usual .notify within 24 hours .Interventions: The licensed nurse may use personal professional judgement at any time that in their opinion requires immediate medical attention . Resident #7 According to the facility Resident Admission Record, dated 10/8/15, Resident #7 was a [AGE] year old female admitted into the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the Quarterly MDS (Minimum Data Set- an assessment), dated 2/25/15, Resident #7 was able to make self understood, and usually understood others. Resident #7 had a BIMS (Brief Interview of Mental Status- a cognitive assessment) of 3/15 indicating severe cognitive loss. Resident #7 demonstrated inattention and disorganized thinking. Resident #7 physical function status: Supervision of one staff member for Bed mobility, transfer, ambulation in/out of room and on/off unit with a walker, dressing, toilet use, personal hygiene, and bathing. Resident #7 was independent with eating. Resident #7 was continent of bowel and occasionally incontinent of bladder. Resident #7's weight was 110 pounds and was without chewing or swallowing problems. Resident #7 medications included an antidepressant and a water pill. Review of the hospital Discharge Summary, dated 5/22/15, Resident #7 returned to the facility after hospitalization [DATE] to 5/22/15 for treatment of [REDACTED]. Review of the Monthly Physician order [REDACTED]. Special Instructions: If gains more than 3 lbs in 24 hours, notify her cardiologist start date 11/24/14. Review of the Treatment Administration Record (TAR), dated 5/1/15 to 5/31/15 reflected the facility failed to document Resident #7's daily weight from 5/1/15 to 5/6/15. A weight of 108 lbs was documented on 5/7/15. There were again no weights documented from 5/8/15 to 5/17/15. On 5/18/15 a weight of 118 lbs. On 5/19/15 a weight of 113 lbs was documented. Review of the physician progress notes [REDACTED]. There was not any documentation of weight changes or further follow up. Review of the Nurses Progress Notes from 5/1/15 to 5/20/15 there was no documentation why the weights were not completed per orders or that the facility Physician or cardiologist was notified of the change in Resident #7's weights and condition. Review of the Nurses Progress Notes reflected: 5/14/15, .2-3+ [MEDICAL CONDITION] in legs and feet . 5/15/15, 12:48 pm .SOB (shortness of breath) with ambulation with walker- short distances . 5/16/15, 11:12 pm 3+ [MEDICAL CONDITION] to both lower legs . 5/16/15, 9:54 pm .weak and confused assisted with meals . Resident #7 was discharged to the hospital 5/20/15 for change in mental status. On 10/21/15 at 3:30 pm during an interview with Unit Manger Registered Nurse (RN) T when asked stated that it was the charge nurse responsible to ensure that the daily weight is completed and reported to the physician if the ordered parameters were not met and would be documented in the nurses notes. RN T stated that she did not typically follow up to ensure daily weights were done and the charge nurse was ultimately responsible to ensure they were completed. RN T also confirmed that Resident #7's facility physician was notified on 5/12/15 but could not verify that further follow up by nursing had been done. RN T stated that due to increased [MEDICAL CONDITION] and change in mental status on 5/20/15 Resident #7 was sent to the hospital. On 10/21/15 at 4:30 pm during an interview with Licensed Practical Nurse (LPN) when asked stated whenever I notify a physician I document in the Nurses Progress notes. Review of the Annual MDS, dated [DATE], Resident #7 was able to make self understood, and usually understood others. Resident #7 had a BIMS (Brief Interview of Mental Status- a cognitive assessment) of 2/15 indicating severe cognitive loss. Resident #7 demonstrated inattention and disorganized thinking. Resident #7 physical function status: Extensive assist of one staff member for Bed mobility, transfer, locomotion on/off unit with a wheelchair, eating, toilet use, personal hygiene, and bathing. Resident #7 did not ambulate in or out of room and required limited assist of one staff member for dressing. Resident #7 was continent of bowel and bladder. Resident #7's weight was 106 pounds. Resident #7's medications included an antipsychotic, antianxiety, antidepressant and a water pill. According to the facility Policy and Procedure dated 6/2008, reflected under, Procedure: 1. The Licensed nurse receiving the order for any Laboratory test will document the order on the appropriate Physicians order form. Have available to the physician for review and signature or Physician will access resident ' s electronic record, review order and provide an electronic signature. A copy may be sent to the Lab (if applicable) and a copy may be placed in the resident ' s medical record .4. Transcribe the order onto the tracking log, include the type of lab in be drawn, date of order and date draw is to be done . Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out, according to Creighton in Law Every Nurse Should Know, 5th Edition, page 98. The nurse is obligated to follow the physician's orders [REDACTED]. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, Perry, P., Potter, A., 1985). Resident #6 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #6 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #6 had a BIM (assessment tool) score of 6 which indicated her ability to make daily decisions was severly impaired, and she required one person physical assist with locomotion on unit in wheelchair, dressing, hygiene, bathing, and tranfers. Review of the Nursing Facility Psychiatric evaluation dated 7/7/15 for Resident #6 revealed under, Treatment Plan-Status and Recommendations/Orders: Her dose of [MEDICATION NAME] has been lowered twice since admission and it is possible that thyrotoxicosis may have been contributing to her previous [DIAGNOSES REDACTED]. Review of the Chemistry Lab Report dated 6/12/15 reflected Resident #6 had a [MEDICAL CONDITION]-Stimulating Hormone (TSH) level of 0.28mIU/mL. Written on the lab report was, 50 mcg an arrow pointing down (decrease) 25 mcg, recheck 6 wks (weeks), and signed with initials of Licensed Practical Nurse(LPN) Y. Review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In an observation and interview on 10/21/15 at 5:30 p.m. LPN HH was observed reviewing the Chemistry Lab Report dated 6/12/15 for Resident #6. LPN HH was asked by this surveyor what the writing on the page meant. LPN HH reported LPN Y wrote to decrease [MEDICAL CONDITION] dose from 50 mcg to 25 mcg and recheck the TSH in 6 weeks. LPN HH was observed checking the telephone orders and the lab log book. LPN HH reported the facility policy and procedure is to transcribe the order on a telephone order and enter the order into the the computer. LPN HH reported she was unable to find an order or results in the computer or the chart for a TSH after 6/12/15 for Resident #6. In an interview on 10/22/15 at 1:00 p.m. LPN Y reported she wrote the order on the Chemistry Lab Report dated 6/12/15 for Resident #6. LPN Y reported the facility policy is to complete a telephone order and enter the order into the computer. LPN Y reported she was unable to find a telephone order in Resident #6 chart or an order in the computer. After LPN Y placed a call to the lab LPN Y reported Resident #6 had not had a TSH drawn since 6/12/15. LPN Y reported the TSH ordered for Resident #6 on 6/12/15 to be rechecked in 6 weeks did not get ordered or completed. In an interview on 10/22/15 at 2:55 p.m. DON B reported it was her expectation that when a nurse receives a telephone or verbal order that the nurse create and follow the order when the order is received. ( )

This citation pertains to intake number MI 259 Based on observation, interview, and record review, the facility failed to ensure three staff members did not engage one (#1) of 20 sampled residents reviewed for abuse from a total sample of 20, in two separate sexually provocative conversations that were recorded with a cell phone camera and shared with at least two other facility staff members, including an attempt to post the recordings on " social media, " resulting in sexual harassment and exploitation of a vulnerable elderly adult, depersonalization, and humiliation. Findings include: According to the facility Abuse and Neglect Procedure, dated 1/08, under Abuse and Neglect, Abuse: willful infliction of injury,..intimidation...resulting physical harm, pain or mental anguish...Verbal Abuse: Use of oral...or gestured language that willfully includes disparaging and derogatory terms to residents...regardless of their age, ability to comprehend or disability. Mental Abuse: Humiliation, harassment and threats of punishment...Physical Abuse: Hitting, slapping, pinching and kicking; also, controlling behavior through corporal punishment. Under "Policy:...All 'alleged' incidents or suspicions involving abuse...mistreatment...will be reported to the employee's immediate Supervisor, Administrator and Director of Nursing..." . Under "Prevention, Investigation, Resident Protection and Reporting Incidents of Abuse/Neglect/Mistreatment/Misappropriation of Property...3. Any injury or trauma sustained by the resident...will be documented in the medical record and on the Resident Abuse Form (6.4.A) the nurse must complete a thorough head to toe body assessment... According to the facility Electronic Communication Device Policy, dated 9/09, under "Purpose: To establish a policy which both limits and defines the acceptable use of electronic communication devices for employee's working within (company name) facilities...". Under "Guidelines...B. Personal Electronic and Camera Enabled Devices...Unless properly authorized, employees must refrain from using electronic devices for personal use during normal work hours. This includes the use of cell phones for personal phone calls, texting, instant messaging and the likes...At no time may these electronic devices be used in patient care areas...the