Every finding on record at The Villa at Parkridge

Based on observation, interview, and record review the facility failed to address and prevent repeated intrusive behaviors by one resident toward another resident in one (Resident #11) out of three reviewed for resident rights. Findings include:Review of the medical record reflected R11 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included morbid obesity. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4-20-26, reflected R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R12 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dysphagia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5-20-26, reflected R12 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/25/26 at 8:59 AM, Resident #11 (R11) was observed in bed. R11 was pleasant, conversant, and answered questioned appropriately. R11 shared that his neighbor, Resident #12, (R12) frequently enters his room, either through the shared bathroom or R11's main doorway. R11 reported that when R12 enters his room he at times will take food off of his meal tray, snacks, and personal belongings. R11 stated that R12's favorite item to take is his potato chips. R11 stated that it does bother him and at times startles him when R12 barges into his room, so he calls out for staff assistance to remove R12. R11 stated that the most upsetting behavior occurs when R12 repeatedly stands in the shared bathroom flushing the toilet over and over again, creating a noise disturbance throughout the day and the night. According to R11, staff have responded by locking the shared bathroom door on R12 room side, making it inaccessible to R12, but then R12 enters R11's room to access the bathroom. R11 reported bringing these concerns to staff several times but stated he was told to move rooms or to just deal with it. R11 expressed frustration and dissatisfaction with how his concerns are being addressed. In an interview on 6/25/26 at 9:55 am, Certified Nursing Assistant (CNA) J stated that R12 does enter R11's room through the connecting bathroom and removes food from his room. CNA J stated that R12 is not permitted to consume food by mouth and despite that being an order, R12 desires to consume food so to acquire the food, he will enter R11's room and remove food items from R11 to consume. CNA J confirmed that R12 does have a behavior of repeatedly flushing the toilet in the shared bathroom over and over again. CNA J stated that R11 will yell when these intrusive behaviors occur.In an interview on 6/25/26 at 10:26 am, social worker (SW) L reported not knowing about the concerns regarding the intrusive behaviors of R12. Review of R12's Care plan revealed a focus area which stated [R12] has a behavior problem spitting on the floor, removing incontinence pad, urinating on the floor, refusing care at times, refusing and removing abd (abdominal) binder and peg tube dressing, refusing bolus feeding at times, cursing staff, pushing staff, self-transferring, toileting without asking for assistance, ambulating without supervision. Physically aggression towards staff, wandering into resident's rooms.Resident raises bed to high position. Resident rummages through closet - removes and replacing items/ rearrangesitems. Refusing showers/ bathing. Eating food outside of diet (NPO). Removing previous trach site dressing. Wanders into other resident's rooms at times. Pulls PEG out at times. Date Initiated: 02/17/2025. The listed interventions on the care plan did not address anything regarding wandering into other resident's rooms. In an interview on 6/25/26 at 12:36 pm, CNA I stated that R11 gets frustrated about R12 entering into his space and the repeated toilet flushing, which causes R11 to yell out in anger when it occurs. In an interview on 6/25/25 at 1:50 pm, Nursing home administrator (NHA) A stated that the facility was recently made aware with the concern regarding R11 and R12 and would develop and implement interventions to reduce the intrusive behaviors.

This citation pertains to intake #3039625 and 3039655 Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident.Findings Include:Resident #1 (R1) Review of the face sheet reflected R1 was admitted to the facility on [DATE], with diagnoses that included auditory hallucinations, delusional disorders, adjustment disorder with anxiety, and paranoid schizophrenia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/25/26, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the face sheet reflected R2 was admitted to the facility on [DATE], with diagnoses that included dementia, post-traumatic stress disorder, and adjustment disorder with anxiety. On 6/25/26 at 10:11 AM, R1 was observed in his room. R1 declined an interview. Review of a Psychiatric follow up note dated 4/27/2026 at 7:13 PM, R1 was admitted on [DATE] following hospitalization for psychosis with paranoid delusions and a disorganized thought process .Patient was evaluated sitting on side of bed. He presents as anxious, cooperative, and pleasant. Patient is to be evaluated for paranoid schizophrenia, whichis [sic] ongoing. He denies any paranoia, delusions, and hallucinations .Patient has mild depression, which is ongoing. He reports feeling continued depression and sadness. He denies any crying or suicidal ideations .Patient has daily anxiety, which has increased. He denies any anxiety or agitation. Per chart notes: patient has episodes of agitation and nervousness. Staff denies any aggression or combativeness. Staff reports patient having increased episodes of agitation. Patient has nightly insomnia, which is ongoing. He reports that he has been sleeping well. Nursing staff denies any other behaviors . Review of an Interdisciplinary Team Note dated 5/23/26 at 7:23 am stated [R1] made allegation towards another resident. Resident appear to be safe in his environment .Review of a Five-day investigation summary submitted to the Michigan Facility Reported Incident system revealed On 5/23/2026 at approximately 4:15 AM, a certified nursing assistant heard loud voices followed by a smack sound. While going down the hall to investigate the CNA heard I asked you to close the door and heard another smack sound. The certified nursing assistant reported that R2 was standing by the door and she stood between both residents. R2 stated that he asked R1 to close the door and R1 called him a racial slur which led him to react. R1 admitted to calling R2 a racial slur but did not use the r so it's not racist, according to R1. The nurse and certified nursing assistant entered the room and R1 was removed from the room. The nurse was assessing R1who claimed R2 slapped him two times because he called him a racial slur. Neither resident complained of pain. R1 admitted that R2 made contact to his face and R1 admitted , but later stated he cannot recall hitting R2 as incident occurred very quickly. R2 further stated he also thought R1 was white. Both residents were educated about the incident. Verbal understanding received. R1 one was assessed with redness noted to the sides of R1's face.Review of R1's Care plan revealed the following R1 displays behavioral symptoms r/t (related to) attempts to sit on floor , increasing the risk of falls or injury, cursing others, expressing frustration, screaming others, agitated and anxious, refusing care, putting self on floor to [NAME] [sic] to the bathroom. Refuses showers. Resident make racial slurs towards others at times, auditory hallucinations. Date Initiated: 10/24/2025. An intervention included Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 10/24/2025.On 6/24/26 at 11:15 am, R2 was observed lying in bed. When queried what occurred between him and the former roommate R2, R1 stated he called me a [racial slur] so I popped him. When questioned further, R2 stated that he hit R1 in the face with a fist two times. When asked why, R2 confirmed it was in response to being called a [racial slur]. The facility summary further indicated that while the facility substantiated physical contact did occur, they could not substantiate abuse due to the interaction not due to intentional harm.Per the State Operations Manual Appendix PP under F600 S483.12 Freedom from Abuse, Neglect, and Exploitation, Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .The word willful means that the individual's action was deliberate (not inadvertent or accidental).Resident #4 (R4) Review of the face sheet reflected R4 was admitted to the facility on [DATE], with diagnoses that included adjustment disorder with anxiety, chronic pain syndrome, and abnormalities of gait and mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/26, reflected R4 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/11/26, reflected R3 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/24/26 at 9:46 am, R3 was observed in room independently ambulating in and out of her room. R3 and R4 had rooms in close proximity of each other. On 6/24/26 at 12:10 pm, R4 was observed in bed. When queried about the incident that occurred between R3 and R4, R4 stated she hit me. She came in here and hit me in the leg with her fist and a comb. When asked if R4 had any further interactions with R3, R4 stated that R3 continues to wander in R4's room, stating she comes in almost daily, She was in here last night R4 said. When asked how she felt during the incident, R4 stated that she felt scared because she can't walk, she has to lay here and get hit. R4 stated that she is afraid every time R3 enters her room. Review of a summary submitted on the Michigan Facility Reported Incident, On 5/25/2026 [R4] reported to a certified nursing assistant that [R3] ambulated into her room and hit her on her left leg with her hand and her right leg with a comb while in bed.Review of R3's care plan revealed the following; [R3] has a behavior problem r/t entering others rooms, picking apart briefs. Resident refuses Bath/showers at times. Resident refuses meals at times. Resident goes into others room, wandering. Resident removes paper towel from out of her bathroom at times to play with it. Refuses weights. Refuses medications at times. Date Initiated: 04/05/2024. An intervention included Staff redirect resident from others rooms. Date Initiated: 12/23/2025. No further interventions were noted to ensure R3 did not continue to enter R4's room without permission. Per the State Operations Manual, Appendix PP, F600 S483.12 Freedom from Abuse, Neglect, and Exploitation, Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful, as defined at S483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Despite R4's credible report that R3 entered R4's space and intentionally struck her, the facility concluded that no intentional harm occurred and failed to implement further and lasting interventions to prevent the potential for a reoccurrence of resident-to-resident abuse.

Based on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings Include:Resident #1 (R1) Review of the face sheet reflected R1 was admitted to the facility on [DATE], with diagnoses that included auditory hallucinations, delusional disorders, adjustment disorder with anxiety, and paranoid schizophrenia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/25/26, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the face sheet reflected R2 was admitted to the facility on [DATE], with diagnoses that included dementia, post-traumatic stress disorder, and adjustment disorder with anxiety. On 6/25/26 at 10:11 AM, R1 was observed in his room. R1 declined an interview. Review of an Interdisciplinary Team Note dated 5/23/26 at 7:23 am stated [R1] made allegation towards another resident. Resident appear to be safe in his environment .Review of a Five-day investigation summary submitted to the Michigan Facility Reported Incident (MIFRI) system revealed On 5/23/2026 at approximately 4:15 AM, a certified nursing assistant heard loud voices followed by a smack sound. While going down the hall to investigate the CNA heard I asked you to close the door and heard another smack sound. The certified nursing assistant reported that R2 was standing by the door and she stood between both residents. R2 stated that he asked R1 to close the door and R1 called him a racial slur which led him to react. R1 admitted to calling R2 a racial slur but did not use the r so it's not racist, according to R1. The nurse and certified nursing assistant entered the room and R1 was removed from the room. The nurse was assessing R1who claimed R2 slapped him two times because he called him a racial slur. Neither resident complained of pain. R1 admitted that R2 made contact to his face and R1 admitted , but later stated he cannot recall hitting R2 as incident occurred very quickly. R2 further stated he also thought R1 was white. Both residents were educated about the incident. Verbal understanding received. R1 one was assessed with redness noted to the sides of R1's face.On 6/24/26 at 11:15 am, R2 was observed lying in bed. When queried what occurred between him and the former roommate R2, R1 stated he called me a [racial slur] so I popped him. When questioned further, R2 stated that he hit R1 in the face with a fist two times. When asked why, R2 confirmed it was in response to being called a [racial slur]. Review of the MIFRI submission record revealed that the incident between R1 and R2 occurred and was discovered on 5/23/26 at 4:30 AM. The abuse allegation was submitted to the MIFRI system on 5/23/26 at 7:11 am. In an interview on 6/25/26 at 2:20 PM, Nursing Home Administrator (NHA) A stated that the timeframe for reporting allegations of abuse to the State Agency was immediately but no later than two hours after the allegation is made. NHA A acknowledged the allegation was not reported within the two hour timeline. Resident #4 (R4) Review of the face sheet reflected R4 was admitted to the facility on [DATE], with diagnoses that included adjustment disorder with anxiety, chronic pain syndrome, and abnormalities of gait and mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/26, reflected R4 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/11/26, reflected R3 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/24/26 at 9:46 am, R3 was observed in room independently ambulating in and out of her room. R3 and R4 had rooms in close proximity of each other. On 6/24/26 at 12:10 pm, R4 was observed in bed. When queried about the incident that occurred between R3 and R4, R4 stated she hit me. She came in here and hit me in the leg with her fist and a comb. When asked if R4 had any further interactions with R3, R4 stated that R3 continues to wander in R4's room, stating she comes in almost daily, She was in here last night R4 said. When asked how she felt during the incident, R4 stated that she felt scared because she can't walk, she has to lay here and get hit. R4 stated that she is afraid every time R3 enters her room. Review of a summary submitted on the Michigan Facility Reported Incident, On 5/25/2026 [R4] reported to a certified nursing assistant that [R3] ambulated into her room and hit her on her left leg with her hand and her right leg with a comb while in bed.Review of the MIFRI submission record revealed that the incident between R3 and R4 occurred and was discovered on 5/25/26 at 7:25 AM. The abuse allegation was submitted to the MIFRI system on 5/25/26 at 11:37 am. In an interview on 6/25/26 at 2:20 PM, Nursing Home Administrator (NHA) A stated that the timeframe for reporting allegations of abuse to the State Agency was immediately but no later than two hours after the allegation is made. NHA A acknowledged the allegation was not reported within the two-hour timeline.

Based on observation, interview, and record review the facility failed to identify, assess, document, and initiate appropriate treatment for a wound in one (Resident #11) out of three reviewed for wound care. Findings includeReview of the medical record reflected R11 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included morbid obesity. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4-20-26, reflected R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/25/26 at 8:59 AM, R11 was observed in his room laying on a standard mattress. R11 reported pain in both legs related to existing wounds but stated that the wounds on his lower extremities had been improving but recently had a new wound that was causing quite the setback. When queried about the wound, R11 used the trapeze bar to lift his upper body, exposing a reddened, open wound on his right scapula. The bedsheet was adhered to the wound, with copious amounts of malodorous, dark red-brown drainage on the sheet surrounding the wound. R11 stated that the wound had been present for approximately three weeks and was painful. R11 recalled multiple occasions that the sheet adhered to the wound. R11 stated that he has had to instruct the Certified Nursing Assistants to wet the sheet before pulling the sheet from the wound. R11 recalled a few times when the CNAs forget to wet the sheet and pulled the sheet from the wound, which resulted in a significant amount of pain and removal of tissue. R11 stated that the nurses do not do much about this wound and sometimes they might put cream on it or a pad. In an interview on 6/25/26 at 9:40 AM, Licensed Practical Nurse (LPN) D reported that she recently assumed the role as the facility Wound Care Nurse. When asked if LPN D had her wound care certification, LPN D stated that she did not. LPN D reported that every Monday the wound provider comes into the facility and does wound rounds to access the wounds in the facility. LPN D stated that the Nurse Practitioner (NP) observed R4's right axillary wound on Monday and ordered a cream and antibiotic. When queried regarding the wound on the right scapula/back area, LPN D did not have knowledge of that wound.After gaining consent to observe the right scapula wound from R11, a joint observation of the right scapular wound was completed with LPN D. R11 used his trapeze bar to lift and slightly rotate his upper body to the left. LPND attempted to visualize the wound, however, had to pause to obtain sterile saline to moisten the bedsheet and attempt to peel the sheet from the skin and wound. After the sheet was loosened, LPN D described the wound observation as an open spot with drainage and bleeding. Another observation of the wound was made, and an open area was observed with drainage, and an odor was noted. R11 stated that the pain was getting unbearable and the wound assessment was discontinued. After exiting the room, LPN D stated, that the area that we jointly observed was a new opening. LPN D stated that staff are expected to do head to toe skin checks twice a week on shower days. If R11 were to refuse a shower, the staff are expected to document any refusals. LPN D said that it is possible R11 refused his skin checks and turning and repositioning.Immediately following the joint observation, R11 was interviewed and denied refusing any skin assessments. He stated that staff turn him to do brief changes and there would be no reason they couldn't observe his skin during those moments. In an interview on 6/25/26 at 9:55 am, Certified Nursing Assistant (CNA) J stated that she knew about the open area on R11's right back/shoulder area. CNA J denied seeing a bandage on it and stated that occasionally R11 would use his back scratcher to scratch the wound. 5 other nursing staff telephone interviews were attempted; however, staff did not return any of the telephone calls. In an interview on 12:43 PM, Nurse Practitioner (NP) H reported that they were in the facility on 6/24/26 to observe R11's wounds. NP H denied knowledge of R11's right scapula wound. Review of skin assessment documentation dated 5/22/26, 5/25/26, 5/28/26, 6/1/26, 6/4/26, 6/15/26, 6/16/26, 6/18/26, and 6/22/26 revealed no documented refusals of the skin assessment and no documentation identifying an open area on the right scapula.Review of the Wound tab in the electronic medical record, last updated on 5/22/26, identified active wounds on the bilateral lower extremities and the right axilla. The Wound tab reflected no measurements or imaging for the right scapula open area. In an interview on 6/25/26 at 2:11 pm, Director of Nursing (DON) B stated that the expectation was for staff to evaluate skin twice a week in conjunction with the resident's shower schedule. If a resident refuses a shower, the nursing staff are expected to attempt a skin assessment and document a refusal. DON B stated CNAs are expected to report any newly identified skin concerns to nursing for evaluation. DON B stated that she would be contacting the Physician promptly to have the open area assessed and have treatment order implemented.

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During an interview on 3/09/2026 at 11:45 AM, Activity Manager Q verified Resident Council President and reported plant to gather residents for Confidential Resident Council Meeting at 3:00 p.m. Requested six months of minutes for review and Activity Manager reported after each meeting concern forms are completed for reported concerns and department managers are responsible for addressing concerns and verified follow up information with be proved with requested minutes. During a Confidential Resident Council Meeting on 3/09/2026 at 3:14 PM there were 12 residents present with 8 residents who actively participated and appeared to be alert and oriented. When asked if staff respond to call light timely, 8 of 8 resident reported ongoing issue with slow response to call lights. Residents reported discussed at every Resident Council Meeting for months with no improvements and management staff say they are working on it. Residents gave examples of call light response times greater than one hour on night shift and then when staff arrive residents were not treated with dignity and resident told, I am busy, we are short staffed, what do you need. Another confidential resident reported always told by staff short staffed after waiting for call light to be answered and stated, That is not our problem when we have to ask for assistance with basic care like going to the bathroom. Another resident who attends monthly verified call lights discussed every month with no improvements. Eight of eight confidential residents were not aware where to locate or how to complete a grievance form or how the process worked.Review of Resident Council Meeting minutes, dated 9/23/25 through 3/8/26, provided by Nursing Home Administrator (NHA) A. Continued review of minutes revealed resident complaints of long call light response times on 5 of 6 months of council meetings. The facility responses were all that staff was re-educated on call light answering. (for past 6 months same facility response to re-educate staff with continued complaints of current call light response times appears not effective.)

Based on observation, interview and record review, the facility failed to notify residents of where to find grievance forms and how to file a grievance as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During a Confidential Resident Council Meeting on 3/09/2026 at 3:14 PM there were 12 residents present with 8 residents who actively participated and appeared to be alert and oriented. When asked if staff respond to call light timely, 8 of 8 resident reported ongoing issue with slow response to call lights. Residents reported discussed at every Resident Council Meeting for months with no improvements and management staff say they are working on it. Residents gave examples of call light response times greater than one hour on night shift and then when staff arrive residents were not treated with dignity and resident told, I am busy, we are short staffed, what do you need. Resident reported made them feel like they were a bother to staff because they had to ask for assistance. Another confidential resident reported always told by staff facility was short staffed after waiting for call light to be answered and stated, That is not our problem when we have to ask for assistance with basic care like going to the bathroom. Another resident who attends monthly verified call lights discussed every month with no improvements. Eight of eight confidential residents were not aware where to locate or how to complete a grievance form or how the process worked.