employee is prohibited from possessing these devices while working in the patient care areas....employees whose electronic communications devices are camera-enabled are prohibited from using that feature on these devices anywhere in the facility... Review of the Resident Admission Record dated 5/13/14 and the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #1 required extensive 2 person assist with bed mobility, transfers, personal hygiene, dressing, and toilet use. The MDS indicated Resident #1's Brief Interview for Mental Status score was 7 which indicated he was severely cognitively impaired. Review of the Incident/Accident Report dated 11/10/14 at 2:00 p.m. for Resident #1, revealed, "On 11/5/14 at 1:30 p.m. resident was making sexually inappropriate comments to 3 female staff members. Redirection was attempted but failed and resident was escorted to the nurses station." Resident #1 was documented as "alert to self"as his level of consciousness. Review of the Investigation revealed that on 11/10/14 CNA "AA" reported to Administrator "A" that she (CNA"AA") was concerned about how two other CNA's had treated Resident #1. CNA "A" reported to Administrator "A"and Director of Nursing (DON) "B" that she (CNA "AA") had been summoned to Resident #1's room by CNA "BB" to help redirect Resident #1's sexually inappropriate behaviors. CNA "AA" reported that when she arrived in Resident's room, CNA "CC" had her cell phone out and was recording the interaction with Resident #1. CNA "AA" asked CNA "CC" to send her the video. There were two video recordings. According to the investigation, the first video recording was with CNA "CC", CNA "BB" and Resident #1. The second video is with CNA "CC", CNA "BB", CNA "AA" and Resident #1. According to CNA "AA", after the redirection attempts failed they brought Resident #1 out to the nurse's station and reported the behaviors to Licensed Practical Nurse (LPN) "DD". The investigation indicated CNA "AA" did not report what happens initially out of fear of co-worker retaliation, but changed her mind and stated, "I would be pissed if someone treated my grandpa that way". CNA "AA" denied sharing the videos with other people and denied posting the videos on social media. The investigation indicated CNA "AA" was suspended pending the outcome of the investigation and Administrator "A" notified the (City) police department. According to the investigation, LPN "DD" reported she was unaware the CNA's had videotaped Resident #1. According to the investigation, on the video, CNA "CC" was heard stating to Resident #1, "That's gross. You're f***ing gross. you're f***ing nasty. I'm going to tell my boyfriend to kick your a**." The investigation indicated that Administrator "A" interviewed CNA "CC" who responded, "yes, I took a video of (Resident #1)". When asked why, CNA "CC" stated, "I thought it was funny". CNA "CC" reported that she sent the video to CNA's "BB" and "AA" because they both asked for it. CNA "CC" stated the video did not go through to CNA "BB". CNA "CC" stated that she did not show it to any other person, nor post it on social media. She admitted to using curse words on the video and also stated that she did not realize that Resident #1 had dementia. According to the investigation on 11/10/13, CNA "CC" was suspended at that time. According to the investigation, on the video, CNA "BB" was heard saying to Resident #1, "You have a wife Rocky. That's not legal, I'm only 18. Stop talking like that. That's inappropriate". CNA "AA" is heard attempting to re-direct Resident #1. The investigation indicated that both CNA "CC" and CNA "BB" were laughing through-out the video. CNA "BB" stated that she did not have a copy of the video on her phone. According to the investigation on 11/10/14, CNA "BB" was suspended and escorted from the building. According to the Investigation dated 11/10/14, CNA "II" stated that she was aware of the video. She stated that CNA "CC" had showed it to her over the weekend (11/7-11/9/14). CNA "II" could not remember which day. She stated it was the day that CNA "CC" worked a double. CNA "II" stated that CNA "CC" approached her and said "you should watch this video, it's really funny about (Resident #1) talking to (CNA "BB")." CNA "II" stated that she advised CNA "CC" she should not be showing that video. Administrator "A" asked CNA "II" what she thought when she viewed the video and CNA "II" stated "I was surprised, I've never seen him that mouthy". She stated that it was wrong for CNA "CC" to have her cell phone on the floor. She stated that she did not report it to anyone. According to the investigation, both CNA "BB" and CNA "CC" were terminated for abuse/neglect, violating resident rights and failure to report. Review of time cards for CNA "BB" reflected that she worked 11/5, 11/6, and 11/9/14. Review of time cards for CNA "CC" reflected that she worked 11/5, 11/8 (16 hours), and 11/9/14. On 11/19/14 at 3:00 p.m., this surveyor viewed 2 videos with CNA "AA" via cell phone