Based on observation, interview and record review, the facility failed to provide adequate nursing staff to ensure that the needs of their residents were met for 11 residents (R7, R41, and R64) and 8 residents identified through confidential group interviews, resulting in insufficient and unmet resident care needs, feelings of frustration, and complaints about not enough staff. Findings includeR7 Review of the clinical record revealed R7 was admitted into the facility on 1/11/2026 with diagnoses that included: paraplegia, neurogenic bowel (loss of normal bowel control caused by nerve damage), and sarcoidosis (an inflammatory disease where the immune system overreacts, causing tiny, swollen lumps to form in organs). According to the Minimum Data Set (MDS) assessment dated [DATE], R7 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On 3/8/26 at 1:13 PM, R7 was observed lying in bed on his back with a personal video game set up for his use. R7 reported that he has waited as long as 3 hours for his call light to be answered and that his roommate is like his legs and will go to the nurses station if R7's call light is on for too long. R7 further reported that when his roommate goes to the nurses station he reports back that the staff are just sitting at the nurses station talking and that it routinely takes an hour plus for staff to respond to his call light. During a Confidential Resident Council Meeting on 3/09/2026 at 3:14 PM there were 12 residents present with 8 residents who actively participated and appeared to be alert and oriented. When asked if staff respond to call light timely, 8 of 8 resident reported ongoing issue with slow response to call lights. Residents reported discussed at every Resident Council Meeting for months with no improvements and management staff say they are working on it. Residents gave examples of call light response times greater than one hour on night shift and then when staff arrive residents were not treated with dignity and resident told, I am busy, we are short staffed, what do you need. Another confidential resident reported always told by staff short staffed after waiting for call light to be answered and stated, That is not our problem when we have to ask for assistance with basic care like going to the bathroom. Another resident who attends monthly verified call lights discussed every month with no improvements. Eight of eight confidential residents were not aware where to locate or how to complete a grievance form or how the process worked. On 03/09/2026 at 2:26 PM three activated call lights were observed on the 300 hall. Two nurses were seated at the nurse's station chatting to each other. On 03/09/2026 at 2:31 PM, R41 was heard screaming I need a nurse from her room. Her family member was observed exiting the room shortly after and proceeded to the nurse's station. On 03/09/2026 at 2:32 PM, the family member returned to R41's room. R41 stated, what did she say. The family member said, she said okay. On 03/09/2026 at 2:39 PM, R41 was heard screaming, I need a nurse, someone help. The family member stated I don't know where they are at, yes i told them you needed help. This is unreal. On 03/09/2026 at 2:41 PM, another call light was activated. Meanwhile, the two nurses remained seated at the nurses' station. On 03/09/2026 at 2:45 PM, a confidential Certified Nursing Assistant entered R41's room. R41 screamed at the CNA stating, I have to go to the bathroom so bad, my call light has been on for over an hour, this is insane. R41's family member said, she's been waiting a very long time. On 03/09/2026 2:48 PM, the confidential CNA was visibly frustrated, stated that there are two nurses, the two at nurses' station that could help with answering call lights, the CNA has had no break, and had 17 residents assigned to her today. On 3/9/26 at 2:50 pm, I inquired with R64 as to why he had his call light activated, as R64 was one of the four. R64 stated that he had his call light activated since after he finished his lunch. R64 stated that his brief was digging into his skin and causing him pain. In an interview on 03/10/2026 at 12:41 PM, Director of Nursing (DON) B stated that all staff are responsible for answering call lights and ignoring call lights is not acceptable.

Based on observation, interview and record review, the facility failed to treat all residents with dignity for one (Resident #7) of two reviewed.Findings include:Review of the clinical record revealed R7 was admitted into the facility on 1/11/26 with diagnoses that included: paraplegia, neurogenic bowel (loss of normal bowel control caused by nerve damage), and sarcoidosis (an inflammatory disease where the immune system overreacts, causing tiny, swollen lumps to form in organs). According to the Minimum Data Set (MDS) assessment dated [DATE], R7 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 3/8/26 at 1:13 PM, R7 was observed lying in bed on his back with a personal video game set up for his use. R7 reported that the staff are rude and that he had enough. R7 reported that staff do not explain what they are doing prior to performing care and often leave him exposed during wound care and pericare. R7 specifically mentioned wound care that was performed recently, R7 stated that his privacy curtain had not been pulled and he wasn't covered up, R7 could see his roommate ambulating within their room and when R7 looked down he realized his genitals were also exposed. R7's roommates are both ambulatory and that staff routinely do not pull his privacy curtain while providing care. R7 further stated that he just wanted basic common courtesy. On 3/8/26 at 1:51 PM, LPN R was observed entering R7's room without knocking. Upon entering the room during my interview, LPN R stated that she sort of knocked, had her phone in her hand and that she was looking for the bladder scanner. LPN R did not knock until she had already opened the door, stuck her head inside and saw I was in the middle of an interview. R7 reported that staff rarely knock before entering their closed door. On 3/10/26 at 2:21 PM, during an interview with Director of Nursing (DON), it was reported that the expectation for staff is that they knock on the door, introduce themselves and wait for an answer prior to entering resident rooms and staff should always pull privacy curtains when performing resident care.

Based on observation, interview, and record review the facility failed to ensure a resident had a call system adapted to their physical limitations in one (Resident #98) out of two reviewed for accommodation of needs. Findings include: Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his bedside table with a handwritten date of 3/6/26 PM that contained about 1/4 of water. R98 had an unpleasant body odor coming from him that indicated that he had not been bathed in quite some time. He has a very unkempt appearance. R98's lips appeared very dry and chapped. R98's toenails were very overgrown. R98's push button call light was clipped to his curtain on his right side and out of reach. I introduced myself to R98 and explained the purpose of my visit, however, R98 did not verbally respond. I continued to make conversation and discovered that R98 understood what I was saying but could not verbalize back to me but could answer by nodding yes or shaking his head no. R98 could answer questions appropriately. When asked about details such as the surroundings or details such as the colors of the clothing I was wearing, R98 answered the questions appropriately. I inquired if R98 was warm and he nodded his head yes. When asked if he had been receiving showers, he shook his head and stated no no no. When asked if he would like a shower, he nodded yes. When asked if he would like to have his face shaved and a haircut, he nodded yes. When asked if he was thirsty, he enthusiastically nodded his head yes. When asked if he could hold a cup and give himself drinks of water, he stated, no no no and raised and lowered his left arm. I observed his left hand and R98's fingers were on a fixed, fanned out position. When asked if he required assistance with eating and drinking, he nodded yes. When inquired how he requested assistance from staff, he shrugged his shoulders. When asked how he communicated his needs to staff, he shrugged his shoulders again. When asked if he used a communication board with pictures, he stated 'no, no, no. When I attempted to leave the room, R98 appeared frantic and looked at the empty Styrofoam cup of water on the bedside table and stated no no no. I asked him if he was thirsty and he nodded yes. I provided him with staff assistance. Review of a Psychiatric note dated 11/10/25 revealed that R98 was able to shake his head to answer simple questions. On 03/09/2026 2:56 PM, R98 was observed in bed in the exact same position. R98's push button call light was positioned on his chest. I inquired if R98 could demonstrate using his call light. R98 looked at me and again showed me that he could only raise and lower his left arm, and his fingers were fixed in a fanned-out position. On 03/10/2026 at 7:57 AM, R98 was observed in his room. R98 was lying flat on his back with his heels not floated. LPN J entered the room and stated that it was hot in the room. A full, room temperature Styrofoam cup of water dated 3/10 22:00 (10:00 pm) was observed on his bedside table with no straw in it. On 03/09/2026 at 3:02 PM, Certified Nursing Assistant (CNA) G stated she is not sure how he communicates his needs and she is not sure if he can use his call light but it is clipped on to him. On 03/10/2026 at 9:58 AM, CNA O stated that R98 cannot use the call light.On 03/10/2026 at 11:23 AM, Unit Manager (UM) I stated that R98 communicates by nodding yes or no or by using the communication board. When queried where the communication board currently was in R98's room, UM I informed me that it was not in his room. R98's call light was observed clipped to the top of his mattress on the right side (his affected side) during the interview. I inquired how R98 notifies staff if he requires assistance. UM I proceeded to unclip the out of reach call light and place it in R98's hand. I asked R98 to demonstrate using the call light. R98 looked at me and again, raised and lowered his arm stating no no no. I asked R98 if he could use the call light and he shook his head to indicate that he was unable to use the push button call light which was obvious due to his left sided functional limitations. When asked how the facility monitors hydration statuses and ensures that R98 is being offered fluids, UM I stated that staff document fluid intake and offer fluids. I held up the full, room temperature water that contained no straw dated 3/10 22:00 and asked R98 if that was his water from last night. R98 nodded yes. I asked R98 if he had anything to drink last night. R98 nodded no. I asked if R98 was thirsty and he indicated that he was thirsty. In an interview on 3/10/26 at 11:26 PM, Director of Nursing B stated a soft touch or pancake call light would be more fitting for R98.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment for one (Resident #72) of two reviewed.Findings include:Review of the clinical record revealed R72 was admitted into the facility on 5/19/25 with diagnoses that included: pancytopenia (blood counts-red blood cells, white blood cells and platelets are lower than normal), immunodeficiency due to drugs, asthma, paraplegia, depression and anxiety. According to the Minimum Data Set (MDS) assessment dated [DATE], R72 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 3/10/26 at 9:31 AM a sign was observed to see staff prior to entering resident room, record review confirmed that R72 was in reverse isolation. Upon entering room, R72 was observed laying on her back in bed, the room was dark with light coming in from the bathroom, the bathroom door was open and a large hole was observed where the wall and ceiling meet in the shower. The exposed wall was observed to have dark, rust colored debris and 2 pipes were exposed. The approximate size of the hole was 6 inches wide by 6 inches long. The ceiling had a replacement piece covering what appeared to be damage to the ceiling. The tub was covered with a board and R72 reported that it had not been usable. There was a brown substance noted in a splatter pattern on the tub exterior, close to the floor. Additionally, there was a white substance noted on the mirror in a vertical streaking pattern. R72 reported that the wall/shower area had been in that condition for an extended period of time and was noted to be worse in the past. A review of R72's physician orders revealed: Reverse isolation (neutropenic precautions), every shift for immunosuppressive long term linezolid use, with a start date of 5/19/25 and no specified end date. On 3/10/26 at 1:16 PM, during an interview with Regional Director of Maintenance (RDM) S and Maintenance Director (MD) T, it was reported that they were aware of need for repair in R72's bathroom and the original problem was a leak in a pipe back in mid-November of 2025 that required repair. Repairs had been made and the holes in the walls/ceiling had been previously repaired, however it was discovered the materials that were used were not fireproof and needed to be replaced again. RDM S agreed that in the current condition it was not homelike.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R135) of four reviewed.Findings Include: Review of the medical record revealed R135 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. Review of the Social Services Comprehensive Evaluation dated 3/4/26 revealed R135 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 3/3/26 revealed Wound Care (L [left] posterior leg): cleanse [with] normal saline, apply Medihoney (Activon) to wound bed, cover with foam dressing. The wound care was ordered to be completed every evening shift, every other day. On 03/08/2026 at 10:13 AM, R135 was observed sitting on the edge of his bed. R135 reported he had a wound on the back of his left calf, but the facility had not changed the dressing since 3/2/26 or 3/3/26. R135 pulled up his pant leg and a dressing dated 3/3/26 was observed on his left calf. R135 reported he had his own wound care supplies from the hospital, but the facility removed the supplies from his room when he was admitted . On 03/09/2026 at 1:38 PM R135 was observed self-ambulating in the hallway. R135 reported his wound care still had not been completed. On 03/09/2026 at 1:47 PM, R135's left calf dressing was observed to be the same dressing dated 3/3/26. Review of Treatment Administration Record (TAR) revealed R135's wound care was checked off and signed out as completed on 3/4/26 by Licensed Practical Nurse (LPN) L, on 3/6/26 by LPN M, and on 3/8/26 by LPN N. In an interview on 03/09/2026 at 2:13 PM, Registered Nurse (RN)/Unit Manager (UM) I reported R135 had a wound on his left calf which was caused by his walking boot. UM I reported she monitored if wound care was completed as ordered by reviewing the TAR and progress notes. UM I reviewed R135's TAR and reported the check mark with initials indicated the wound care was completed. UM I reported if the wound care was not completed, the TAR would reflect a code 9 and then have a coordinating progress note. On 03/09/2026 at 2:17 PM, with UM I, R135 was observed in bed. R135's bandage was observed with the date of 3/3/26. UM I agreed R135's dressing was dated 3/3/26 and therefore had not been changed since then. On 03/09/2026 at 2:49 PM, UM I changed R135's dressing to which he responded, It's about time. R135's wound was observed as an open area with a red wound bed and drainage on the removed dressing. In a telephone interview on 03/09/2026 at 1:56 PM, LPN N reported she worked with R135 last night (3/8/26). LPN N reported R135 did have ordered wound care, but she could not recall if she completed the wound care on 3/8/26. When asked why it was checked off and signed off as completed on the TAR, LPN L then reported she did the wound care. When informed that R135's dressing was dated 3/3/26, LPN N then reported she knows she did a dressing last night but could not recall if it was for R135. LPN N reported she did not know why the wound care was signed out as completed but not done. In a telephone interview on 03/10/2026 at 11:14 AM, LPN L reported they worked on 3/4/26, but could not recall R135. When asked if she performed any wound care that day, LPN L reported she changed a dressing on another resident's heel. When asked if she performed any wound care/changed a dressing on the back of a resident's calf, LPN L stated, No. When asked what a check mark and their initials reflected on the TAR, LPN L reported that indicated the wound care was done. LPN L reported if the wound care was not done, the TAR would indicate a special code and then she would make a progress note. When asked why the TAR reflected R135's wound care was completed when it was not, LPN L stated, maybe I checked it off. Review of R135's progress notes revealed no indication as to why wound care was not completed on 3/4/26, 3/6/26, or 3/8/26. In an interview on 03/10/2026 at 10:54 AM, Director of Nursing (DON) B reported LPN L, LPN M, and LPN N did not follow the physician's orders for R135's wound care. DON B reported there was no reason as to why the wound care should be signed out as completed but not done. DON B reported she was in the process of educating the nursing staff related to this concern. In an interview on 03/10/26 at 11:02 AM, LPN M reported she was not sure if R135 had any ordered wound care. LPN M reported if the TAR showed a check mark and her initials, then she would assume the wound care was completed. When she was informed that R135's dressing was dated 3/3/26, LPN M reported R135 mentioned that to her yesterday. LPN M reported since R135's dressing was dated 3/3/26, she probably did not do his wound care on 3/6/26. Review of the personnel files revealed on 1/20/25, LPN N received an Employee Discipline Form for documenting that a catheter change was performed, but it was not completed. On 10/20/23, LPN L received an Employee Discipline Form for not completing skin evaluations and falsified documentation. On 3/9/26, LPN M received a Corrective Action for Minor Offenses for documenting wound care as completed but not dated for that day (3/6/26).

Based on observation, interview and record review the facility failed to prevent misappropriation of resident property for one (Resident #34) of one reviewed.Findings include:Review of the clinical record revealed R34 was admitted into the facility on 2/10/26 with diagnoses that included: difficulty in walking and partial intestinal obstruction. According to the Minimum Data Set (MDS) assessment dated [DATE], R34 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 3/8/26 at 12:24 PM, R34 was observed sitting at the edge of the bed, eating lunch. R34 reported that a staff member entered his room that morning while he was asleep, stated she needed to use his phone charger, removed R34's phone from his charger and plugged her phone in and left it at his bedside. A pink, iPhone was observed to be plugged in and charging at R34's bedside. R34 described the staff member, and it was determined the phone belonged to CNA U. On 3/8/26 at 12:55 PM, during an interview with Unit Manager (UM) V, it was reported that it would not be appropriate for staff to have their cellphones in resident rooms or to charge their personal cellphones in resident rooms, using residents' personal property. On 3/8/26 at 1257 PM, UM V entered R34's room and discussed the staff members phone being charged in his room. UM V removed the iPhone and reported that she would address the concern.

Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were developed and implemented for three out of 24 residents (Resident #'s 12, 41, & 98). Findings Included: Resident #12: Per the facility face sheet R12 was admitted to the facility on [DATE]. Record review of R12's care plans revealed an active care plan that was in place with a Focus of .antidepressant medication r/t (related to) bipolar, depression. There was an intervention on R12's care plan to, Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes Dated 6/20/2025. There was no documentation of monitoring R12's antidepressant medication for any of the care planned adverse reactions. RR of the care plan revealed a. Focus that R12 had a .mood problem r/t dx (diagnosis) of generalized anxiety disorder, post-traumatic disorder, chronic, vascular dementia, mild, with anxiety, major depressive disorder, recurrent, moderate., dated 6/8/2025. The intervention on the care plan was to, Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 06/08/2025, and Monitor/record/report to MD (Medical Doctor) prn mood patterns s/sx (signs/signs and symptoms) of depression, anxiety, sad mood as per facility behaviour (sic) monitoring protocols. dated 6/8/2025. Another intervention revealed to, Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behaviour (sic) monitoring protocols. Date Initiated: 06/08/2025 Upon review of R12's electronic medical record (EMR) no documentation of monitoring of R12's mood for signs and symptoms, feelings, mood patterns, depression, anxiety, sadness, etc ., was found. In an interview on 3/10/2026 at 9:31 AM, Director of Nursing (DON) B stated there was no documentation for monitoring R12's antidepressant medication, which was Lexapro, as she was not able to find any documentation upon review of R12's EMR. DON B stated that the nurses were responsible to document on the care plan interventions of signs and symptoms and mood for the monitoring of. DON B stated that the information would be reviewed and discussed in an Interdisciplinary (IDT) meeting for Psychology follow-up if needed. During the same interview DON B stated that there was no documentation of monitoring of R12's mood per the care plan intervention to, Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Date Initiated: 06/08/2025, or Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behaviour (sic) monitoring protocols. Date Initiated: 06/08/2025 In an interview on 3/10/2026 at 9:43 AM Social Worker (SW) S stated nursing would document the monitoring of the changes in R12's mood, and the monitoring for signs and symptoms of antidepressant use. SW S said when there was a concern, she would see it pop up on the clinical alert in the EMR system. SW S was not able to locate any documentation of monitoring of R12's mood or signs and symptoms related to antidepressant use in R12's EMR. SW S stated that it was a concern for her because she was not able to follow up with the resident and do a three day psychosocial evaluation when the documentation was not in a resident's EMR and she was not alerted to it. SW S said it was her expectation that the monitoring be documented because that is the only way she was going to know what is going on with a resident. Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his bedside table with a handwritten date of 3/6/26 PM that contained about 1/4 of water. R98 had an unpleasant body odor coming from him that indicated that he had not been bathed in quite some time. He has a very unkempt appearance. R98's lips appeared very dry and chapped. R98's toenails were very overgrown. R98's push button call light was clipped to his curtain on his right side and out of reach. I introduced myself to R98 and explained the purpose of my visit, however, R98 did not verbally respond. I continued to make conversation and discovered that R98 understood what I was saying but could not verbalize back to me but could answer by nodding yes or shaking his head no. R98 could answer questions appropriately. When asked about details such as the surroundings or details such as the colors of the clothing I was wearing, R98 answered the questions appropriately. I inquired if R98 was warm and he nodded his head yes. When asked if he had been receiving showers, he shook his head and stated no no no. When asked if he would like a shower, he nodded yes. When asked if he would like to have his face shaved and a haircut, he nodded yes. When asked if he was thirsty, he enthusiastically nodded his head yes. When asked if he could hold a cup and give himself drinks of water, he stated, no no no and raised and lowered his left arm. I observed his left hand and R98's fingers were on a fixed, fanned out position. When asked if he required assistance with eating and drinking, he nodded yes. When inquired how he requested assistance from staff, he shrugged his shoulders. When asked how he communicated his needs to staff, he shrugged his shoulders again. When asked if he used a communication board with pictures, he stated 'no, no, no. When I attempted to leave the room, R98 appeared frantic and looked at the empty Styrofoam cup of water on the bedside table and stated no no no. I asked him if he was thirsty and he nodded yes. I provided him with staff assistance. Review of a Psychiatric note dated 11/10/25 revealed that R98 was able to shake his head to answer simple questions. On 03/09/2026 2:56 PM, R98 was observed in bed in the exact same position. On 03/10/2026 at 7:57 AM, R98 was observed in his room. R98 was lying flat on his back with his heels not floated. On 03/10/2026 at 11:23 AM, R98 was observed flat on his back with his heels on the mattress. Review of the Face Sheet and Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 1/26/26, reflected R41 was a [AGE] year-old female admitted to the facility on [DATE], with recent re-admission 1/9/26 related to acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis (dangerous, altered mental state caused by severe accumulation of carbon dioxide in the blood) and sleep apnea. R41 had other diagnoses that included morbid obesity, chronic obstructive pulmonary disease, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression. The MDS reflected that R41 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. Review of R41 History and Physical, dated 1/4/26, reflected that R41 had been transferred to the hospital from the facility with diagnosis that included community acquired pneumonia. Continued review reflected R41 had diagnosis that included obesity hypoventilation syndrome ([NAME]). During an observation and interview on 3/08/2026 at 10:00 AM, R41 was lying in bed in hospital gown with oxygen via nasal canula in place. R41 appeared depressed and repeated several times, I do not know how much longer I can stand this. When asked what she meant by that R41 reported was very unhappy with her stay at the facility including care and current guardianship issues. R41 son was at the bedside and appeared to be supportive to R41. R41 reported had lived at the facility for about six months after a very long hospital stay related to decline in health. R41 reported had two recent hospital transfers related to pneumonia and respiratory failure in January, and hospital had discharged her with orders to continue to use Bi-level Positive Airway Pressure (BIPAP) machine and had not used since January because staff to do not assist her with it. Verified machine was located in R41's closet. R41 reported to facility staff and provider that BIPAP needed to be used at night but continues to not use. R41 reported was aware of risks of not using ordered BIPAP and reported labs had been abnormal related to not BIPAP and reported was worried health would decline again and would never be able to discharge from facility. Review of the Electronic Medical Record (EMR) reflected R41 was transferred to the hospital on 1/4/26 and returned to the facility on 1/5/26 with diagnosis of pneumonia. Continued review reflected R41 transferred back to the hospital on 1/6/26 related to acute on chronic respiratory failure with hypoxia and hypercapnia and CO2 narcosis and returned to the facility on 1/9/26. Review of R41 Care Plans, dated 10/23/25, reflected, Resident has potential for difficulty in breathing r/t [related to] CHF [chronic heart failure], COPD, chronic respiratory failure, OSA [obstructive sleep apnea] and requires use of BiPAP.Interventions BiPAP per MD [medical doctor] order. During an interview on 3/10/2026 at 11:36 AM, Assistant Director of Nursing (ADON) C verified R41 was admitted to the hospital on [DATE] and 1/6/26 related to pneumonia and respiratory issues and verified R41 had history of COPD with use of BIPAP. ADON C reported R41 had Physician orders for BIPAP prior to 1/4/26 transfer to the hospital with hospital discharge orders to continue use and reported appeared R41 BIPAP was not re-ordered when re-admitted on [DATE] and should have been. ADON C verified R41 did not have a physician order for BIPAP after 1/5/26 and 1/9/26 hospital admission, however, was on R41 Care Plan, dated prior to 1/4/26 transfer to the hospital and would expect staff to follow care plans.

Based on observation, interview, and record review, the facility failed to ensure an effective and consistent means of communication in one (Resident #98) out of two reviewed. Findings include. Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his bedside table with a handwritten date of 3/6/26 PM that contained about 1/4 of water. R98 had an unpleasant body odor coming from him that indicated that he had not been bathed in quite some time. He has a very unkempt appearance. R98's lips appeared very dry and chapped. R98's toenails were very overgrown. R98's push button call light was clipped to his curtain on his right side and out of reach. I introduced myself to R98 and explained the purpose of my visit, however, R98 did not verbally respond. I continued to make conversation and discovered that R98 understood what I was saying but could not verbalize back to me but could answer by nodding yes or shaking his head no. R98 could answer questions appropriately. When asked about details such as the surroundings or details such as the colors of the clothing I was wearing, R98 answered the questions appropriately. I inquired if R98 was warm and he nodded his head yes. When asked if he had been receiving showers, he shook his head and stated no no no. When asked if he would like a shower, he nodded yes. When asked if he would like to have his face shaved and a haircut, he nodded yes. When asked if he was thirsty, he enthusiastically nodded his head yes. When asked if he could hold a cup and give himself drinks of water, he stated, no no no and raised and lowered his left arm. I observed his left hand and R98's fingers were on a fixed, fanned out position. When asked if he required assistance with eating and drinking, he nodded yes. When inquired how he requested assistance from staff, he shrugged his shoulders. When asked how he communicated his needs to staff, he shrugged his shoulders again. When asked if he used a communication board with pictures, he stated 'no, no, no. When I attempted to leave the room, R98 appeared frantic and looked at the empty Styrofoam cup of water on the bedside table and stated no no no. I asked him if he was thirsty and he nodded yes. I provided him with staff assistance. Review of a Psychiatric note dated 11/10/25 revealed that R98 was able to shake his head to answer simple questions. On 3/8/26, a confidential staff member stated that they do not have a way to effectively communicate with R98, so they do their best to guess R98's needs. On 03/09/2026 2:56 PM, R98 was observed in bed in the exact same position. R98's push button call light was positioned on his chest. I inquired if R98 could demonstrate using his call light. R98 looked at me and again showed me that he could only raise and lower his left arm, and his fingers were fixed in a fanned-out position. On 03/09/2026 at 3:02 PM, Certified Nursing Assistant (CNA) G stated she does not have a way to communicate with R98. CNA G stated she is not sure if he can use his call light, but it is clipped on to him. On 03/10/2026 at 7:57 AM, R98 was observed in his room. R98 was lying flat on his back with his heels not floated. LPN J entered the room and stated that it was hot in the room. A full, room temperature Styrofoam cup of water dated 3/10 22:00 (10:00 pm) was observed on his bedside table with no straw in it. On 03/10/2026 at 11:23 AM, Unit Manager (UM) I stated that R98 communicates by nodding yes or no or by using the communication board. When queried where the communication board currently was in R98's room, UM I informed me that it was not in his room. R98's call light was observed clipped to the top of his mattress on the right side (his affected side) during the interview. I inquired how R98 notifies staff if he requires assistance. UM I proceeded to unclip the out of reach call light and place it in R98's hand. I asked R98 to demonstrate using the call light. R98 looked at me and again, raised and lowered his arm stating no no no. I asked R98 if he could use the call light and he shook his head to indicate that he was unable to use the push button call light which was obvious due to his left sided functional limitations. When asked how the facility monitors hydration statuses and ensures that R98 is being offered fluids, UM I stated that staff document fluid intake and offer fluids. I held up the full, room temperature water that contained no straw dated 3/10 22:00 and asked R98 if that was his water from last night. R98 nodded yes. I asked R98 if he had anything to drink last night. R98 nodded no. I asked if R98 was thirsty and he indicated that he was thirsty. Review of R98's Care Plan revealed an intervention to encourage to point to make needs know however, no staff mentioned that as an option, nor would that be an applicable form of communication considering the very limited range of motion for R98's left arm.

Based on observation, interview, and record review the facility failed to ensure activities of daily living, including showers, shaving, grooming, and nail care, were being completed in one (Resident #98) out of two residents reviewed for activities of daily living. Findings include. Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his bedside table with a handwritten date of 3/6/26 PM that contained about 1/4 of water. R98 had an unpleasant body odor coming from him that indicated that he had not been bathed in quite some time. He has a very unkempt appearance. R98's lips appeared very dry and chapped. R98's toenails were very overgrown. R98's push button call light was clipped to his curtain on his right side and out of reach. I introduced myself to R98 and explained the purpose of my visit, however, R98 did not verbally respond. I continued to make conversation and discovered that R98 understood what I was saying but could not verbalize back to me but could answer by nodding yes or shaking his head no. R98 could answer questions appropriately. When asked about details such as the surroundings or details such as the colors of the clothing I was wearing, R98 answered the questions appropriately. I inquired if R98 was warm and he nodded his head yes. When asked if he had been receiving showers, he shook his head and stated no no no. When asked if he would like a shower, he nodded yes. When asked if he would like to have his face shaved and a haircut, he nodded yes. When asked if he was thirsty, he enthusiastically nodded his head yes. When asked if he could hold a cup and give himself drinks of water, he stated, no no no and raised and lowered his left arm. I observed his left hand and R98's fingers were on a fixed, fanned out position. When asked if he required assistance with eating and drinking, he nodded yes. When inquired how he requested assistance from staff, he shrugged his shoulders. When asked how he communicated his needs to staff, he shrugged his shoulders again. When asked if he used a communication board with pictures, he stated 'no, no, no. When I attempted to leave the room, R98 appeared frantic and looked at the empty Styrofoam cup of water on the bedside table and stated no no no. I asked him if he was thirsty and he nodded yes. I provided him with staff assistance. Review of a Psychiatric note dated 11/10/25 revealed that R98 was able to shake his head to answer simple questions. Review of the Care Plan stated bathing: physical assist.Review of the MDS: Section GG Physical Abilities revealed R98 was dependent on bathingReview of the task list reflected that R98's shower days were scheduled for Wednesdays and Saturday. The past thirty days revealed that R98 had only received bed baths in the past 30 days and zero showers.On 03/10/2026 at 12:14 PM, Director of Nursing (DON) B stated that Activity of Daily living care should be being completed on residents. When queried on showers, DON B reviewed the documentation for R98's ADL'S and was unable to find any refusals. DON B attempted to locate a preference for bed baths vs. showers in the care plan but could not locate that in the care plan either.

Based on observation, interview and record review the facility failed to ensure consistent availability of water at the bedside, failed to ensure hydration was offered, and failed to document fluid intake in one (resident 98) of 2 reviewed for hydration. Findings include.Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his bedside table with a handwritten date of 3/6/26 PM that contained about 1/4 of water. R98 had an unpleasant body odor coming from him that indicated that he had not been bathed in quite some time. He has a very unkempt appearance. R98's lips appeared very dry and chapped. R98's toenails were very overgrown. R98's push button call light was clipped to his curtain on his right side and out of reach. I introduced myself to R98 and explained the purpose of my visit, however, R98 did not verbally respond. I continued to make conversation and discovered that R98 understood what I was saying but could not verbalize back to me but could answer by nodding yes or shaking his head no. R98 could answer questions appropriately. When asked about details such as the surroundings or details such as the colors of the clothing I was wearing, R98 answered the questions appropriately. I inquired if R98 was warm and he nodded his head yes. When asked if he had been receiving showers, he shook his head and stated no no no. When asked if he would like a shower, he nodded yes. When asked if he would like to have his face shaved and a haircut, he nodded yes. When asked if he was thirsty, he enthusiastically nodded his head yes. When asked if he could hold a cup and give himself drinks of water, he stated, no no no and raised and lowered his left arm. I observed his left hand and R98's fingers were on a fixed, fanned out position. When asked if he required assistance with eating and drinking, he nodded yes. When inquired how he requested assistance from staff, he shrugged his shoulders. When asked how he communicated his needs to staff, he shrugged his shoulders again. When asked if he used a communication board with pictures, he stated 'no, no, no. When I attempted to leave the room, R98 appeared frantic and looked at the empty Styrofoam cup of water on the bedside table and stated no no no. I asked him if he was thirsty and he nodded yes. I provided him with staff assistance. Review of a Psychiatric note dated 11/10/25 revealed that R98 was able to shake his head to answer simple questions. On 03/09/2026 2:56 PM, R98 was observed in bed in the exact same position. R98's push button call light was positioned on his chest. I inquired if R98 could demonstrate using his call light. R98 looked at me and again showed me that he could only raise and lower his left arm, and his fingers were fixed in a fanned-out position. On 03/10/2026 at 7:57 AM, R98 was observed in his room. R98 was lying flat on his back with his heels not floated. LPN J entered the room and stated that it was hot in the room. A full, room temperature Styrofoam cup of water dated 3/10 22:00 (10:00 pm) was observed on his bedside table with no straw in it. On 03/09/2026 at 3:02 PM, Certified Nursing Assistant (CNA) G stated she is not sure if he can use his call light but it is clipped on to him. On 03/10/2026 at 9:58 AM, CNA stated that R98 cannot use the call light.Review of the MDS Section GG- Functional Abilities- revealed R98 was dependent on staff for bringing food or liquid to R98's mouth.Review of R98's Electronic Medical Record revealed no consistent documentation or monitoring for fluid intake.On 03/10/2026 at 11:23 AM, Unit Manager (UM) I stated that R98 communicates by nodding yes or no or by using the communication board. When queried where the communication board currently was in R98's room, UM I informed me that it was not in his room. R98's call light was observed clipped to the top of his mattress on the right side (his affected side) during the interview. I inquired how R98 notifies staff if he requires assistance. UM I proceeded to unclip the out of reach call light and place it in R98's hand. I asked R98 to demonstrate using the call light. R98 looked at me and again, raised and lowered his arm stating no no no. i asked R98 if he could use the call light and he shook his head to indicate that he was unable to use the push button call light which was obvious due to his left sided functional limitations. When asked how the facility monitors hydration statuses and ensures that R98 is being offered fluids, UM I stated that staff document fluid intake and offer fluids. I held up the full, room temperature water that contained no straw dated 3/10 22:00 and asked R98 if that was his water from last night. R98 nodded yes. I asked R98 if he had anything to drink last night. R98 nodded no. I asked if R98 was thirsty and he indicated that he was thirsty. In an interview on 03/10/2026 at 12:14 PM Director of Nursing (DON) B stated that the facility staff should be offering fluids to the dependent residents every two hours and documenting fluid intake in the medical record.The observed lack of consistent fresh water/full old water at the bedside and incomplete documentation of fluid intake limited the facilities ability to monitor R98's hydration status.

Based on observation, interview, and record review, the facility failed to ensure residents receive necessary respiratory care and services that was in accordance with professional standards of practice for 1 (Resident #41) of 1 resident reviewed for respiratory care resulting in the potential for respiratory distress and exacerbation of respiratory conditions. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) with a Assessment Reference Date(ARD) of 1/26/26, reflected R41 was a [AGE] year-old female admitted to the facility on [DATE], with recent re-admission 1/9/26 related to acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis (dangerous, altered mental state caused by severe accumulation of carbon dioxide in the blood) and sleep apnea. R41 had other diagnoses that included morbid obesity, chronic obstructive pulmonary disease, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression. The MDS reflected that R41 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact.Review of R41 History and Physical, dated 1/4/26, reflected that R41 had been transferred to the hospital from the facility with diagnosis that included community acquired pneumonia. Continued review reflected R41 had diagnosis that included obesity hypoventilation syndrome ([NAME]).During an observation and interview on 3/08/2026 at 10:00 AM, R41 was lying in bed in hospital gown with oxygen via nasal canula in place. R41 appeared depressed and repeated several times, I do not know how much longer I can stand this. When asked what she meant by that R41 reported was very unhappy with her stay at the facility including care and current guardianship issues. R41 son was at the bedside and appeared to be supportive to R41. R41 reported had lived at the facility for about six months after a very long hospital stay related to decline in health. R41 reported had two recent hospital transfers related to pneumonia and respiratory failure in January, and hospital had discharged her with orders to continue to use Bi-level Positive Airway Pressure (BIPAP) machine and had not used since January because staff to do not assist her with it. Verified machine was located in R41's closet. R41 reported to facility staff and provider that BIPAP needed to be used at night but continues to not use. R41 reported was aware of risks of not using ordered BIPAP and reported labs had been abnormal related to not BIPAP and reported was worried health would decline again and would never be able to discharge from facility. Review of the Electronic Medical Record (EMR) reflected R41 was transferred to the hospital on 1/4/26 and returned to the facility on 1/5/26 with diagnosis of pneumonia. Continued review reflected R41 transferred back to the hospital on 1/6/26 related to acute on chronic respiratory failure with hypoxia and hypercapnia and CO2 narcosis and returned to the facility on 1/9/26.Review of R41 Hospital After Visit Summary, dated 1/9/26, reflected, 71 y.o. [year old] cis-gender female admitted with Altered mental status, unspecified altered mental status type.This seems to be related to hypercapnia [excess of carbon dioxide]. This resolved with the BIPAP.It is stressed that the patient needs to have her BiPAP for when she sleeps and naps.Plan.Continue BiPAP when napping and sleeping. Review of the Hospital Labs, dated 1/6/26, reflected R41's venous CO2 was significantly elevated to 76 mmHg with normal range between 34-50 mmHg (indicating a potential emergency including respiratory failure.)Review of R41 Care Plans, dated 10/23/25, reflected, Resident has potential for difficulty in breathing r/t [related to] CHF [chronic heart failure], COPD, chronic respiratory failure, OSA [obstructive sleep apnea] and requires use of BiPAP.Interventions BiPAP per MD [medical doctor] order.Review of R41 Physician Orders, dated 10/23/25 through 1/5/26, reflected orders for BIPAP at bedtime on at night. Continued review of Physician orders with no evidence of orders for use of BIPAP after 1/9/26 return from the hospital to current (3/8/26). Review of the Medication Administration Record (MAR) and Treatment Administration Records (TAR), date 1/1/26 through 1/4/26, reflected R41 had orders for use of BIPAP every night. Continued review of the MAR and TAR, dated 1/9/26 to 3/8/26 reflected no evidence of BIPAP used for R41. (Two months without use of Physician ordered BIPAP). During an interview on 3/10/2026 at 11:36 AM, Assistant Director of Nursing (ADON) C verified R41 was admitted to the hospital on [DATE] and 1/6/26 related to pneumonia and respiratory issues and verified R41 had history of COPD with use of BIPAP. ADON C reported R41 had Physician orders for BIPAP prior to 1/4/26 transfer to the hospital with hospital discharge orders to continue use and reported appeared R41 BIPAP was not re-ordered when re-admitted on [DATE] and should have been. ADON C verified R41 did not have a physician order for BIPAP after 1/9/26 hospital admission, however, was on R41 Care Plan, dated prior to 1/4/26 transfer to the hospital. ADON C reported was most likely a transcription error. During an interview on 3/10/2026 at 12:48 PM, ADON C reported located R41 BIPAP machine and supplies in the closet and was currently working on setting up equipment. During an interview on 3/10/2026 at 2:21 PM, ADON C reported would expect staff to recognize if R41 had prior order BIPAP when she returned to the facility from hospital to re-order and/or double check hospital discharge summary and Unit Managers expected to verify orders as well. ADON C reported and verified R41 use of BIPAP was now in place moving forward.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and not falsified for one (R135) of 24. Findings include:Review of the medical record revealed R135 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. Review of the Social Services Comprehensive Evaluation dated 3/4/26 revealed R135 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 3/3/26 revealed Wound Care (L [left] posterior leg): cleanse [with] normal saline, apply Medihoney (Activon) to wound bed, cover with foam dressing. The wound care was ordered to be completed every evening shift, every other day. On 03/08/2026 at 10:13 AM, R135 was observed sitting on the edge of his bed. R135 reported he had a wound on the back of his left calf, but the facility had not changed the dressing since 3/2/26 or 3/3/26. R135 pulled up his pant leg and a dressing dated 3/3/26 was observed on his left calf. R135 reported he had his own wound care supplies from the hospital, but the facility removed the supplies from his room when he was admitted . On 03/09/2026 at 1:38 PM R135 was observed self-ambulating in the hallway. R135 reported his wound care still had not been completed. On 03/09/2026 at 1:47 PM, R135's left calf dressing was observed to be the same dressing dated 3/3/26. Review of Treatment Administration Record (TAR) revealed R135's wound care was checked off and signed out as completed on 3/4/26 by Licensed Practical Nurse (LPN) L, on 3/6/26 by LPN M, and on 3/8/26 by LPN N. In an interview on 03/09/2026 at 2:13 PM, Registered Nurse (RN)/Unit Manager (UM) I reported R135 had a wound on his left calf which was caused by his walking boot. UM I reported she monitored if wound care was completed as ordered by reviewing the TAR and progress notes. UM I reviewed R135's TAR and reported the check mark with initials indicated the wound care was completed. UM I reported if the wound care was not completed, the TAR would reflect a code 9 and then have a coordinating progress note. On 03/09/2026 at 2:17 PM, with UM I, R135 was observed in bed. R135's bandage was observed with the date of 3/3/26. UM I agreed R135's dressing was dated 3/3/26 and therefore had not been changed since then. On 03/09/2026 at 2:49 PM, UM I changed R135's dressing to which he responded, It's about time. R135's wound was observed as an open area with a red wound bed and drainage on the removed dressing. In a telephone interview on 03/09/2026 at 1:56 PM, LPN N reported she worked with R135 last night (3/8/26). LPN N reported R135 did have ordered wound care, but she could not recall if she completed the wound care on 3/8/26. When asked why it was checked off and signed off as completed on the TAR, LPN L then reported she did the wound care. When informed that R135's dressing was dated 3/3/26, LPN N then reported she knows she did a dressing last night but could not recall if it was for R135. LPN N reported she did not know why the wound care was signed out as completed but not done. In a telephone interview on 03/10/2026 at 11:14 AM, LPN L reported they worked on 3/4/26, but could not recall R135. When asked if she performed any wound care that day, LPN L reported she changed a dressing on another resident's heel. When asked if she performed any wound care/changed a dressing on the back of a resident's calf, LPN L stated, No. When asked what a check mark and their initials reflected on the TAR, LPN L reported that indicated the wound care was done. LPN L reported if the wound care was not done, the TAR would indicate a special code and then she would make a progress note. When asked why the TAR reflected R135's wound care was completed when it was not, LPN L stated, maybe I checked it off. Review of R135's progress notes revealed no indication as to why wound care was not completed on 3/4/26, 3/6/26, or 3/8/26. In an interview on 03/10/2026 at 10:54 AM, Director of Nursing (DON) B reported LPN L, LPN M, and LPN N did not follow the physician's orders for R135's wound care. DON B reported there was no reason as to why the wound care should be signed out as completed but not done. DON B reported she was in the process of educating the nursing staff related to this concern. In an interview on 03/10/26 at 11:02 AM, LPN M reported she was not sure if R135 had any ordered wound care. LPN M reported if the TAR showed a check mark and her initials, then she would assume the wound care was completed. When she was informed that R135's dressing was dated 3/3/26, LPN M reported R135 mentioned that to her yesterday. LPN M reported since R135's dressing was dated 3/3/26, she probably did not do his wound care on 3/6/26. Review of the personnel files revealed that previously each of the nurses LPN N, LPN M and LPN L had falsified medical records: LPN N received an Employee Discipline Form for documenting that a catheter change was performed, but it was not completed on 1-20-25. LPN L received an Employee Discipline Form for not completing skin evaluations and falsified documentation on 10/20/23. LPN M received a Corrective Action for Minor Offenses for documenting wound care as completed but not dated for 3/6/26.