with date and time stamp of 11/5/14 at 2:42 p.m. CNA "AA" verified that these were the two videos that CNA "CC" had sent to her on 11/5/14. The first video showed the following: The video began with Resident #1 sitting in his wheelchair in his room; CNA "BB" was standing to the right of Resident #1. Resident #1 was heard to ask CNA "BB", 'Do you want to play with my peter?' CNA "CC" was heard laughing in the background. CNA "BB" stated to Resident #1, 'That's not nice (Resident's #1's name). I'm only 18 that's gross'. CNA "BB" moved around Resident #1 and removed his wheelchair pedals by lifting his right leg and then his left leg and then sat on Resident #1's bed to the left of him. Resident #1 stated 'You made my peter big for your p****'. Laughing CNA "BB" stated 'I don't think my boyfriend would like that'. CNA "CC" was still laughing in the background. Resident #1 then said 'Does your boyfriend f*** you?' CNA "CC" stated to Resident #1, '(Resident #1) you're f***ing gross, stop it. Stop talking like that'. Resident #1 stated, 'My peter is 8 inches long'. CNA "CC" was heard to say off camera, 'No (Resident #1) it's not, I gave you a shower today and it is little'. Both CNA "BB" and "CC" were heard laughing off camera. CNA "BB" then asked Resident #1, 'What about my boyfriend? I will report you. That is inappropriate'. CNA "CC" was heard laughing off camera. CNA "BB" then stood up from Resident #1's bed and began replacing Resident #1's foot pedals on his wheelchair then asked Resident #1, 'what if I was only 14'? CNA "CC" was heard to say 'You're f***ing gross, f***ing nasty and your d*** is little, you need to stop' CNA's "BB" and "CC" were laughing through-out the video. The video recording was approximately 2 minutes and 5 seconds long. Review of the second video showed the following: The video began with Resident #1 sitting in his wheelchair in his room; the door of his room was to his right and was observed to be open. CNA "AA" was observed to be standing to the right of Resident #1. CNA "BB" and "CC" were off camera and were heard laughing as the video began. An unidentified resident was observed to wheel past Resident #1's open door and asked CNA "AA" for assistance. CNA "AA" responded she would be in to assist unidentified resident in a few minutes. The unidentified resident proceeded past door and out of camera view. Resident #1 said to CNA "AA", 'My pecker was made for your p****y'. CNA "AA" responded, "Why do you want to get us into trouble'? (Audible laughing in the background) CNA "AA" was observed to look at the camera and then turned back to Resident #1 and ask 'What did you have for lunch'? Resident #1 stated, 'Fun? I can give you some fun if you play with my peter'. CNA "CC" stated '(Resident #1) you're too old for that, you play with your own peter. You need to have all male caregivers then so they can play with your peter if you want. My boyfriend is gonna kick your a**'. Both CNA "BB" and "CC" were heard laughing through-out the video recording. This video recording was approximately 1 minute and 55 seconds. During both video recordings Resident #1 was observed to sit with his hands in his lap. Resident #1 was not observed to attempt to touch either CNA "AA" or "BB". During a telephone interview on 11/19/14 at 10:15 a.m., CNA "AA" confirmed that said incident occurred on Wednesday 11/5/14 after lunch when she was asked by CNA "BB" to help with putting Resident #1 to bed. CNA "BB" stated to CNA "AA", 'Oh my God, have you heard (Resident #1) being hypersexual'? CNA "AA" stated that when she first entered the room with her. CNA "CC" was standing in front of Resident #1 with her cell phone in her hand. As the conversation with Resident #1 progressed CNA "AA" noted that CNA "CC" was video recording the interaction with Resident #1. CNA "AA" stated that both CNA "BB" and "CC" were laughing the whole time she was in the room. Resident #1 did not seem upset but agreed that a reasonable person would be upset if being recorded without permission. CNA "AA" stated, "I know it was not right". CNA "AA" stated that she did not immediately report what had happened because the administrator was on vacation and she did not feel comfortable with any other management staff and fear of employee retaliation. CNA "AA" reported that any suspicion of abuse was to be reported immediately. CNA "AA" stated that she did ask CNA "CC" to send her the video of Resident #1 and that CNA "AA" sent it to her phone at approximately 2:30 p.m. on 11/5/14. CNA "AA" reported she did not share the video via social media and only showed the recorded video to CNA "LL" on Monday 11/10/14 about 12:00 p.m. prior to reporting to Administrator "A". During a telephone interview on 11/19/14 at 9:50 a.m., CNA "BB" stated that she and CNA "CC" was attempting to help Resident #1 back to bed after lunch when Resident #1 started talking really perverted saying thing like "let me lick your pussy, grab my peter, I have a big peter". CNA "BB" reported that CNA "CC" began laughing and recording resident #1 with her cell phone. CNA "BB" stated (Resident #1) "was reaching for our private areas and I then went to get CNA "AA" because when had worked with him in the past and worked well with him. CNA "BB" stated that she watched the recorded videos prior to leaving that day and that CNA "CC" had attempted to send the videos to CNA "BB's" Facebook page, but it was unsuccessful. CNA "BB" stated she asked CNA "CC" to delete the video from her phone at that time. CNA "BB" stated, "I guess she didn't". CNA "BB" reported that this was abuse and that it should have been reported immediately. When asked if a reasonable person would be upset by being video recorded without their knowledge, CNA "BB" stated, "Absolutely". On 11/19/14 at 11:25 a.m. a telephone interview was attempted with CNA "CC". CNA "CC" stated that she was on the road driving and asked to call surveyor back. This writer attempted to reach CNA "CC again 11/19/14 at 2:15 p.m. without success. This surveyor left a message for a return call. On 11/19/14 at 9:30 a.m. an interview with Administrator "A" stated when CNA "CC was asked if she still had the video recording of Resident #1 on her cell phone, CNA "CC" responded, "My phone is broken". Administrator "A" confirmed that CNA's "AA, BB, and CC were immediately suspended and fires upon completion of investigation. On 11/21/14 at 10:00 a.m. an interview with Administrator "A" stated that she was here at the facility working on 11/5/14 and was in the building at the time of the alleged abuse. Review of the progress notes dated 11/5/14 to 11/14/14 reflected no documentation of assessment of Resident #1's medical, physical or psychosocial needs after alleged abuse occurred. On 11/19/14 at 4:45 p.m. an interview with DON "B" stated that Resident #1's sexual behaviors were new and stated that there had not been any assessment of Resident #1's medical, physical or psychosocial needs after the incident on 11/5/14. On 11/20/14 at 1:30 p.m. an interview with Social Worker Director (SW) "GG" and SW assistant "EE". SW "GG" stated she was not aware that Resident #1 had sexually inappropriate behaviors. SW "EE" stated that it had been reported to her on 11/5/14 at approximately 2 p.m. that Resident #1 had been verbally/sexually inappropriate with care. SW "EE" stated that she observed Resident #1 and spoke briefly to him to complete an assessment for MDS purposes but did not do any kind of follow up after the allegation of abuse had been identified on 11/10/14. Both SW "GG" and "EE" stated that it was policy to follow up with residents after an allegation of abuse. In an interview on 11/20/14 at 1:10 p.m., Family Member #1 stated that "(Resident #1) would just die" if he knew he had said those things and that it had been recorded. According to the Reasonable Person Concept, Resident #1 would likely feel humiliation, dehumanization, and anger if he had the coginitive ability to understand the verbal and mental abuses that occurred as well as the threat of physical abuse from the facility staff CNA's.

This citation pertains to intake MI 243 Based on interview and record review the facility failed to ensure 1 (Resident #102) of 4 sampled residents, from a total sample of 4 residents reviewed remained free from abuse when a family member of another resident walked into Resident #102's room and sexually assaulted her resulting in Resident #102 feeling emotionally distraught and at risk for anxiety and depression due to the reported sexual assault. Findings: Record review of a "Resident Admission Record", dated 10/24/2011 and a "Minimum Data Set" (MDS), dated [DATE] indicated Resident #102 was an [AGE] year old woman originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #102 was able to understand others and make herself understood. A "Brief Interview for Mental Status" (BIMS) indicated Resident #102 was cognitively intact. Record review of a "Facility Report 24 hours", dated 11/25/2011, revealed on 11/24/2011 at 2:30 p.m. Resident #102 alleged a family member of another resident came into her room and was sexually inappropriate. Record review of a "Facility Report and Time Line" regarding events pertaining to Resident #102 revealed that Resident #102 put her call light on and Certified Nursing Assistant (CNA) #6 responded at approximately 2:15 p.m. on 11/24/2011. Resident #102 stated to CNA #6, "Im glad to see you, I have something to tell you." Resident #102 reported to CNA #6 that a man was in her room and fondled her breast and put his mouth over her breast, he had his hands down her skirt and touched her "there" (private area) and asked her if she liked it. Resident #102 described the man as an older man, casually dressed wearing a jacket. According to the timeline/report, CNA #6 reported the allegation to Licensed Practical Nurse (LPN) #5 at 2:20 p.m. LPN #5 immediately went to Resident #102 who reported to her that a male visitor had come into her room and pulled her right breast out of her bra