Based on observation and interview, the facility failed to provide a functional window for one (Resident #98) out of 2 reviewed for environment. Findings include: Review of the medical record reflected R98 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included apraxia following cerebral infarction (inability to make voluntary movements or gestures even though you have the physical ability and understanding to do so), dysarthria (motor speech disorder where damage to your nervous system causes the muscles that produce speech to become paralyzed or weakened) and weakness/paralysis affecting the right dominant side following a stroke. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/16/26, reflected R98 was rarely or never understood. On 03/08/2026 at 10:28 AM, Resident #98 (R98) was observed in his room wearing only an adult brief, lying flat on his back, heels not elevated off the mattress. R98's room was very warm. R98 had a Styrofoam cup on his bedside table with a handwritten date of 3/6/26 PM that contained about 1/4 of water. R98 had an unpleasant body odor coming from him that indicated that he had not been bathed in quite some time. He has a very unkempt appearance. R98's lips appeared very dry and chapped. R98's toenails were very overgrown. R98's push button call light was clipped to his curtain on his right side and out of reach. I introduced myself to R98 and explained the purpose of my visit, however, R98 did not verbally respond. I continued to make conversation and discovered that R98 understood what I was saying but could not verbalize back to me but could answer by nodding yes or shaking his head no. R98 could answer questions appropriately. When asked about details such as the surroundings or details such as the colors of the clothing I was wearing, R98 answered the questions appropriately. I inquired if R98 was warm and he nodded his head yes. When asked if he had been receiving showers, he shook his head and stated no no no. When asked if he would like a shower, he nodded yes. When asked if he would like to have his face shaved and a haircut, he nodded yes. When asked if he was thirsty, he enthusiastically nodded his head yes. When asked if he could hold a cup and give himself drinks of water, he stated, no no no and raised and lowered his left arm. I observed his left hand and R98's fingers were on a fixed, fanned out position. When asked if he required assistance with eating and drinking, he nodded yes. When inquired how he requested assistance from staff, he shrugged his shoulders. When asked how he communicated his needs to staff, he shrugged his shoulders again. When asked if he used a communication board with pictures, he stated 'no, no, no. When I attempted to leave the room, R98 appeared frantic and looked at the empty Styrofoam cup of water on the bedside table and stated no no no. I asked him if he was thirsty and he nodded yes. I provided him with staff assistance. Review of a Psychiatric note dated 11/10/25 revealed that R98 was able to shake his head to answer simple questions. On 03/10/2026 at 7:57 AM, R98 was observed in his room. R98 was lying flat on his back with his heels not floated. LPN J entered the room and stated that it was hot in the room. A full, room temperature Styrofoam cup of water dated 3/10 22:00 (10:00 pm) was observed on his bedside table with no straw in it. On 03/08/2026 at 10:28 AM duct tape was observed applied on the perimeter of the window preventing it from being opened or cracked, effectively sealing it shut. The room continued to feel room very warm. I asked R98 if he was warm and he nodded his head, yes. On 03/10/2026 at 9:20 AM, eight months of requested work order requests forR98's room revealed no work order pertaining to the window. On 03/10/2026 at 9:34 AM, Maintenance P Stated that the purpose of the duct tape on the window was to because when the temperatures were low, the window was drafty causing the cold to come in. Maintenance P stated that the facility intended to get some window people out to repair the windows. Of note, on 3/9/26 the high temperature was 72 degrees. It is reasonable to believe that R98 would have enjoyed being able to crack the window to enjoy cooler room temperatures and fresh air.

This citation pertains to Intake # 2589332.Based on interview and record review the facility failed to immediately assess and notify the physician and responsible party of a fall with major injury for one Resident (#3) of three reviewed.Findings include:Review of the clinical record revealed Resident 3 (R3) was admitted to the facility on [DATE] and transferred to the hospital on 8/6/20 where a fractured right hip was discovered. Further review of the clinical record scored 13 out of 15 on the Brief Interview for Mental Status. There was no documentation in the clinical record on 8/5/26 that indicated R3 had a fall. A late entry nursing progress note dated 8/07/25 revealed that on 8/5/25 R3 was observed sitting next to his bed and R3 was unable to articulate what happened. Licensed Practical Nurse (LPN) N and Certified Nursing Assistant (CNA) O placed R3 back to bed. LPN N documented R3 had no injuries, no pain and that a body assessment was conducted. There was no notation that R3's physician or Responsible party had been notified on 8/05/25 of the incident. Further review of the clinical record there was no documentation that range of motion to any extremities was assessed, no documentation regarding neuroglial checks. Review of Occupational Therapy Notes dated 8/06/25 revealed R3 was complaining of right hip and told the therapist that he fell the day before. Therapy had notified nursing. Nursing note dated 8/06/25 reflected nursing was notified by therapy that R3 reported he fell the day prior and had complaints of right hip pain. R3 guardian came to visit on 8/6/25 and was notified about R3's fall from R3's roommate. R3's guardian went to talk to Administration and requested R3 to be sent to the hospital immediately. Review of R3 fall investigation which included hospital records, revealed R3 sustained a right hip fracture that required surgical repair. On 8/20/25 at 9:25 am during an interview with Assistant Director of Nursing (ADON) C she reported nobody was aware that R3 fell until Therapy had notified her. LPN N was aware but forgot to document it and pass the information along. When queried why the Physician and Responsible party wasn't notified until the day after the fall, ADON C stated they had just found out and had not had a chance to contact them before R3's roommate told the Responsible party/guardian. On 8/20/25 at 12:01pm during a phone interview with LPN N she reported she observed R3 on the floor on his right side about 4:00pm on 8/05/2025. LPN N stated she helped R3 into bed and thought R3 was fine. When queried about assessment, LPN N stated R3 denied pain and neuro checks were initiated but wasn't sure if they were documented, LPN N also stated a body check was done and was ok when asked to elaborate about a body check, LPN N stated she looked over R3's body for cuts. abrasions, bruises. When queried if any type of range of motion had been done LPN N stated no. When queried why she did not notify R3's physician and Responsible party/guardian, LPN N stated didn't have a reason, she just didn't. On 8/20/25 at 11:50am during an interview with the Director of Nursing (DON) B she reported the expectation was that after a fall or any type of incident once the resident was fully assessed and safe the physician and responsible party were to be notified.

Based on observation, interview and record review, the facility failed to ensure hot liquid/food was served at a safe and appropriate temperature for one (Resident #101) of three reviewed for accident hazards, resulting in second-degree thermal burn (damage to outer and second layer of skin, causing blisters, pain and discoloration) on R101 abdomen, groin and right inner thigh, open wounds and increased risk for infection. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, cerebral infarct with hemiplegia affecting right dominant side, hypertension (high blood pressure), chronic kidney disease requiring dialysis, heart failure, atrial fibrillation (irregular heart rate), kidney cancer with removal and weakness. The MDS reflected R101 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set-up assist with eating, dependent on staff for dressing, toileting, transferring and bed mobility, and maximal assist (helper does more than half the effort) with hygiene and bathing. Review of the Facility Reported Incident (FRI) report, dated 12/18/24, reflected R101 was his own responsible party. Continued review reflected, On the evening on 12/17/24 at approximately 2045[8:45 p.m.] [R101 initials] asked for CNA to warm up a food item for him (cup of noodles). CNA warmed up the item in the microwave for 3-4 minutes per the residents request and then returned the food item to him and set up per resident request while he was in the bed. The resident was allowing the food to cool down when he reached to throw a napkin away in the trash and he accidentally knocked the food over onto himself . Review of R101 Skin Progress Note, dated 12/17/24 at 8:52 p.m., reflected, Resident has NEW skin issue(s) observed. 1 Abdomen - Open skin wound, Right thigh (front) -Burn skin . Review of R101 Nursing Progress Note, dated 12/17/24 at 8:55 p.m., reflected, Resident accidentally poured hot noodle on himself while eating in bed, and got burned-out with hot noodle. First aids provided, and resident was educated to avoid eating hot meals in bed. Review of R101 Care Plan, dated 4/10/24 through current (1/8/25), reflected interventions that included, Dining: Resident is independent. Requests assistance at times. Setup as needed. Review of R101 Skin Incident Report, dated 12/18/24 at 12:52 p.m. (over 15 hours after incident), reflected nurse description, Resident was eating cup bowl of noodles, in the action of throwing something away, resident mistakenly knocked off meal unto lap which contained hot liquid. The form included resident description, Resident able to verify and tell how he burned himself. The form included, Injuries observed at time of incident including abdomen, groin and right thigh. The incident report reflected the Physician, Director of Nursing, Nursing Home Administrator and family member were notified 12/18/24 at 2:02 p.m.(over 15 hours after burn incident). Review of R101 Interdisciplinary resident screen, dated 12/24/24, reflected R101 preferred to eat meals with plate on lab. Continued review reflected recommend over the lap tray when in bed with scoop plate and bowl with suction cup for safety with feeding self. During an interview on 1/8/25 at 12:50 p.m. Director of Nursing (DON) B and Nursing Home Administrator (NHA) A reported the FRI for R101 was reported to the State of Michigan on 12/18/24 and immediate plan of correction was implemented. NHA A reported Certified Nurse Aid did not check food temperature after heating R101 single serving of noodles prior to giving to R101 on 12/17/24 that caused burns to R101 abdomen, groin and thigh. NHA A reported there was not a thermometer available for staff to use at that time. NHA A reported the risk to residents was immediately removed 12/18/24 and the facility alleged compliance date was 12/26/24. NHA A reported the facility failed to follow facility reheating policy. DON B was unable to say what was expected of staff for immediate burn treatment other than to remove the source and was unsure if facility had policy to address. Review of R101 facility Skin Observation, dated 12/17/24 at 8:52 p.m., reflected new wound that included open skin wound to abdomen and burn to right thigh. Review of R101 Nursing Progress Note, dated 12/18/24 at 11:14 a.m., reflected, Followed up with patient skin incident to lower right abdomen, right thigh and right groin. Abdomen dermis layer of skin off, pink tissue observed, no drainage or bleeding. Right thigh and groin, blister observed, dark areas surround blister sites. Patient report minimum pain. Areas will remain open to air with aloe vera gel applied to them 3x a day. Patient aware of treatment in place. Patient aware of what occurred in incident and able to tell writer what happened. Patient able to handle hot liquids with no barriers. MD notified. Monitoring in place. Review of R101 Wound Care Consult, dated 12/20/24, reflected, Wound Assessment(s) Wound #1 Right Groin is an acute Partial Thickness Burn 2nd Degree .Initial wound encounter measurements are 4cm length x 4 cm width with no measurable depth, with an area of 16 sq cm .The wound margin is undefined Wound bed has no, granulation; no slough, eschar and no epithelialization present .fluid filled intact blister . Wound #2 Abdomen - RLQ [right lower quadrant] is an acute Partial Thickness Burn 2nd Degree .Subsequent wound encounter measurements are 8cm length x 3cm width x 0.1 cm depth, with an area of 24 sq cm and volume of 2.4 cubic cm .There is moderate amount of serous drainage noted which has no odor .The wound margin is undefined Wound bed has 100%, pink, granulation . Wound #3 Right Thigh is an acute Partial Thickness Burn 2nd Degree .Initial wound encounter measurements are 8cm x 6cm with no measurable depth, with an area of 48 sq cm .The wound margin is attached to wound base .fluid filled intact blister . Plan .Wound Cleansing Cleanse wound with Normal Saline Treatments Apply Silvadine (on ABD direct) QDay/PRN[every day and/or as needed]-Right groin, abdomen, right thigh .Secondary Dressing . Review of R101 Physician orders, dated 12/18/24 through 12/27/24, reflected, Apply aloe vera gel to lower abdomen, right groin, and right thigh every shift[three times daily] for wound care. Continued review of R101 Physician orders, dated 12/21/24 through 1/6/25, reflected, Apply silver sulfadiazine to abdomen, right thigh and groin and cover with clean dry dressing every evening shift for burn. Review of the Medication Administration Record (MAR), dated 12/1/24 through 12/31/24, reflected R101 received both aloe vera gel treatment three times daily to three burn areas and silver sulfadiazine every day on 12/20/24 and 12/21/24. Review of R101 Nursing Progress Note, dated 12/21/24 at 11:40 p.m., reflected, At approximately (21:30) treatment was completed on resident burn area. Resident called the nurse and requested for the cream wiped off, upon checking the area, a whitish looking like lotion was on the areas of the burn, that did not match the previous ointment applied to the area, upon querying the resident, a cream Dermasil was noted on the bed and open. Resident asked if he had applied the cream and he did not respond and as the writer cleaned up the sites, resident called 911 stating that the cream had entered his blood stream. [Named ambulance service] arrived, report was given to the attendants. Review of R101 Nurse Progress Note, dated 12/22/24, reflected, Wound care in place from ER visit, and to be kept for one week. Review of the Nurse Progress Note, dated 12/30/24, reflected, Resident burn sites cleansed with normal saline, resident refused for silver to be applied to sites. Collagen with silver material placed over sites with clean dry dressing to cover. Patient reported minimum pain during dressing change. Abdomen site pink and slightly moist. R[right] groin pink/red and moist. R thigh white and moist, no sloth, later of epidermis seen. Review of the facility Wound Assessment Details, dated 12/30/24, reflected R101 had a facility acquired thermal heat partial thickness 2nd degree burn to groin area that measured 5 cm length x 5 cm width with no depth with moderate amount serosanguineous drainage. Continued review of the document reflected the wound was 70% bright pink or red and 30% loose slough with 1/10 pain. Continued review of the document included pictures, dated 12/30/24 at 6:44 a.m., that appeared to have depth to wound (not reflected on assessment.) Review of the facility Wound Assessment Details, dated 12/30/24 at 6:43 a.m., reflected R101 had a facility acquired thermal heat partial thickness 1st degree burn to abdomen that measured 8 cm length x 4 cm width with no depth with scant serous drainage. Continued review of the assessment reflected the wound was 100% bright pink or red. Review of the facility Wound Assessment Details, dated 12/30/24 at 6:54 a.m., reflected R101 had a facility acquired thermal heat full thickness 2nd degree burn to right thigh that measured 8 cm length x 8 cm width x 0 depth with light serous drainage. Continued review of the assessment reflected 100% pale pink or red epithelial tissue. Continued review included pictures that appeared to be 80% pale/white area of slough (non-viable tissue). Review of the Burn Clinic Consult note, dated 1/6/25, reflected R101 abdomen burn had healed and thigh and groin wound had some eschar on wounds with no signs of infection. Continued review of the note reflected SSD[silver sulfadiazine] daily to groin and thigh burns and follow up with burn unit in one week. Review of R101 facility Wound Assessment Details, dated 1/8/25, reflected the following: ~Groin burn wound-5 cm x 5 cm x 0 cm with 60% red/pink tissue and 40% slough. Review of picture wound bed appeared to have black eschar(dead skin). ~Abdomen burn-healed. ~Right Thigh burn-7 cm x 7 cm x 0 cm with 50% epithelial and 50% slough. Review of picture wound bed appeared to have about 80% yellow slough. During a telephone interview on 1/8/25 at 1:50 p.m., Licensed Practical Nurse(LPN) C reported worked part time at facility and was not working at time of R101 burn. LPN C reported was educated prior to returning to the floor that microwaves had been removed from floors and if residents request for food to be heated/reheated to use microwave in staff breakroom. LPN C reported staff were educated on Heating/Reheating Policy including to check temperature of food prior to giving to residents. LPN C reported had not received education related to Heat/Reheating food prior to R101 incident including new hire education in November of 2024. LPN C reported did not receive education related to immediate response for burn treatment and was unaware of facility had policy. During a telephone interview on 1/8/25 at 2:12 p.m., Certified Nurse Aid(CNA) D reported was made aware of R101 burn incident about a week after when education was received that microwaves had been removed from the each floor and moved to staff breakroom. CNA D reported educated that if residents request food be heated/reheated staff must check the temperature prior to serving to resident. CNA D reported was unsure what temperature to serve resident food or of what the facility policy was. CNA D reported temperatures should be on each resident chart. CNA D reported was a new hire in November 2024 and did not receive education for heating/reheating food at that time. During a telephone interview on 1/8/25 at 2:34 p.m., CNA E reported was not working at the time of R101 incident. CNA E reported was educated upon returned that microwaves had been removed from floors and relocated to staff breakroom. CNA E reported education included heating/reheating resident food including staff required to temp food after heating and policy was on microwave and thermometer was available. CNA E reported R101's hands are stiff and often spilled food so seemed like common sense not to serve hot food in bed. CNA E reported often worked with R101 and had seen burn wounds and R101 had complained of pain at wound sites. CNA E reported R101 would remind CNA E to be careful of burn areas with care and positioning related to pain. CNA E reported did not receive education related to immediate care for burn. During an interview on 1/8/25 at 3:46 p.m., Registered Nurse (RN) H reported was told by CNA I R101 had spilled noodles on himself 9:00 p.m. during medication pass. RN H reported was unsure when R101 spilled food on self but reported immediately went to R101 room and found R101 laying in bed and R101 told her he had spilled hot noodle in lap. RN H reported R101 did not have cloths on and was covered with sheet with no evidence of wet sheet or noodles on R101 and reported was unsure if CNA I had changed sheets. RN H reported R101 reported burned right thigh and abdomen and completed skin assessment. RN H reported R101 was African American and difficult to see if any red areas. RN H reported patted area with damp washcloth, applied petroleum jelly and ABD dressing, and called Nurse Manager J. RN H reported R101 did not report pain and areas were not open. When asked about Skin assessment completed on 12/17/24 for RN H that indicated open abdominal would, RN H reported she did not recall. RN H reported had not received education from facility about heating/reheating food for residents prior to incident but facility provided after. RN H reported did not Notify Physician, Nursing Home Administrator or Director of Nursing. During a telephone interview on 1/8/25 at 4:19 p.m., Nurse Manager J reported was notified by RN H about R101 burn to right thigh and abdomen on the evening of 12/17/24 after she had gone to bed and was unsure of time. Nurse Manager J reported RN H applied normal saline and first aid at the time of the burn. When asked how she knew what RN H did for first aid, Nurse Manager J reported she did not tell her what to do but nurses are trained to clean with normal saline and perform first aid. Nurse Manager J reported observed R101 burn area 12/18/24 with blister noted to right thigh and groin and open skin to abdomen. Nurse Manager J reported would expect staff to perform first aid, contact physician, manager, and Director of Nursing and document in progress notes. Nurse Manager J reported received education 12/18/24 about facility reheating policy and had not received prior. During an observation and interview on 1/8/25 at 5:00 p.m., R101 was laying in bed and appeared able to answer questions without difficulty. R101 reported had burned self with hot noodle soup few weeks prior. R101 reported had own personal single cups of noodle soup and asked CNA I to heat up. R101 reported CNA I brought back to him and placed on hand held mirror in between legs in the bed. R101 reported was too hot so was letting cool down when he accidentally spilled and burned right inner thigh and abdomen area and groin area. R101 reported fortunately groin area was mostly protected by brief because that is a sensitive area. R101 reported he yelled out because it hurt when the soup spilled and used call light to alert staff and reported 10/10 pain on pain scale at time. R101 reported he immediately removed covers but had already burned skin and CNA I answered call light within about two minutes. R101 reported told CNA I what happened she notified RN H who looked at area and covered with dressings. R101 reported at no time did anyone place normal saline or cool cloths on areas. R101 reported no one else looked at burned areas until the next day. R101 reported he told CNA and nurses he had pain and stated, of course that hurt, it is a sensitive area. I told everyone that came in to look at area it hurt. R101 skin tone is black with area on abdomen that appeared scared and healed about 8cm x 4 cm of pink skin. R101 reported on 12/21/24 staff were arguing who was going to complete treatments and R101 lost trust facility was caring for areas appropriately and called 911 and was taken to university burn unit who placed dressing to remain in place for one week. R101 reported facility staff then provided routine treatment after that and followed up with burn unit yesterday with improvements. During an observation on 1/8/25 at 5:20 p.m., observed two microwave in locked first floor breakroom. The facility Heating and Reheating Guidelines were located on the front of one microwave with thermometer and alcohol swabs in area. During an observation and interview on 1/9/25 at 9:50 a.m., R101 denied any concerns and reported planned to leave for dialysis soon. R101 reported staff had provided him with small tray with perimeter that appeared about 12 by 8 inches to use in lap if needed. R101 reported did not like to use bedside table related to mobility. During an observation on 1/9/25 at 10:10 a.m., the third floor pantry had sign on it to keep door locked. This surveyor opened unlocked door and verified no microwave was in pantry. During an interview on 1/9/25 at 10:15 a.m., Licensed Practical Nurse (LPN) L was asked to sign a form after R101 burn incident but was not familiar with R101. LPN L reported was told if heating/reheating resident food to do so in 1st floor breakroom, and not to serve too hot. When queried what was too hot, LPN L reported was unsure and stated, maybe use glove and touch. LPN L reported or lifted temporal thermometer off medication cart and stated, not sure if I should check with this. LPN L reported was unsure of facility policy and where to locate. Review with the facility in-service and, Reheating Foods and Liquids in the Microwave, on 1/9/25 at 10:54 a.m., reflected LPN L met requirements for reheating food/liquids on 12/20/24. Continued review of the FRI investigation reflected Quality Assurance and Performance Improvement (QAPI) past non-compliance sign in dated 12/24/24, did not included the Nursing Home Administrator (NHA) A, Director of Nursing (DON) B or the Medical Director signature. During a telephone interview on 1/9/25 at 11:12 a.m., CNA I reported had worked at the facility for over one year and was present at time of R101 burn incident on 12/17/24. CNA I reported R101 asked her to heat R101's personal single serving cup of [NAME] noodles for 4 minutes in the microwave. CNA I reported R101 requested staff to assist heat meals almost every night. CNA I reported after heating she placed towel on resident lab while laying in bed, with hand held mirror under towel as flat surface, and place cup of hot noodles on surface between R101 legs. CNA I reported R101 turned on light about 45 minutes to one hour later and told her he had spilt noodles on himself and thinks it caused burn. CNA I reported removed wet towel with few noodles on it and threw away empty cup of noodles. reported thinks he burn self. CNA I reported R101 did have open skin on abdomen R101 was pulling back skin. CNA I reported difficult to see if skin discolored because it was so ashy and dry. CNA I reported R101 appeared calm at the time and did not recall complaints of pain. CNA I reported sheet was wet that was on top of R101 and she changed sheet and R101 had brief on. CNA I reported she then exited R101 room and notified RN H what had happened and RN H went to R101. CNA I reported R101 told RN I what had happened, RN I looked at skin and R101 asked for bandaid and RN I told her it needed to dry out with no immediate fist aid observed, including cool compress. CNA I reported had not received prior education at facility for heating/reheating food and received education after R101 burn incident related to heating only not first aid for burns. CNA I reported shift ended on 12/17/24 at 11:00 p.m. and was unable to recall who shift report was given to and reported did not tell oncoming staff about R101 burn incident. CNA I reported did not provide any additional care for R101 on 12/17/24 between 9:00 p.m. and 11:00 p.m. Review of CNA I unsigned witness statement, dated 12/18/24, reflected CNA I saw noodles and liquid on floor when first entering R101 room when R101 reported had spilled soup on himself. CNA I reported management called her 12/18/24 on telephone for statement and did not say noodles and liquid were on the floor and had not seen statements. During an observation on 1/9/25 at 12:15 p.m., during meal service CNA filled coffee cup from insulated drink dispenser in 200 hall took to room [ROOM NUMBER] with no cover. During an observation on 1/9/25 at 12:17 p.m. the 300 pantry had sign posted on door keep door closed. Paper towel was stuffed in door lock to prevent door from locking. This surveyor opened door to pantry and verified no microwave in pantry and no call light. During an interview on 1/9/25 at 12:43 p.m., CNA M reported after resident was burned facility removed microwaves from all of the resident floors. If residents request to have food heated or reheated microwave is located in staff breakroom on first floor. CNA M reported staff should not serve residents food that is too hot. When ask what too hot meant CNA M was unable to answer and reported was unsure what facility policy was. During an interview on 1/9/25 at 1:04 p.m., Assistant Director of Nursing (ADON) O reported had been in position over two years. ADON O reported first heard about R101 burn from 12/17/24 on 12/18/24 at morning meeting after reviewing skin assessment completed by RN H. ADON O was queried what was first aid included for burn and ADON O reported first aid should included cool down area with cool water and non adhesive dressing. ADON O reported would expect staff to provided immediate first aid, notify nurse, who would notify physician, responsible party, DON, NHA for all events including burns and document at time of the event. ADON O reported complete R101 pain and skin assessment 12/18/24 and was first to contact R101 physician on 12/18/24. ADON O reported would not expect petroleum jelly to be used for acute burn treatment. During an interview on 1/9/25 at 2:19 p.m., Wound Nurse (WN) P reported had been in position for two years. WN P reported was notified of R101 burn wound on 12/18/24 and observed two blistered areas to right thigh and right groin and pink open skin to abdomen. WN P reported called R101 physician who ordered aloe vera jell from plant they got from local grocery store daily and not to cover unless out to dialysis. WN P reported would not expect staff to apply petroleum jelly to acute burn. WN P reported completed R101 skin incident/accident report on 12/18/24 that should have been completed at the time of the incident on 12/17/24. WN P reported prior to observing R101 on 12/18/24 had removed foam dressing from right thigh, groin and abdomen. WN P reported staff should have immediately cooled site by adding cool water. WN P would expect staff to immediately cool down burn site, while also notifying nurse, physician, DON and NHA because immediate change of condition. WN I reported R101 had orders for aloe vera three times daily from 12/18/24 until silvadene cream arrived that was ordered 12/20/24 and verified MAR reflected R101 received both between 12/20/24 and 12/21/24 until sent to emergency room . WN P verified R101 had dressing placed at hospital on 12/22/24 that remained in place for 7 days. WN P verified staff had documented R101 was provided dressing changes between 12/22/24 and 12/28/24, however, reported the MAR was not correct because R101 would not allow staff to remove dressing for the ordered 7 days. During an interview on 1/9/25 at 3:31 p.m., DON B and NHA A reported were first notified of R101 burn incident on 12/18/24 at morning meeting by ADON O. NHA A reported would have expected staff to notify them immediately of R101 burn. DON B reported would expect CNA to notify nurse immediately, who would assess, notify physician, DON, NHA and state of Michigan if needed. During an interview on 1/9/25 at 4:45 p.m. DON B reported facility had no evidence of prior education provided to staff for heating/reheating resident food before R101 incident. Review of the facility, Heating and Reheating Guidelines, dated 2/20/24, reflected, Purpose: The facility will ensure that resident personal food is handled in a safe and sanitary manner to prevent cross contamination and to minimize the risk of food borne illness. The facility will follow any manufactures instructions when preparing food .Guideline 1. Only trained facility staff are authorized to hear and reheat food for residents. 2. Items being heated reheated will be checked for use-be-date .3. Packaged foods will be heated and reheated to microwave following package instructions 4. For reheating precooked food items, microwave to internal temperature of 165 degrees for 15 seconds. 5. Allow heated and reheated food to sit for 2 minutes or according to the manufactures instructions prior to serving to the resident . Review of the facility, Accidents Policy, dated 6/29/21, reflected, Accidents refers to any unexpected or unintentional incident, which results or may result in injury of illness to a resident .Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident , including the need to supervision and/or assistive devices. Evaluate/analyze the hazards ad risks and eliminate them, if possible, identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and , if not reduce the risk of an accident . Review of the State of (State Name) Department of Community Health Alert, titled, Scalding Injuries Caused by Excessive Hot Water: Food and Hot Beverage Temperatures, Revised August 5, 2008, revealed, Background: In all age groups, tap water scald injuries have been cited as the second most cause of serious burns. A scald is a burn caused by spills, immersion, splash, or contact with hot water, food and beverages, or steam. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin also burns full depth (through the skin layers and into tissue) more quickly .Although Federal and State agencies do not specify temperatures appropriate to the consumption of hot beverages, facilities should be aware of the risk for harm to a resident from contact or consumption of hot beverages.Scalds can commonly occur from hot food, beverages, or steam . The estimated time for a person to receive second-degree burns was noted as follows: 120 degrees. Time to receive second-degree burn: 8 minutes. 124 degrees. Time to receive second-degree burn: 2 minutes. 131 degrees. Time to receive second-degree burn: 17 seconds 140 degrees. Time to receive second-degree burn: 3 seconds. 150 degrees. Time to receive second-degree burn: Less than one second. The facility put into place processes implemented to prevent further occurences. Utilizing the facilities guidelines on heating and reheating food/saftey of hot liquids. Monitoring was inititated with audits and results reported to Quality Assurance. The facility was determined to be in compliance with the action plan as of 12-26-24.

This citation includes to intake MI 905. Based on observation, interview, and record review the facility failed to properly prevent and contain Covid 19 infections for 39 residents (Resident #94, 100, 20, 75, 64, 266, 101, 22, 90, 41, 56, 84, 42, 43, 34, 2, 106, 87, 55, 81, 32, 416, 417, 36, 10, 85, 112, 11, 102, 31, 5, 70, 418, 264, 48, 104, 17, 38, 96) out of 114 residents, resulting in Immediate Jeopardy when the facility failed to appropriately implement infection control and prevention measures to control the spread of Covid 19, failed to properly cohort and isolate Covid 19 positive residents from Covid 19 negative residents (Resident #63, 414, 49) and 39 residents were identified to have tested positive for Covid 19 between the dates of 1/3/2022 and 1/21/2022 leading to Immediate Jeopardy. Findings Include: In an interview on 1/12/2022, at 1:38 PM, Infection Control Preventionist (ICP) C stated that she used a tracking tool to track Covid 19 residents and staff. ICP C stated she did not have any documentation of any audits, nor had identified the root cause for the recent spread of covid 19 infections in the facility. ICP C said she did perform donning and doffing (placing on and off respectively) of personal protective equipment (PPE) observations of the facility staff however, ICP C stated she did not have any documentation of those audits. ICP C said the only things she had implemented to stop the spread of the current Covid 19 outbreak was staff education and monitoring of resident vital signs and respiratory assessments. In another interview on 1/13/2022, at 10:58 AM, ICP C stated that when residents were tested for Covid 19 she was required to read the Covid 19 test results, but another nurse would document the results on a document that was then given to her and placed on her desk. S ICP C as not able to provide information or documentation of actions put into place for residents and/or staff who tested positive for Covid 19. ICP C stated that she referred to the Centers for Disease and Prevention (CDC) for the policies and procedures (PP) for Covid 19. Record review of the facility's Policy/Prodedure for Covid 19, titled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19), dated 3/26/2020 and revised on 12/27/2021, revealed under, Monitoring Activities and Surveillance, The following activities should be completed by the IP/designee (ICP): Record-keeping of the above activities to include mapping the area in the facility where symptoms are being identified, Review of PPE equipment that is currently available, with reordering items as necessary (eye/face shields, gowns, gloves, masks), Random observations of hand hygiene by staff to ensure appropriate technique is used, Random observations of staff donning/doffing appropriate PPE (standard, contact, and/or droplet),Random observations of environmental cleaning with approved EPA products of the high-touch areas In an observation on 1/26/2022, at 9:12 AM, Maintenance Assistant (MA) I was observed arriving at room [ROOM NUMBER] with a bed mattress on a wooden cart that also had a sheet on it. MA I was observed to place the mattress on its side onto the floor in the doorway of room [ROOM NUMBER] with no protective barrier between the mattress and the floor. room [ROOM NUMBER] was observed to be an isolation room that also had an over the door hanging pockets that contained PPE, including gloves and gowns. MA I was observed to enter room [ROOM NUMBER] with only an N95 mask and googles on. MA I did not put gloves or a gown on prior to entering room [ROOM NUMBER]. MA I was then observed to spray a cleaner onto the top of the mattress that was on a bed in room [ROOM NUMBER] next to the door were a resident had resided that tested positive for Covid 19 and had been recently moved to the fourth floor. MA I was then observed to remove the mattress from the bed, leave the room, did not wash, or sanitize his hands and placed the mattress on the wooden cart. MA I did not clean the sides or the bottom of the mattress and did not clean or sanitize the bed frame or anything else in the area of the bed situated by the room door. MA I was then observed to pick up the mattress that was on the floor, and re-enter room [ROOM NUMBER], again without donning a gown or gloves, and place the mattress on the bed, then exit room [ROOM NUMBER] without washing or sanitizing his hands. The sheet on the mattress MA I placed on the bed was observation to have dirt from the floor all over the side it. In an observation on 1/26/2022, at 9:21 AM, Certified Nurse Aid (CNA) J was observed to enter room [ROOM NUMBER] to retrieve breakfast trays from two residents who resided in that room. CNA J entered room [ROOM NUMBER] with only an N95 face mask and googles on. CNA J did not don gloves nor a gown prior to entering room [ROOM NUMBER]. CNA J stated that it was his second day back to work in the last two months, and stated that he was instructed by a nurse, who's name he could not recall, on Friday 1/21/2022, that if he was just to delivering food trays into the isolation rooms he only needed to wear goggles/face shields, and an N95 but did not need to don a gown or gloves, because putting gowns on took too long in between each isolation resident room, and the resident's food were getting cold before the trays were delivered. Of note, the observation made was of CNA J removing food trays from room [ROOM NUMBER] at the end of the meal, and not delivering them. CNA J was not observed to have washed or sanitized his hands upon entering or exiting room [ROOM NUMBER]. On 1/13/2022, at 12:19 PM, the Administrator was notified of the Immediate Jeopardy, that was identified on 1/13/2022 and determined beginning on 1/3/2022, when the facility failed to appropriately implement infection control and prevention measures to control the spread of Covid 19, failed to properly cohort and isolated Covid 19 positive residents from Covid 19 negative residents, and 31 residents were identified to have tested positive for Covid 19 between the dates of 1/3/2022 and 1/13/2022. On 1/19/2022 the facility provided an acceptable plan to remove the Immediate Jeopardy as follows: 1). On 01/13/2022 the 7 identified Covid negative residents were moved from the 4th floor and relocated to the non-covid units to prevent the spread of COVID -19 infection. 2). On 01/13/2022 the 14 identified unvaccinated residents who were exposed to positive residents and staff members have been placed under transmission-based droplet precautions. 3). All residents residing in the facility are at potential risk for the spread of infection related to improper PPE utilization. 4). All 113 residents were audited on 01/13/2022 by the Facility Management Team. a. The audit consisted of the Management Team assessing all COVID-19 positive and exposed resident as far back as 01/01/2022 when the first staff person was positive for COVID-19. On 01/13/2022 the 85 negative residents were tested for COVID-19. Of the 85 residents tested , 5 residents were positive. 3 of the new positive residents were already on the COVID-19 unit and in droplet precaution related to previous exposure. The 3 remained on the COVID-19 Unit to isolate in place. The other 2 new positive residents were from the second floor and already in droplet precautions related to previous exposure. The 2 residents were moved to the COVID-19 unit to isolate in place per CDC guidelines. 1 roommate on 2nd floor was exposed, but already on droplet precautions and will remain on droplet precautions per the CDC guidelines. 5). All 113 residents were audited by the Facility Management Team. b. The audit consisted of the Management Team reviewing the 14 unvaccinated residents who had exposure to positive COVID-19 residents and staff members as dating back to 01/01/2022 when the first staff person was positive to ensure that proper transmission-based precautions were implemented. 6). An audit of all 45 present employees was completed by 01/13/2022 by the Facility Management Team. c. The audit consisted of the Management Team assessing all facility staff to ensure they were appropriately donning and doffing gowns, and properly using face shields, goggles, and N95 to further prevent the spread of COVID-19 per CDC Guidelines. 7). All residents currently residing in the facility were audited on 01/13/2022 for infection surveillance to identify possible COVID-19 disease before the spread to others in the center. On 01/13/2022 in-service education was initiated for proper PPE utilization, surveillance, mapping and tracking for COVID-19 per CDC guidelines for Villa 107 building staff, including contracted therapy, contracted housekeeping/laundry, and contracted agency members. In-service's education ongoing. 8). On 01/13/2022 the Regional Vice President of Clinical Services educated the DON on appropriately cohorting COVID-19 positive and exposed residents per CDC guidelines. 9). On 01/13/2022 the Regional Vice President of Clinical Services educated the DON on system surveillance to identify possible COVID-19 disease and infections before they spread to others in the facility, line listing, mapping and tracking. 10). On 01/13/2022 the Regional Vice President of Clinical Services educated the DON on properly implementing transmission-based precautions on unvaccinated residents potentially exposed to positive employees and enforce the proper PPE utilization, surveillance, mapping and tracking for COVID-19 per CDC guidelines. 11). On 01/13/2022 the DON immediately in-serviced the ADON/Infection Preventionist on appropriately cohorting COVID-19 positive and exposed residents per CDC Guidelines. 12). On 01/13/2022 the DON immediately in-serviced the ADON/Infection Preventionist on system surveillance to identify possible COVID-19 disease and infections before they spread to others in the facility, line listing, mapping, and tracking. 13). On 01/13/2022 the DON immediately in-serviced the ADON/Infection Preventionist on properly implementing transmission-based precautions for unvaccinated residents exposed to positive employees per CDC Guidelines. 14). In-servicing for all staff was started on 01/13/2022 by the DON/Designee on appropriate use of gowns, goggles, face shields, and N95s. At this point 45 out of 107 have been in-serviced. Facility staff will not be able to work on the units until they have been in-serviced. 15). All new hires will receive training on the facilities practice on Transmission-Based Precautions and the proper use of PPE. 16). Daily monitoring is ongoing for residents and staff related to COVID-19 and testing per CDC guidelines. Although the Immediate Jeopardy was removed on 1/28/22 the facility remained out of compliance at a scope of isolated that is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency. In an interview on 1/12/2022 at 12:55 PM, Infection Control Preventionist (ICP) C stated Registered Nurse (RN) R called the facility on 1/01/22, reported symptoms of headache and sore throat that began in the morning on 1/01/22, and had tested positive for COVID-19. RN R had last worked at the facility on 12/31/21 and worked on the fourth floor. ICP C reported Resident #36 (R36) had symptoms of shortness of breath, tested positive for COVID-19 on 1/03/22, was transferred to the hospital and returned on 1/05/22; R36 resided on the fourth floor, had two roommates (Resident #10 & #85) that also tested positive for COVID-19 on 1/03/22. ICP C stated there were residents in rooms 406, 407, 410 and 412 that were COVID-19 positive, as of 1/10/22 and sharing the same room with residents negative for COVID-19; and planned to move the negative residents to different rooms on the same date of the interview. Residents in room [ROOM NUMBER] included Resident #22, that tested positive for COVID-19 on 1/10/22 and Resident #63, who was negative for COVID-19. Residents in room [ROOM NUMBER] were Resident #90, that tested positive for COVID-19 on 1/13/22; Resident #42 that tested positive for COVID-19 on 1/10/22; and Resident #264 that tested positive for COVID-19 on 1/18/22. Residents in room [ROOM NUMBER] included Resident #22 that tested positive for COVID-19 on 1/10/22 and Resident #414 that was negative for COVID-19. Residents in room [ROOM NUMBER] included Resident #96 that tested positive for COVID-19 on 1/10/22, Resident #84 that tested positive for COVID-19 on 1/11/22, and Resident #49 that was negative for COVID-19. According to lists provided during survey, the following additional residents tested positive for COVID-19 on 1/03/22: Resident #94, 64, 55, 81, 32, 416, 417, 85, 112, 11, 102, 31, 5, 70, and 418. The following additional residents tested positive for COVID-19 on 1/05/22: #266, 106, and 87. The following additional residents tested positive for COVID-19 on 1/10/22: Resident #101, 20, 75, 42, and 2. The following residents tested positive for COVID-19 on 1/11/22: Resident #41, 56, 84, 43, and 34. Additional Residents tested positive for COVID-19 on 1/13/22: Resident #43, 100, and 104. The following residents tested positive for COVID-19 on 1/18/22: Resident #63 and 17. Residents tested positive for COVID-19 on 1/21/22 were resident #38 and 48. In review of Resident #90's medical record, they tested positive for COVID-19 on 1/13/22, a care plan regarding COVID-19 positive status was not initiated until 1/18/22 and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/20/22 at 11:00 AM Licensed Practical Nurse (LPN) RR was observed standing in the doorway of room [ROOM NUMBER], talking to two residents that had tested positive for COVID-19. LPN RR was observed with her mask down under her nose. LPN RR' was interviewed on the same date and time and stated she used same mask and shield without cleaning when going into a resident's room that had not tested positive for COVID-19/status not confirmed, after providing care for COVID-19 positive residents. 1/20/22 at approximately 11:10 AM Certified Nurse Assistant (CNA) UU was observed donning a gown in the hallway and touched gown on floor when donning, continued to don, tied ties around neck, placed over head and then put arms through the sleeves, then tied around waist. CNA UU was observed wearing an N95 mask and face mask on over top of the N95. In an interview, CNA UU stated staff were instructed to wear both masks. CNA UU stated they put their N95 mask into a brown bag to re-use for a week. Licensed Practical Nurse/Unit Manager PP was interviewed on 1/20/22 at 11:15 AM and stated he didn't instruct staff to clean face shields between caring for residents that do not have the same infection. On 1/21/22 at 12:03 PM, unknown housekeeping staff member was observed coming out of the staff break room with an N95 mask hanging around his neck. Housekeeper staff member donned the N95 mask on face, did not perform hand hygiene and proceeded to get on the elevator. On 01/12/2022 at 9:45 am during the entrance conference, with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B, it was reported that the 4th floor of the facility was divided in 2 sections with fire doors separating the unit. DON B reported the South side of the 4th floor was where Covid positive residents were residing. On 01/12/22 at 10:35 AM upon exiting the elevator on the 4th floor Licensed Practical Nurse (LPN)RR was observed coming out of the closed fire doors LPN RR was not wearing a gown, proceeded to sit at the common nurses station without performing hand hygiene. When queried about the positive vs negative Covid side of the 4th floor, LPN RR Stated she thought the whole unit was positive for Covid. While standing at the 4th floor Nurses station, LPN/Unit Manager PP was observed entering a room without donning a gown and wearing a cloth mask. Unidentified Nurse on the North side of the 4th floor unit was observed at the medication cart and passed medications without donning a gown this too was observed by LPN/Unit Manager PP whom volunteered he would address Personal Protective Equipment (PPE) with the Nurse. LPN/Unit Manager PP was asked to clarify what NHA A and DON B had reported about the division of the hall which side was positive for Covid and what side was negative, LPN/Unit Manager PP reported the entire unit Pretty much was positive for Covid. On 01/13/2022 at 1:42pm, Resident #55 whom tested positive for Covid and resided on the 4th floor was observed exiting the service elevator on the main floor with an unidentified Dietary employee. R55 was observed to be barefoot and was not wearing a mask. At 1:50PM a female was observed in the 4th floor resident lounge, she was observed talking on a cell phone and had not donned any PPE including a mask, LPN PP reported the person in the resident lounge was a Certified Nursing Assistant (CNA) but she did not know her name. By 01/25/22 the facility had a N95 mask and face shield/goggles mandate in place for all care areas of the facility. At 12:49 pm Psychiatry group Social Worker X was observed on the second floor entering and exiting resident rooms without wearing a face shield or goggles. On 01/28/22 at 08:36 AM, LPN/Unit Manager PP and agency CNA JJ were observed sitting behind the 4th floor Nurses station, agency CNA OO was observed standing at the station, the 3 were carrying on a conversation for over 6 minutes with agency CNA OO 's mask being worn below her nose the entire time. During an interview on 1/12/22 at 12:55 PM, Infection Preventionist (IP) C reported Registered Nurse (RN) R called the facility on 1/1/22, reporting they had tested positive for COVID-19. RN R had last worked at the facility on 12/31/21. The facility's resident COVID-19 outbreak began on 1/3/22, with Resident #31 (R31). COVID-19 positive residents were moved to the fourth floor of the facility. At the time of the interview, IP C reported the facility had 28 residents in-house that were currently COVID-19 positive and an additional (29th) resident that had been sent to the hospital the day prior. IP C reported COVID-19 was spreading fast, and the entire fourth floor was under Transmission-Based Precautions (TBP) as of 1/10/22. According to IP C, a gown, N95 mask and face shield or goggles were required to enter rooms on the fourth floor. A N95 and face shield or goggles was required in the hallway of the fourth floor. During the interview on 1/12/22 at 12:55 PM, IP C did report there were four resident rooms that were housing both COVID-19 positive and COVID-19 negative residents in the room for the past two days, since the positive tests on 1/10/22. According to IP C, they made sure the residents were six feet apart and that the curtain was drawn until they could do room changes. IP C stated they were trying not to move anyone that had been exposed to COVID-19 to a different floor due to the rapid spread. According to IP C the Medical Director wanted them to keep the residents on one unit. IP C stated, It gets tight when we have to move anyone positive and exposed. IP C reported the Health Department encouraged them to move positive residents in with other positive residents and exposed residents in with other exposed residents. During an interview that began on 1/13/22 at 10:19 AM, IP C reported three residents had tested positive for COVID-19 on 1/11/22, but they had not been added to the facility line listing yet. IP C also reported that Nurse SS was not included on the staff line listing because they tested at home and not did not test at the facility. IP C was unsure of when Nurse SS had last worked at the facility or the date of their positive test. IP C stated Nurse SS worked on the third floor but wherever they were needed. IP C stated Nurse SS for sure worked on the third floor, but she would have to see where Nurse SS worked on other days (prior to their positive COVID-19 test). When asked what was implemented for residents after a staff member tested positive, IP C stated they checked residents for symptoms and tested them. When asked, IP C reported vaccination status was taken into consideration for the residents, however, unvaccinated residents were not placed in precautions after potential exposure to COVID-19 positive staff. When asked if there was a reason that unvaccinated residents were not placed in precautions after exposure to positive staff, IP C stated because there are no symptoms, and they monitored for symptoms. If a staff member tested positive, the facility reviewed where staff last worked and which staff and residents they worked with. IP C again denied that TBP were implemented for unvaccinated residents that were cared for by a staff member that had tested positive. She stated if a resident was exposed by another resident, they were put in precautions. IP C did not have an answer for the difference in those practices. She then stated that they put residents in precautions when they were exposed to their positive roommate because they shared the same room. When asked how close contact was defined, IP C reported 15 minutes of close contact, within six feet. IP C stated that was for one interaction that lasted 15 minutes. On 1/13/22 at 12:13 PM, IP C reported via email that Nurse SS last worked 1/2/22 on the third floor of the facility. Nurse SS's symptoms of dry cough, fever, muscle pain and fatigue began on 1/4/22, and they tested positive 1/5/22. According to the Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing Homes .Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection .Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP [Healthcare Personnel] caring for them should use full PPE [Personal Protective Equipment] (gowns, gloves, eye protection, and N95 or higher-level respirator) . (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) According to CDC, .A close contact is someone who was less than 6 feet away from an infected person (laboratory-confirmed or a clinical diagnosis) for a cumulative total of 15 minutes or more over a 24-hour period. For example, three individual 5-minute exposures for a total of 15 minutes . (https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html) On 1/19/22 at 3:42 PM, a staff member was observed at a medication cart on the second floor, with their N95 mask below their nostrils. On 1/25/22 at 12:49 PM, Social Worker (SW) X was observed in a resident room with the door open, wearing a KN95 mask and eyeglasses. The room door was observed to have a PPE hanger on the door and signage for droplet and contact precautions. SW X reported they were told to wear a mask and social distance when in the facility. No facility staff were observed to educate SW X on PPE use on the unit. According to the facility policy, titled, Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19), revised 12/27/21, .For resident on Contact Precautions: staff don [put on] gloves and isolation gown before contact with resident and his/her environment .For resident on Droplet Precautions: staff don gloves, isolation gown, facemask, and eye protection . During a meal pass observation on 1/27/22 at 12:21 PM, Certified Nurse Aide (CNA) CC was observed to touch the outside of their eye protection goggles, the outside of their N95 mask, then touch beverage lids, open the meal cart and pull trays out for Resident #77 (R77) and #314 (R314). CNA CC then grabbed a beverage mug and condiments before taking the delivery cart with meal trays for R77 and R314 to their room. CNA CC did not perform hand hygiene between touching their eye protection goggles, their N95 and meal trays/items. On 1/27/22 at 12:37 PM, Laundry Aide (LA) EE was observed on the first floor of the facility, near the elevators, without a mask on. Business Office Director (BOD) DD stopped LA EE and told her she could not be in the building without a mask on. LA EE stated she was about to put it on, then pulled a mask out of her pocket. On 1/27/22 at 3:31 PM, a facility staff member was overheard telling someone on the second floor that they could not be on the unit without eye protection on. The individual was observed to be wearing an N95 mask and eyeglasses. On 01/20/22 at 10:27 a.m. upon entering the elevator on the 1st floor Licensed Practical Nurse (LPN) FF was observed exiting the elevator with her KN-95 mask down around her neck. Once LPN FF saw this surveyor she appeared to laugh and stated, I at least have it around my neck. LPN FF then was observed placing her KN-95 mask properly over her mouth and nose.