and put his mouth on her breast and his hand down her skirt and briefly squeezed her private area. According to the time line/report of the incident, at approximately 2:25 p.m. all staff were alerted to the description of the suspect and instructed to be on alert for the visitor in question. Record review of a hospital "Emergency Department" record dictated by a physician on 11/24/2011, identified Resident #102's chief complaint as sexual assault. The "History of Chief Complaint" described Resident #102 as an [AGE] year old female brought by ambulance from a local nursing home where she reported she was sleeping in her room and when she woke up suddenly she realized there was a man sitting in her wheelchair beside her bed who stated that he wanted to examine her stomach. She (Resident #102) was uncertain if he was a health care worker or not but the man raised up her gown and apparently put his hand on her abdomen and then reached down into her adult diaper into the groin area but when I (the emergency room physician) questioned her as to whether or not he actually entered her vagina she stated he did not. The patient (Resident #102) then states that he reached up and took her breast out of her bra and put his mouth on her breast and then asked her if she liked that and she stated emphatically no and then the man got up and left and she immediately reported this to the personnel at the nursing home and police were notified. The police requested that we delay examining the patient (Resident #102) until they were able to come and question her, which we did and it was noted that although the patient has a history of dementia with intermittent confusion that at the present time, she is entirely alert and oriented and aware of what happened to her and very lucid as to her description of the events that recently took place. The physical examination on the patient was essentially negative and the patient (Resident #102) states that she was not physically harmed but was emotionally distraught over the events. In an interview on 12/05/2011 at 2:12 p.m., CNA #6 revealed she did respond to a call light at the start of her shift on 11/24/2011. According to CNA #6, Resident #102 was speaking rapidly with wide eyes that a man had come in her room, with a dark jacket and a beard, taken her breast out of her bra, fondled her breast and put his mouth on her breast and a hand down her skirt and asked if she liked it. CNA #6 confirmed she had reported the allegation immediately to the LPN in charge that day and that she escorted police to Resident #102's room when they arrived at the facility. CNA #6 also stated she had to assist Resident #102 with personal hygiene after she soiled herself, something not typical for Resident #102, but according to CNA #6 resident #102 soiled herself because she was scared. CNA #6 recalls the care specifically because she had to make Resident #102 wait until she asked the police, who were called to the scene, if it was all right to change Resident #102's brief due to the nature of the allegation. During an interview on 12/06/2011 at 10:50 a.m., CNA #13 stated that she recalled seeing a man who fit the description given by Resident #102 of the alleged perpetrator standing outside Resident #102's room on 11/24/2011. In an interview on 12/05/11 at 2:50 p.m., CNA #10 revealed she had been sitting at the nurses station on the unit that Resident #102 resided on and recalled seeing a man that fit the description given by the resident. CNA #10 stated the alleged perpetrator was in a hurry, walking fast when he passed the nurses station asking for the code to unlock the door and exit. During an interview at 10:53 a.m. on 12/05/2011, LPN #5 said she briefly saw a man fitting the description given by the resident as she was sitting at the nurses station giving report at about 2:15 p.m. on 11/24/2011. LPN #5 also stated Resident #102 was alert and oriented when she went to find out what had happened and also stated Resident #102's roommate had also seen a man in the room with the same description. During an interview on 12/06/2011 at 11:25 a.m., CNA #8 stated that she saw the suspect come out of Resident #102's room, he said "Hi" as he walked away and asked for the code to get out of the facility as he passed the nurses station. During an interview on 12/06/2011 at 2:15 p.m., Housekeeper #11 stated she saw a man fitting the description of the suspect enter the mens room near the lobby and the main entrance of the facility at approximately 2:30 p.m.. Housekeeper #11 stated she had never seen the man in the facility before but recognized him from the community. During an interview on 12/05/2011 at 11:45 a.m., Resident #102 recounted the events that had occurred on Thanksgiving day, 11/24/2011 at 2:00 p.m. exactly as had been reported by the facility and the hospital records. When asked by this surveyor if she had been physically hurt, Resident #102 said no but that the incident was very upsetting and should never have happened. ( )