This citation pertains to MI 642. Based on observation, interview and record review, the facility failed to 1) formulate effective interventions to prevent falls for three (Resident #38, #111 and #117) of 13 reviewed for accidents; and 2) perform smoking assessments for two (Resident #7 and #62) of 13 reviewed for accidents, resulting in the potential for continued falls, major injury, unsafe smoking practices and smoking hazards. Findings include: Resident #38 (R38): Review of the medical record reflected R38 was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)], malignant neoplasm of unspecified part of bronchus or lung, personality disorder, attention deficit [CONDITION(S)] disorder and adult failure to thrive. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/21, reflected R38's cognition was not fully assessed. The same MDS reflected R38 required limited to extensive assistance of one person for activities of daily living. The Quarterly MDS, with an ARD of 12/22/21, reflected short-term and long-term memory were not assessed, and the Brief Interview for Mental Status (BIMS- a cognitive screening tool) score was 99 (unable to complete the interview). On 1/20/22 at 2:26 PM, R38 was observed lying in bed. Their bed was in a low position, and an over-bed table was near the right bedside. R38 was observed to have one bare foot and a sock on their other foot. Review of R38's Activities of Daily Living (ADL) Care Plan reflected it was initiated on 9/14/21. The focus area reflected, The resident has potential for an ADL self-care performance deficit r/t [related to] [CONDITION(S)] & malignant neoplasm. Interventions included: -Encourage the resident to use bell to call for assistance (initiated 9/14/21) -Monitor/document/report PRN [as needed] any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function (initiated 9/14/21) -BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse (initiated 9/22/21) The same Care Plan had one intervention dated for 11/1/21 and all additional interventions were dated for 12/13/21. It was not until 12/13/21 that R38's Care Plan reflected how they performed tasks such as dressing, eating, oral care, personal hygiene and toilet use. R38's Fall Risk Evaluation, dated 9/14/21, reflected a score of 14, which indicated a high risk for falls. R38's Care Plans reflected a potential risk for falls related to medications and chronic disease processes. The Care Plan was initiated 9/14/21, however, their only interventions until 10/22/21 reflected: -Anticipate and meet the resident's needs (initiated 9/14/21) -Ensure footwear fits properly (initiated 9/22/21) An Incident report for 10/22/21 at 2:15 PM reflected R38 had a fall outside while smoking when supervised. R38 caught themselves on a fence to prevent the fall. The report reflected shoes were in place, and there were no injuries. R38 was re-educated to use their walker when going to activities. The report reflected R38 was oriented x3 before and after incident. The report section titled, Investigate did not include any documentation. The report reflected there were no investigative statements or staff interviews. R38's Care Plan intervention, dated 10/22/21, reflected R38 was educated to use their walker when out on activities. An Incident Report for 10/27/21 at 9:30 AM reflected R38 fell while ambulating (walking) in the bathroom. R38 was last observed at 9:00 AM, positioned correctly, sitting in bed. The report reflected the fall was witnessed, and R38 sat on the floor in the bathroom. According to the report, R38 had non-skid footwear was in place, R38's bed was in a low position, and their call light was in reach. There were no injuries. The report reflected R38 had poor safety awareness and was oriented x2 before and after the incident. The report section titled, Investigate did not include any documentation. The report reflected there were no investigative statements or staff interviews. R38's Care Plan intervention, dated 10/27/21, reflected they were re-educated on the use of their call light for assistance. An Incident report for 11/28/21 at 4:31 PM reflected R38 had an unwitnessed fall while ambulating in their room. R38 was last observed at 4:00 PM, sitting on their bed, positioned correctly, with their call light in reach. R38 was found sitting on the floor, next to their roommates bed. R38 had non-skids socks on, their call light was in reach and their bed was in a low position. There were no injuries. The report reflected R38 was oriented x1 before and after the incident. The report reflected the intervention was to re-educate the resident on call light use. The report section titled, Investigate did not include any documentation. The report reflected there were no investigative statements or staff interviews. R38's Care Plan intervention, dated 11/28/21, reflected re-education on the use of a walker and asking for assistance. A resolved intervention, dated 11/28/21, reflected re-education to use the call light and ask for assistance. An Incident Report for 12/10/21 at 9:36 PM reflected R38 had an unwitnessed fall while ambulating in the corridor/hallway. R38 was last observed at 9:00 PM and was in bed, positioned correctly with the call light in reach. R38 was observed sitting on the floor in the hallway with non-skid socks on. There were no injuries. The report reflected the intervention was to continue to encourage the resident to ask for assistance. The report reflected R38 was oriented x1 before and after the incident. The report section titled, Investigate did not include any documentation. The report reflected there were no investigative statements or staff interviews. R38's Care Plan intervention, dated 12/10/21, reflected to continue to encourage R38 to ask for assistance. An Incident Report for 12/18/21 at 9:19 PM reflected R38 had a witnessed fall while ambulating in the hallway/corridor. The report reflected the resident was last observed at 8:30 PM, resting in bed, positioned correctly, with call light in reach. R38 was observed sitting on the floor in the hallway with non-skid socks on. There were no injuries. The report reflected an intervention to re-educate on the use of a walker and asking for staff assistance. The report reflected R38 was oriented x3 before and after the incident. The report section titled, Investigate did not include any documentation. The report reflected there were no investigative statements or staff interviews. R38's Care Plan was not reflective of a new intervention. An Incident Report for 12/31/21 at 10:30 AM reflected R38 had an unwitnessed fall while ambulating their room. R38 was last observed at 10:30 AM, lying in bed, positioned correctly, with the call light in reach and the bed in a low position. R38 was observed lying on the floor, on their right side, by their bed, wearing non-skid socks on. There were no injuries. The report reflected the intervention was to educate the resident to use a wheelchair for ambulation. The report reflected R38 was oriented x1 before and after the incident. The report section titled, Investigate reflected, .Administrator review, nursing assessments, care plan updated, [Director of Nursing], Physician and family notified. The report reflected there were no investigative statements or staff interviews. R38's Care Plan intervention, dated 12/31/21, reflected re-education on the use of a wheelchair for ambulation. An Incident Report for 1/14/21 at 7:30 PM reflected R38 fell while ambulating in their room. The fall was witnessed by R38's roommate. R38 was last observed at 6:15 PM, lying in bed, positioned correctly, with the call light in reach. R38 was observed sitting on the floor near their bed, with non-skid socks in place. There were no injuries. The report reflected an intervention to monitor for safety and continue to reeducate. The report reflected R38 was oriented X2 before and after the incident. The report section titled, Investigate reflected R38 was non-compliant with interventions for safety. There were no investigative statements. A staff interview reflected an interview with R38's roommate, where it was reported that R38 got up and was told by their roommate to sit back down or they would fall. R38 sat down on the floor, and their roommate called for the nurse. R38's Care Plan did not reflect a new intervention. During an interview with Director of Nursing (DON) B and Unit Manager (UM) D on 2/1/22 at 4:56 PM, it was reported that R38 had several falls and was very determined to do things on their own. It was reported they continued to educate R38. In addition, R38 had been changed from a wheelchair to a walker, had a low bed and floor mats at the bedside. When asked if education was effective for R38, DON B reported R38 had a BIMS of 15 (cognitively intact), but it had recently changed. DON B stated the best they could do was place floor mats to prevent injury. When asked where a root cause analysis could be located, DON B stated it was sometimes in the incident report and in the medical record. A root cause would be at the end of the incident report, under the conclusion for the investigative section. Resident #111 (R111): Review of the medical record reflected R111 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included displaced intertrochanteric fracture of the left femur, intraarticular fracture of lower end of left radius, chronic obstructive pulmonary disease, muscle weakness and unspecified dementia without behavioral disturbance. The Significant Change in Status/Medicare 5 day MDS, with an ARD of 12/13/21, reflected R111's cognition, memory, mood and potential indicators of [CONDITION(S)] were not assessed. The same MDS reflected R111 did not walk and required supervision to total assistance of one to two or more people for activities of daily living. On 1/20/22 at 11:02 AM, R111 was observed lying in bed with their eyes closed. Oxygen via nasal cannula was in place and running at 2 liters per minute. R111's bed was in a low position, and a fall mat was observed on the floor at the right bedside. R111's call light was clipped to their blankets. On 1/27/22 at 12:15 PM, R111 was observed in bed with their eyes closed. Their bed was in a low position, and their call light was in reach. An over-bed table with a beverage cup was at the right bedside. A Progress Note for 9/27/21 at 6:47 PM reflected R111 had right orbital (area around the eye) bruising and bruising to the bridge of the nose. R111 stated they fell on the floor the night prior. A Progress Note for 9/28/21 at 12:36 PM reflected R111 had right eye bruising and stated they fell but did not tell anyone. An Incident Report for 9/27/21 at 6:00 PM reflected that R111 had an unwitnessed fall in their room during a transfer. According to the report, R111 was last observed at 5:30 PM. The fall was documented as self-reported, and R111 got back in bed independently. R111 sustained a bruise to their right eye. The staff interview section of the report reflected R111's roommate reported R111 rolled out of bed and got up independently. The report reflected R111's cognition prior to and after the incident was oriented x2. R111's Care Plan intervention, dated 9/27/21, reflected a mat was placed at the bedside. A Progress Note for 12/5/21 at 8:24 AM reflected R111 was observed lying on their right side, on the floor of their room. R111's Progress Notes reflected a fall on 12/5/21 with complaints of left hip pain and wrist pain. R111 was sent to the emergency room (ER). A Physician's Progress Note for 12/10/21 at 7:45 AM, reflected, .transferred back from [Hospital] after she was evaluated for left hip pain after she sustained a fall. She was found to have left intertrochanteric fracture. She underwent left cephalmedullary nail .on 12/5/21 .She also had distal radius fracture on the left. She underwent closed reduction in the emergency department with immobilization and sugar tong splint . An Incident report for 12/5/21 at 6:45 AM reflected R111 had an unwitnessed fall while ambulating in their room. R111 was last observed and checked and changed at 6:00 AM. They were resting in bed, positioned correctly, with their call light in reach. R111 was observed lying on their right side, next to the window. Their bed was in the low position, non-skid socks were in place, the call light was in reach, and a fall mat was on the floor. The report reflected R111's cognition prior to and after the incident was oriented x1. R111 was admitted to the hospital and sustained fractures of the left hip and left wrist. Fall was behavioral. Will readmit to a room closer to the nurses station and have therapy eval [evaluate]. This was an unpredicted fall. resident [sic] has not had a fall related to getting up from bed and falling while ambulating in the past. Will re-eval [re-evaluate] after readmission . R111's Care Plan interventions, dated 12/6/21, reflected to move their room closer to the nurses station upon readmission and for therapy to re-evaluate. During an interview on 1/27/22 at 3:00 PM, Certified Nurse Aide (CNA) CC reported R111 had a mat on the side of the bed and a low bed. CNA CC reported not knowing which side of the bed R111's floor mat was to be on. CNA CC stated they changed the floor mat to the side of the bed that R111 was laying on. R111 did not use their call light and hollered out, according to CNA CC. During a phone interview on 2/1/22 at 12:46 PM, Licensed Practical Nurse (LPN) GG reported R111's fall happened at shift change. R111 had slept all night, and there were no problems on their shift. LPN GG stated R111 was getting up or whatever they were doing and fell in their room. R111 typically walked around independently but was not allowed to do so. If staff saw R111 up, they would put them back to bed. In regards to determining interventions after falls, LPN GG reported for most residents, they made sure the bed was in the lowest position and a floor mat was at the bedside. If a resident moved around by themselves most of the time, they made sure the bed was in a low position/close to the floor. When asked if they attempted to determine why a resident was up or what they were trying to so, LPN GG stated residents always wanted to get up, even though you tell them they should go back to bed. Residents just wanted to get up and move around, even though staff tried to redirect them. Resident #117 (R117): Review of the medical record reflected R117 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included [CONDITION(S)], chronic obstructive pulmonary disease, hypertension and diabetes. The Admission MDS, with an ARD of 11/8/21, reflected R117 scored 13 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R117 was coded for supervision level with physical assistance of one to two or more people for activities of daily living. R117's bathing was coded for total dependence of one person assist. Review of the medical record reflected R117 was discharged from the facility on 11/29/21, with a return anticipated. R117's Fall Risk Evaluation, dated 11/4/21 and locked on 11/30/21, reflected a score of 18, which indicated a high risk for falls. A Progress Note for 11/4/21 at 5:39 PM reflected R117 had limited upper extremity (arm) mobility, lower extremity (leg) weakness and was legally blind. A Progress Note for 11/4/2021 at 11:01 PM reflected R117 had highly impaired vision, near [CONDITION(S)] and wore glasses. R117's Care Plans did not include an ADL Care Plan or R117's fall risk upon admission. R117's Care Plan with a focus area of being at risk for falls related to weakness was initiated on 11/30/21, after R117 had a fall and was discharged to the hospital. The care planned intervention, dated 11/30/21, reflected to anticipate and meet the resident's needs. A Progress Note for 11/29/21 at 4:10 PM reflected R117 was found lying on the ground in the hallway at 3:30 PM. R117 reported falling hard on their head and having a lot of head and back pain. R117 requested to go to the hospital. R117 left for the hospital at 4:10 PM. An Incident Report for 11/29/21 at 3:30 PM reflected an unwitnessed fall in the hallway/corridor while ambulating. R117's cognition prior to and after the incident was oriented x3. The report reflected R117 was last observed at 2:00 PM, sitting on the edge of the bed, with their call light in reach. The fall type reflected, Fall caused by patient intent or behavior. According to the report, R117 had non-skid socks, their bed was in the lowest position and their call light was in reach. The report section titled, Investigate did not include any documentation. The report reflected there were no investigative statements or staff interviews. There was no documentation pertaining to root cause analysis During an interview with DON B and UM D on 2/1/22 at 4:56 PM, it was reported if a resident was assessed to be a high fall risk upon admission, they automatically used a low bed, they were oriented to the room and call light, personal items were in reach, and they were provided with non-skid socks. DON B reported those items were generally care planned but was unsure why they had not been for R117. DON B reported they normally conducted a root cause analysis, but R117 discharged to the hospital and never returned, so they did not have the opportunity. The facility policy titled, Fall Evaluation Safety Guideline, with an effective date of 11/28/17, reflected, .A fall evaluation is used to identify individuals who have predicting factors for falls .Fall prevention is achieved through an IDT [interdisciplinary team] . approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls .Understanding contributing and predicting factors that present will assist with determining individualized care approaches .Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible .A Fall Risk Evaluation will be completed .If the evaluation finds the resident at risk, implement resident specific interventions/precautions .Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions .The Interdisciplinary team (IDT) will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise at a minimum quarterly with increased frequency as needed to reduce resident falls .The IDT will evaluate the effectiveness of the individualized interventions .All residents identified as at risk for falls will be reviewed for individualized interventions .Post Fall Action .Root Cause Analysis-Determine causal factors of fall .Evaluate effectiveness of interventions . Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] (paralysis of legs and lower body), chronic obstructive pulmonary disease, [CONDITION(S)] [CONDITION(S)] secondary to blood loss, stage 4 pressure ulcer to left hip, stage 4 pressure ulcer to right buttock, stage 4 pressure ulcer to right hip, [CONDITION(S)] (low platelets in blood), injury at T-2 to T-6 level of thoracic spinal cord, abnormal posture, muscle wasting atrophy, muscle weakness, protein-calorie malnutrition, peripheral vascular disease, hypertension (high blood pressure), major depressive disorder, neuralgia (pain along nerves) and neuritis (inflammation of peripheral nerves causing pain), gastro-[CONDITION(S)] reflux (heart burn), flaccid neuropathic bladder, peripheral vascular disease, acute [CONDITION(S)], and neuromuscular dysfunction of the bladder. R7's most recent Minimum Data Set (MDS) with the Assessment Review Date (ARD) of 12/25/2021 was not assessed. During observation and interview on 01/20/2022 at 02:34 p.m. R7 was laying in bed. R7 was alert to time, place, and person. R7 explained that she did smoke but only five or six times per month. She also explained that she performs her own ADLS. Review of the medical record revealed that R7 was an independent smoker as identified in her plan of care focus statement (revised 01/08/2022). The medical record further revealed that the facility completed R7's smoking assessment on 04/1/2021 and 09/15/2021. Both smoking assessments identified R7 to have an assessment score of 0.0, which delineated her as a safe independent smoker. Resident #62 (R62) Review of the medical record revealed R62 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], [CONDITION(S)] disorder, unsteadiness on feet, weakness, muscle weakness, [CONDITION(S)] (below normal potassium in blood), attention deficit [CONDITION(S)] disorder, tremors, and [CONDITION(S)]. During observation and interview on 01/20/2022 at 12:33 p.m. R62 was laying in bed and pleasant during conversation. R62 explained that he smoked and would go outside independently. Review of the medical record revealed that R62 was an independent smoker as identified in his plan of care focus statement (revised 1/26/2022). The medical record further revealed that the facility completed R62's smoking assessments on 01/28/2021, 04/28/2021, 09/15/2021, and 09/30/202. The smoking assessments completed on 04/28/2021 and 09/15/2021 identified R62 to have an assessment score of 2.0 (unsafe to smoke independently). The smoking assessments completed on 1/28/2021 and 09/30/2021 identified R62 to have an assessment score of 0.0, which delineated him as a safe independent smoker. Document review of the facility provided policy Smoking Guideline (effective date 11/28/2017) revealed that procedure number two states: The evaluation is to be used at the time of admission, annually, with quarterly review, and with change of condition. In an interview on 01/26/2021 at 01:10 p.m. the Director of Nursing (DON) B was questioned what the policy was concerning resident smoking assessment and the time that those assessments were to be completed. DON B explained that it was policy that resident smoking assessments be completed on admission, every quarter, and if there is a change in the resident's condition. DON B also explained that she had identified this issue through a Quality Assurance process earlier in the year. When this surveyor identified that R7 and R62 did not have current quarterly resident smoking assessments completed DON B confirmed that the smoking assessments for R7 and R62 had not been complete. When questioned if the facility was compliant with the current policy DON B explained that the facility was not currently compliant.

This Citation Pertains to Intake Number MI 849 Based on interview and record review, the facility is placed in Immediate Jeopardy for its failure to provide acceptable quality of care in accordance with professional standards of practice and the resident's care plan for one resident (Resident #1), by its failure to provide appropriate care for a change of condition, including new [CONDITION(S)] activity and respiratory distress. Immediate Jeopardy: Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not have on either when EMS (Emergency Medical Services) arrived for a change of condition with respiratory distress. The nurse caring for the resident did not apply oxygen for a low oxygen saturation rate of 88%;. The resident began to vomit and had [CONDITION(S)]-like activity. The nurse called 911 for assistance and then called 911 again to cancel because the resident had an Advance Directive for Do Not Resuscitate (DNR). The resident was still breathing and had a pulse. When EMS entered the building, the Nurse met them at the elevator and said they were not needed because the resident had an Advance Directive for DNR. The Advance Directive did not indicate not to treat the resident for a change of condition. Upon EMS's entry into the resident's room, the nurse left the unit and did not return until EMS was leaving for the hospital with the resident. The resident's oxygen saturation rate (O2sat) had decreased to 70% (normal range > ,d+[DATE]% via pulse oximeter reading) on room air. The lack of appropriate care was likely to lead to a further decline in condition, serious harm, injury, or death. On [DATE] at 5:20 AM, Resident #1 was found in her room by a nurse aide with a change of condition. The Nurse K assessed the resident to have respiratory distress with dried vomit on her face. The facility failed to provide any immediate care or interventions. The facility contacted the physician and was advised to call 911. The facility called EMS. Upon EMS arrival, the facility tried to prevent EMS from seeing the resident by reiterating that the resident was a DNR, EMS was not needed and that they should leave. On [DATE] after arrival to the 2nd Floor, EMS went to Resident #1's room, heard the resident gurgling and saw the resident vomiting black fluid. EMS indicated Resident #1 was in the process of having a [CONDITION(S)]. EMS responded that the resident was still breathing, had a heartbeat, and required care. The Nurse K left the floor to try to obtain discharge paperwork. A nurse aide was the only staff member left on the floor for approximately 40 residents. The nurse returned immediately prior to the resident's transfer without paperwork. The facility did not provide all the necessary transfer paperwork. EMS obtained a copy of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 died at the hospital on [DATE]. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the IJ that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated [DATE], revealed that the resident had severe cognitive loss and needed assistance with all care. A review of the Care Plans for Resident #1 indicated the following: The resident has Congestive Heart Failure, date initiated [DATE], with Interventions: Give cardiac medications as ordered, dated [DATE]. The resident has Diabetes Mellitus, date initiated [DATE] with Interventions: Diabetes medication as ordered by doctor . dated [DATE]. The resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has shortness of breath r/t use of [CONDITION(S)] (continuous positive airway pressure)/[CONDITION(S)]. Settings are: Rate 12 breaths a minute, Ipap cm water - 16 cm water, Epap cm water- 8 cm water, Fi02 30%, date initiated [DATE] with Interventions: (specify interventions) help to decrease/mange shortness of breath, date initiated [DATE]. The interventions were never specified; Monitor/document breathing patterns. Report abnormalities to MD Date initiated [DATE]; Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger, date initiated [DATE]. The resident has oxygen therapy 2 L (liters) nasal cannula during the day related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2 L ATC (around the clock), dated 2//,d+[DATE]. The care plan contradicted itself; it said oxygen 2 L during the day and oxygen 2 L around the clock (continuous). A review of the physician orders provided the following: 02 continuous via Nasal Canula at 2L/min, every shift, document L/min, dated [DATE]. [CONDITION(S)] ,d+[DATE] with backup rate of 12 and 2L/min, 02 bleed in, every night shift . dated [DATE]. Do Not Resuscitate, no directions specified . dated [DATE]. A review of the progress notes identified a nurses note written for [DATE] at 5:20 AM by Nurse K, Resident observed to be in respiratory distress with small amount of vomit, respirations 26, P (pulse) 110, unable to access blood pressure. Dr. (L) called, ordered to send resident to hospital. 911 called. A progress note dated [DATE] at 6:41 AM, Resident left via ambulance with 2 attendants (responsible party) called . On further review of the medical record, there was no additional assessment data or description of the resident's change of condition. There was no documentation of interventions provided for the resident's respiratory distress or vomiting. There was no mention if the resident was wearing the oxygen or [CONDITION(S)] when the nurse entered the room. The last documented oxygen saturation rate was on [DATE] at 8:25 PM- 98% on Room Air, documented by Nurse K. There was no mention if oxygen or the [CONDITION(S)] was applied at this time. On [DATE] at 12:29 PM, an interview with Confidential Person D provided, On [DATE] she (Resident #1) went to the hospital. They had to intubate her. When I got to the hospital, they said she almost died . The doctor asked about intubation, and I said 'Yes'. The Paramedic was there and told me what happened at the facility. He said she was having seizures. They were trying to help her, and the Nurse said she was a DNR. At the hospital, the doctor came out and talked to me. They were working hard to save her; a lot of people were in the room at the hospital. The first time I saw her she was lying flat. It was awful. I asked if she was going to die. The doctor said she was on two life supports. I had a bad feeling. They did all the tests, but her brain activity was low. DNR does not mean you let a person suffer. The facility didn't call me. A doctor called and asked how fast could I get there (to the hospital). She died a few days later. An interview with facility Physician L on [DATE] at 3:40 PM revealed, I saw her (Resident #1) twice. I just took over for the other doctor. The nurse called me, and they told me she vomited and was having seizures. She did not have a history of seizures. She was seizing and they took her to the hospital. She may have aspirated when she had a [CONDITION(S)]. I had just saw her a few days before. She was not actively dying. On [DATE] at 4:14 PM, Nurse K was interviewed about Resident #1 and stated, She was 'OK' at night, then the aide said she was having trouble breathing. When I looked in there, she had a little vomit and looked pale. Her vitals weren't good: pulse ox (oxygen saturation level) was 88%. I couldn't get a blood pressure; the pulse ox was low. I called the Unit Manager, the doctor and I called 911 right away. I didn't put her on oxygen. The Unit Manager said she was a DNR and didn't need to go. EMS arrived and I was trying to get her paperwork around. I said she was DNR. They said they were allowed to see her. I told them she was DNR, and they said they were taking her anyway. I left EMS in there. There was one aide on the floor. I went to the 3rd floor and then the 4th floor to try and get the paperwork to print. I couldn't get the paperwork to print, and I pulled it out of the chart: Facesheet and DNR form. I couldn't get the med sheets. I didn't give them the med sheets. During an interview with the Director of Nursing and Administrator on [DATE] at 4: 30 PM related to Resident #1's change of condition and lack of appropriate care prior to transfer to the hospital on [DATE], the Director of Nursing was asked what the process was for care of a resident with a serious change of condition, she said the resident was vomiting and had decreased mentation and the doctor was contacted and the resident sent to the hospital. Reviewed with the Director of Nursing and Administrator that the nurse had said she tried to cancel the 911 call, based on the Unit Manager's recommendation, because the resident was a DNR and then the nurse left the floor upon EMS's arrival, leaving the resident without care. The nurse did not provide any documented interventions for the resident's signs and symptoms and when EMS left, she could not provide all of the necessary paperwork for continuity of care at the hospital, including the medication list. The Director of Nursing said she would check into the issues. An interview with Certified Nursing Assistant E on [DATE] at 1:50 PM provided, I worked with (Nurse K) and Nurse Aide G we divided the hall. When I was doing my rounds, at 5:20 AM she (Resident #1) had something like blood coming from her mouth, then she was breathing fast. Her eyes were rolling up and down. Her face was shaking. I went and called the nurse. (Nurse K) came and when she saw that, she said (Resident #1) had to go to the hospital. She went to the nursing station. I wanted to change the resident, but I couldn't change her by myself because of her condition. (Nurse K) called EMS for help. After she called, she asked for the number for the Unit Manager. I gave her the number and she said call her right away. The Unit Manager said did you check the DNR or CPR and (Nurse K) said, 'She is a DNR.' The Unit Manager told her if it is DNR you don't need to send her. You can cancel that. (Nurse K) called 911 and said I have to cancel. Then the bell rand and it was 911 at the door. I went to (the resident's) room and (Nurse K) went to meet them. They came in the room, and I was there. On [DATE] at 12:07 PM, Paramedic C was interviewed about Resident #1 and stated, We were called for difficulty breathing and altered mental status. Then one of the dispatchers sent us a message and said they (the facility) tried to cancel us. Our policy said we are supposed to make contact. We were at the first-floor elevator, and someone met us- a female. She said they had just called and canceled us. They didn't need us anymore. She said the patient was a DNR and we didn't need you. We asked if she died and they said, 'No,' so we went upstairs, and she was in poor condition. She was on room air. We assessed her and put her on a non-rebreather (oxygen mask with higher oxygen flow). One of us suctioned her. We were concerned about her pulse ox of 70%. She was gurgling. She had been vomiting black fluid and was sitting upright with her head leaning back. Her entire body was tensed up with rapid side to side eye twitches. We gave her Versed (a medication commonly used emergently with seizures). We were slightly delayed in leaving for the hospital because the facility did not have paperwork ready. The one who talked to me at the elevator, separated from me. Then we ran into the one we originally met at the elevator, and she gave us some paperwork out of the patient's chart. We turned over the paperwork at the hospital. A review of the Facility Video of the front entrance, main floor hallway and elevator door and 2nd floor elevator door was completed on [DATE] at 3:30 PM with the Administrator. On [DATE] at approximately 5:40 AM, EMS was observed at the Main entrance to the facility and walking to the front entrance doors; At 5:41 AM, Nurse K (identified by the Administrator) as the staff member who was observed standing in the doorway to the elevator on the first floor, talking to the two EMS personnel. All 3 wore masks and there was no sound on the video, but their heads were moving slightly and per body language, appeared to be talking. Nurse K then moved aside and the 2 EMS personnel entered the elevator. All 3 were seen exiting the 2nd floor elevator at approximately 5:42 AM. The EMS personnel were seen walking towards the 2nd floor elevator with Resident #1 on a stretcher approximately 5:56 AM. Then one EMS person ran out of the elevator towards the Nurses' desk and came back with paper in her hands and entered the elevator. Per the Administrator the cameras did not have a view down the hallway towards the resident's room. A review of the Hospital records dated [DATE]-[DATE] for Resident #1 revealed the following: Prehospital Care Report (EMS), dated [DATE]: 5:35:06 AM- Call Received. 5:35:06 AM- Dispatched. 5:35:13 AM- En Route. 5:40:01 AM- On Scene. 5:42:01 AM- Patient Contact. 5:56:12 AM- Left Scene. 6:04:04 AM- At Destination (hospital). 6:04:04 AM- Transfer of Care. Current Meds: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]: No known Medications, Patient list not available . Dispatch Reason: Breathing Problems; abnormal breathing . Chief Complaint: AMS (Altered mental status); Secondary Reason: [CONDITION(S)], vomiting, Respiratory failure . 5:42:01 AM- Airway: Partially Obstructed: Choking, Nasal flaring, Intercostal Retraction; Breathing rate: rapid; Quality: labored; Lung sounds: Left Rhonchi; Lung sounds: Right Rhonchi; Skin color: Pale; Skin Temperature: Hot; Skin Condition: Diaphoretic, Moist . 5:45:58 AM- BP: Systolic unable to complete/Diastolic unable to complete; Pulse: 160 (high); Resp: 40 (high); SPo2: 75 (low). 5:50:11 AM- . Resp: 0 Effort: Absent . 5:59:11 AM- . Resp: 0 Effort: Mechanically Assisted . Narrative History Text: Pt (patient) is 75F ([AGE] year-old female) with an active [CONDITION(S)], evidence of recent vomiting, and respiratory failure, time of onset unknown . (facility) staff called 911 for (Altered Mental Status and Difficulty in Breathing) called back to cancel EMS as EMS was arriving, stating the pt is DNR and EMS was no longer needed. Staff met EMS at elevator to cancel, was asked if the pt had lost pulses, stated she had not but she was a DNR, that treatment/transport was not needed, and that her supervisor had instructed her not have the patient transported. Staff was informed that EMS would be making contact regardless, and that any decisions regarding transport would be made after assessment. Pt history largely unavailable to EMS due to difficulty obtaining report/paperwork and pt condition requiring continuous airway management. (At the facility) pt actively seizing with full body tonic/clonic activity, black vomit present on face/torso, gurgling respirations audible from hallway. Pt SPO2 70% on room air. Unable to suction initially due to jaw clenched from [CONDITION(S)] activity; placed on 15 L per minute by NRB (non-rebreather mask), versed administered. Pt moved to stretcher via sheet lift. Pt's roommate stated that the pt had been like this for a while now, but was unable to specify further . By arrival to ambulance, pt had relaxed sufficiently to open her [NAME] and airway was clear at this time. OPA (oropharyngeal airway), which pt tolerated. Pt's respiratory effort and rate was rapidly declining, respirations appearing almost agonal . Pt transported remaining distance to ER, pulling over once en route for a pulse check due to concern for cardiac arrest . A Hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . unresponsive female . presenting with hypoxic respiratory failure . Patient was intubated . Airway was clear without significant evidence of aspiration . possible left sided pneumonia . The patient was admitted to (Medical Intensive Care Unit) for when this episode of new onset [CONDITION(S)], acute hypoxic respiratory failure secondary to [CONDITION(S)], demeaning ischemia, and probable left lower lobe pneumonia A progress note in the Hospital chart written by Physician M, dated [DATE] at 7:15 AM, Patient signed out to me from prior provider who reports patient presents with altered mental status, decreased blood pressure, hypoxemia and new onset [CONDITION(S)] with likely aspiration from nausea and vomiting . A hospital note by Physician O written on [DATE], Assessment: Acute-on-chronic hypoxic respiratory failure, New-onset seizures, Bacteremia with (Gram positive cocci) in clusters, possible vegetation noted on TEE (cardiac test), Suspected left lower lobe pneumonia and E. Coli [CONDITION(S)], Chronic diastolic CHF . A progress note by Hospital Physician P dated [DATE], Staph epidermidis bacteremia, usually discounted as contaminant, but could be a true infection in this case given the overall picture and the TEE findings of cardiac vegetation . [CONDITION(S)] secondary to above as well as possible left lower lobe pneumonia . Recommendations: Continue [MEDICATION(S)] (antibiotic) . for bacteremia as well as [MEDICATION(S)] (antibiotic) . A discharge note by Physician Q, dated [DATE], Active Problems: Hypoxemia . Patient died on [DATE] . Patient had new onset seizures and was hypoxic to 75% on presentation requiring intubation . Transitioned to comfort care, terminal wean and passed away shortly after . A review of the facility policy titled, Notification of Changes Guideline, dated [DATE] and revised [DATE], Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and /or the resident representative, according to their authority, and reported to the attending physician . All pertinent information will be made available to the provider by the facility staff . Significant Change in status- deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications . The intent of the guidelines is to provide appropriate and timely information about changes relevant to a resident's condition . to the parties who will make decisions about care, treatment, and preferences to address the changes . In life threatening conditions, activate the emergency response system immediately . A review of the facility policy titled, Advance Directives and Care Planning Guidelines, dated [DATE] and revised [DATE], Guideline Purpose: It is the practice of the facility to establish, implement and maintain written guidelines for advance directives . The resident has the right to accept, request, refuse and /or discontinue medical or surgical treatment . Treatment refers to interventions provided for purposes of maintaining/restoring health and well-being, improving functional level, or relieving symptoms . Facility Removal/Abatement Plan for IJ for F-684 received and approved on [DATE]. A tour of the facility and review of the facility training and audits was completed on [DATE] to confirm enactment of the Abatement Plan that included the following: 1. [DATE]- A 100% audit was completed on very resident (109 of 109 residents) by the Nursing Administration Department for the potential of a change in baseline condition. The Nursing Administration Department documented all physical findings on the General SBAR (Situation, Background, Assessment, Recommendation) Tool. Findings were documented. Interventions and recommendations were implemented as indicated. 2. [DATE]- In-servicing for current Nursing Staff was initiated by the Nursing Administration Department. In-servicing included that they are not to delay emergency response treatment at any time. 3. [DATE]- In-servicing for all Licensed Nurses was initiated by the Nursing Administration Department to include that the Nurses are to provide all necessary transfer paperwork to the Emergency Response Team upon transfer from the facility. 4. [DATE]- Education was initiated for all licensed nursing staff on the definition of Do-Not-Resuscitate and the proper protocol by Nursing administration. 5. [DATE]- The Clinical Management Team began monitoring- If 911 is dispatched to the facility, a member of the Clinical Management Team will directly monitor the Nursing Staff for proper coordination of emergency care. 6. [DATE]- The Clinical Management Team began monitoring if 911 is dispatched to the facility, a member of the Clinical Management Team will directly monitor the Licensed Nurses to ensure all necessary paperwork has been provided to the emergency dispatch team prior to resident transfer. 7. [DATE]- DON/Designee will review every 911 discharge from the facility to ensure that no delay in emergency treatment services occurred and that the facility provided all the necessary transfer paperwork. This audit is to be continued ongoing. 8. [DATE]- Audit Results will be reported to the QA committee for monitoring and follow-up. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Scope of No actual harm with potential for more than minimal harm that is not immediate jeopardy and a Severity of Isolated until compliance can be verified by the State Agency (SA).

This Citation Pertains to Intake Number MI 849. Based on observation, interview and record review, the facility failed to provide a safe and monitored environment to prevent a fall with a serious head injury for one resident (Resident #3) of three residents reviewed for falls from a total sample of eight residents, resulting in Resident #3 having an unwitnessed fall in her room, hitting her head and obtaining a deep laceration on the middle of her forehead, above her nose, into her hairline. Findings Include: On 6/25/21 at 10:45 AM, a tour of the 300 Hall identified a census of 27 residents with 3 nurse aides, 2 nurses and a Nurse Manager. While walking down the hall, Resident #3 was observed in the hallway, sleeping in a wheelchair; her feet were extended straight out in front of her. She had a line of sutures and staples observed in the middle of her forehead, beginning above the bridge of her nose and extending into her hairline. Her eyes were very puffy and discolored purple, yellow and green. The resident had dried food on her face. A bedside table was sitting at the end of her feet. Her breakfast tray was still on it and food was all over the table and on the floor. Staff were observed walking by and no one assisted the resident to bed or made an attempt to clean up the resident, meal tray or food on the floor. The resident looked as if she could slide right out of the wheelchair. During an interview with Unit Manager J on 6/25/21 at 11:00 AM, the nurse was asked why Resident #3 had bruises on her face and sutures and staples on her forehead and stated, She fell forward and hit her head. The nurse walked into the room to the second bed by the window. There was another resident in the first bed. The room had a narrow path to the other side of the room. The bed was placed next to the wall with a small open area in front of it and a bathroom directly across from it with approximately 6 feet from bed to the door of the bathroom. The nurse pointed at a piece of furniture and said they thought the resident tried to get up and hit her head on the furniture. Nurse J said the bed was in a different position at that time, with the bed closer to the dresser. Resident #3: A record review of the Face sheet progress notes and MDS assessment indicated Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, [CONDITION(S)], heart failure, diabetes, weakness, anxiety, hypertension, hearing loss, and obesity. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss and needed assistance with all care, including 2-assist with transfers. The resident fell in her room on 6/22/21 and was transferred to the hospital with a laceration on her forehead. She returned to the facility on [DATE]. A review of a progress notes revealed the following: 6/22/2021 at 5:52 PM, CNA (Certified Nursing Assistant) alerted nurse that a resident experienced an unwitnessed fall and there was blood visible on the floor. LPN entered resident room and discovered resident on floor, in side lying position . noted a 6-7-inch laceration across the resident's forehead . MD made aware of fall and (EMS) transport to hospital at 5:43 PM . 6/22/2021 at 6:52 PM, Fall Risk Evaluation . Fall risk score is 20; Fall risk scored above 5, resident is high risk for falls . 6/23/2021 at 1:15 AM, Resident returned to the facility by 1:15 AM via stretcher . 5 staples and 11 sutures noted to right midline in the frontal region of her forehead . 7/2/2021 Resident moved to larger space for easier monitoring . A review of the Incident and Accident Report, dated 6/23/2021- 6/30/2021 for the fall involving Resident #3 on 6/22/2021 revealed, Event date 6/22/2021 at 5:40 PM . Resident was observed lying on floor at foot of bed. A wound approximately 6 inches was observed in forehead, and blood was observed to be on the floor next to head . Fall to floor Unwitnessed . Was the resident injured; Yes . Major Injury . deep laceration in mid-forehead . A new Plan of Care/Intervention has been completed to prevent further events. Note: A new Plan of Care/Intervention Must be completed to prevent further events and these new changes communicated to staff . A review of the physician orders provided, 6/23/2021 at 7:00 PM, Hourly safety checks, every hour for fall risk. A review of the Medication Administration Record (MAR) for June 2021 revealed, Hourly safety checks. Every hour for fall risk, order date 6/23/2021 at 6:18 PM. The Nurses began the checks at 12:00 AM on 6/24/2021. They were not completed every hour as ordered. On 6/26/2021 there was no documentation of Safety checks for 6:00 AM nor 7:00 AM. A review of the MAR for July 2021 revealed the Hourly safety checks were not completed as ordered. On July 1st, 2021, there were 6 missing entries with no explanation: 2:00 AM, 3:00 AM, 4:00 AM, 5:00 AM, 6:00 AM and 7:00 AM. The facility was not providing the care designated to ensure the resident's safety. A review of the resident's Care Plan revealed the following: The resident has potential for an ADL (activities of daily living) self-care performance deficit related to decreased mobility, date initiated 4/21/2018 with Interventions: Transfers: Resident requires Sit-to-Stand mechanical lift, dated initiated 3/25/2020; Bed Mobility: Physical assist every 2 hours and as needed, dated initiated 4/21/2018. The resident is High risk for falls related to history of falls, dementia and poor safety awareness. Resident has behavior of placing self on floor, date initiated 4/30/2020 with Interventions: Anticipate and meet the resident's needs, date initiated 11/20/2018; Check on resident regularly and provide assistance if she is awake and preferring to change position or get out of bed, date initiated 1/12/2020; Follow facility fall protocol, date initiated 5/1/2018; Monitor resident while in bed or wheelchair. During sleep and awake times, date initiated 6/22/2021; Floor mats placed at bedside, dated initiated 6/22/2021; The resident needs a safe environment with even floors free from spills and/or clutter . date initiated 11/20/2018. A review of the Visual/Bedside Kardex Report, for Resident #3 identified the following: The resident needs a safe environment with even floors free from spills and/or clutter . Monitor resident while in bed or wheelchair During sleep and awake times- 6/22/2021; Transferring: Transfers requires Sit-to-Stand; Check on Resident Regularly . Transferring physical assistance with 2-persons with full body sling and Hoyer lift . Monitoring: Monitor the resident for safety . The Kardex had no mention of the 1-hour Safety Checks and the Transfer section had 2 identified means of transfer using either the Sit-to- Stand lift or the Hoyer lift. The Care Plan did not mention the Hoyer lift. Neither lift would fit in the resident's room as observed on 6/25/2021 and 6/29/2021. A review of the Tasks, POC Response History for Transfer physical assistance of two persons with full body sling and Hoyer lift, from 6/16/2021 to 6/29/2021 revealed Did you use a mechanical lift for transferring? and No, was documented 18 times. There was great inconsistency in following safety precautions for Resident #3. On 6/29/21 at 11:15 AM, the Director of Nursing was present when Resident #3 was viewed sleeping in her bed. There was just enough room to walk from one side of the room to the other. The room smelled of urine and was very cluttered with furniture, bedside tables and wheelchairs. The bed was moved again and pointed out into the room towards the bathroom door. There was about 2 feet from the bed to the bathroom door and approximately 2 from the bed to the window on the side; the Director of Nursing said the bed couldn't be by the wall. The Director of Nursing was asked how the staff had room to transfer the resident, as she was care planned for transfer with a Sit-to-Stand lift with 2-person assist. The Director of Nursing said they moved the furniture around. The Director of Nursing was asked if this was safe for the resident, if she attempted to transfer herself again and stated, We don't have a lot of options. On 6/30/21 at 10:29 AM, Nurse W was interviewed and was asked about staffing on the 300 Hall., Nurse W said she was the nurse for Resident #3 on 6/22/21 when the resident fell . She said the nurse aide assigned to Resident #3 was off the floor working with the Director of Nursing on staffing schedules, Nurse W herself was off the floor in the supply room. Nurse W said CNA X happened to walk down the hall and see that Resident #3 was not in bed and went into the room to see why. She said there were four nurse aides scheduled for the shift 3:00 PM to 11:30 PM, but 1 was moved to another floor, so there were three. There were 2 nurse aides and 1 Nurse on the hall at the time of the resident's fall. The Nurse was asked about staffing and said, there were usually enough nurses, but it was common to have to pull CNAs from one floor and move them to another floor. A review of the facility policy titled, Fall Evaluation Safety Guideline, effective date 11/28/17 provided, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention . The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which this facility has control and provides appropriate supervision to each resident . Develop and implement interventions . Provide safe, clutter free environment . eliminate hazards .

This citation pertains to intake MI 9223. Based on interview and record review, the facility failed to follow standards of practice for one Resident (#2) of one resident reviewed for emergency care. This deficient practice resulted in a choking incident which required hospitalization , intubation, hospice services, and contributing to death. Findings include: Resident #2 On [DATE] at 11:16 AM, during an interview, the confidential complainant stated relayed the following regarding Resident #2. We were working short staffed that day on the COVID (specialized quarantine unit) unit . We had to pass trays and the DON (Director of Nursing) and the Administrator were helping to pass trays. A tray was passed to (Resident #2) by a floor Nurse along with the DON and set the tray on her bed. (Resident #2) is a feeder, and as they are walking out, I was walking in with the right tray and that is when I noticed food flying everywhere and (Resident #3) was in distress. I realized (Resident #2) was choking and screamed for help. The nurse . responded, and me and him were the ones who were trying to do the thrusting to get it out, and he asked me to go and get the other nurse. She (other nurse) asked me what was going on, and I said one of you guys gave her the wrong tray, and she (Licensed Practical Nurse [LPN] I) said to me, Oh, it was me. They grabbed the suction trying to get the hot dog out. I was seeing (Resident #2's) face, her lips were turning blue. I kept asking why are you not doing the [MEDICATION(S)] on her, and then a third nurse came on the scene. I asked her why they are not doing the [MEDICATION(S)] on (Resident #2). Then she asked the same of them, and then she took over and tried the [MEDICATION(S)] and it wasn't working. So the ambulance was called . She was holding her throat making no sounds, lips turning gray, and holding her throat. When asked who was the one doing the suctioning, stated (LPN I and LPN J). I was told she came back with a [CONDITION(S)](eostomy), and that she came back on hospice, and eventually passed away. A review of the face sheet for Resident #2 revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Order Summary Report printed on [DATE] revealed Resident #2 was on a controlled carbohydrate diet pureed texture, honey consistency, double meat and large portions, superfoods as able diet, ordered and started on [DATE]. A review of a Health Status Note for Resident #2 dated [DATE] at 12:25 PM, revealed the following: observed resident coughing and drooling clear thick [MEDICATION(S)], resident is disoriented at baseline and unable to communicate appropriately. noted partially bit hotdog and rice on food tray on bed. suction initiated oxygen n.c (nasal cannula) with [MEDICATION(S)] maneuver. 911 called r/t (related to) increased drooling, coughing and gasping for air. MD (physician) DON (Director of Nursing) and guardian notified. resident sent to (local hospital via 911 at 1250 (12:50 PM). (Author LPN J) A review of a Health Status Note for Resident #2, dated [DATE] at 12:53 PM revealed the following: Writer was called to room. (Resident #2) had eaten a bite os (sic-of) sausage and rice and was choking. Staff tried suction, the [MEDICATION(S)] and provided O2 (oxygen) at 3 l (liter) per min(minute) until EMS (Emergency Medical Services) arrived. (Author LPN I) A review of the hospital History & Physical for Resident #2, dated [DATE], read in part: . Upon my evaluation, (Resident #2) had a high probability of imminent or life-threatening deterioration due to acute hypoxemic and hypercapnic [CONDITION(S)], which required my direct attention, intervention, and personal management . presents from the (facility) after having a witnessed choking event. (Resident #2) reportedly is on a soft, pureed diet but attempted to eat a hot dog and choked on the hot dog. (Resident #2 developed respiratory distress with unsuccessful attempt to dislodge hot dog piece. On presentation to ED (Emergency Department), (Resident #2 was non-responsive, with HR (heart rate) 111, BP (blood pressure) ,d+[DATE], and saturating in the 80's on RA (room air). Oxygenation did not improve with bag masking, and hot dog piece was removed using forceps. (Resident #2) continued to saturate poorly, so (Resident #2) was emergently intubated in the ED. (Resident #2) was subsequently admitted to the (Intensive Care Unit) for further management . Acute hypercapnic hypoxic [CONDITION(S)], due to asphyxiation secondary to food impaction -s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Acute metabolic [CONDITION(S)] -Suspect secondary to [CONDITION(S)] . A review of the hospital Nutritional Consultation Note for Resident #2, dated [DATE], read in part: . Responding to consult for EN (Enteral Nutrition) recommendations and orders. (Resident #2) presents from ECF (Extended Care Facility) after witnessed choking episode on a hot dog . Recommend starting EN as follows via OGT (oral gastric tube): [MEDICATION(S)] (artificial nutrition brand) 1.5 at 20 ml (milliliter)/hr (hour) x (times) 8 hrs (hours), 30 ml/hr x 8 hrs, to a goal of 40 ml/hr x 24 hrs/day with 50 ml water flush Q (every) 4 hrs . A review of the hospital Palliative Consult for Resident #2 dated [DATE], read in part: Prognosis: PRISM 1 (Resident #2 is a PRISM 1, which is a mortality prediction tool that generates the probability of a patient's risk of dying within the first 30 days of admission based on the information know at the time of admission. PRISM 1 is considered the sickest of patients with generally >20% chance of death in 30 days and a high risk for 30 day readmission . A review of the hospital ICU Transfer Note for Resident #2, dated [DATE], read in part: . presented from the (facility) after developing respiratory distress from choking on food. (Resident #2) was initially intubated on admission ,d+[DATE](2021). Extubated on ,d+[DATE](2021) and re-intubated shortly after . Given (Resident #2's) Hx (history) of aspiration and dysphagia, likelihood of aspiration causing repeat [CONDITION(S)] is high. ((Resident #2) care was d/w (discussed with) sister and palliative care, decision was made to proceed with comfort care. The possibility of PEG (Percutaneous Endoscopic Gastrostomy) and [CONDITION(S)] (tracheostomy) tube placement were discussed and the family does not wish to proceed with that . A review of the hospital Discharge Summary for Resident #2, dated [DATE] read in part: . Acute hypoxic and hypercapnic [CONDITION(S)] initially sec. (secondary) to asphyxiation due to food impaction--foreign body removed . failure to thriveve (sic), dysphagia . (Resident #2) extubated on ,d+[DATE](2021), re-intubated same day due to decompensation . Family discussed w(with)/palliative care and she was transitioned to comfort care, extubated on [DATE] . Dispo: (Disposition) To Facility w/(hospice provider) . On [DATE] at 1:20 PM, during an interview, the Administrator stated Resident #2 had just been moved onto the PUI (Persons Under Investigation for COVID-19) unit because her room mate had tested positive (for COVID-19). The nurse (LPN I) who was on that day was unfamiliar with (Resident #2) and gave her the wrong tray. The Administrator stated Resident #2 was given a tray that was not hers and she began choking on a piece of hot dog. The Administrator stated Staff did suctioning and performed the [MEDICATION(S)] and ultimately EMS was called. A review of an Admission Summary note for Resident #2 dated [DATE] at 12:29 PM read in part: Resident (#2) returned to the facility . (Hospice Provider) in the facility to see (Resident #2) - all labs, tests, and procedures discontinued. Resident (#2) is admitted to (Hospice Provider) . A review of a Hospice Note for Resident #2, dated [DATE] at 7:27 AM, read: Hospice: resident (#2) with no respirations no pulse (physician) called, hspice (sic) called said will be here daughter informed. A review of a Discharge/Transfer Summary note for Resident #2, dated [DATE] at 3:52 PM, read in part: .Representatives from (funeral home) transported remains out of the facility at 11:30 AM. A review of the standards of practice information retrieved on [DATE] from: https://www.aedcpr.com/articles/choking-victim-how-to-help/ [MEDICATION(S)] Maneuver The [MEDICATION(S)] Maneuver (aka Abdominal thrusts) is the most common first aid technique for choking. However, it is important to note that this technique is used on conscious victims only. To perform abdominal thrusts: Stand behind the person and place one foot ahead of the other for balance. If the choking victim is a child, crouch or kneel behind them and keep your head on their shoulder. Put your arms around the person ' s waist. Make a fist with one hand and grab your fist with the other hand. Keep your hands rested slightly above the person ' s navel (belly button). Note: If the person is overweight or pregnant, position your hands higher, around their breastbone. Next, make quick upward and inward thrusts, as if you were trying to lift the person up. Perform ,d+[DATE] thrusts, or until the blockage is cleared. It is important to know when to call for an ambulance. If you are the only rescuer on the scene, try to use ,d+[DATE] abdominal thrusts before calling 911. But if you ' re not alone, have someone else call for an ambulance while you perform first aid. Also, call 911 if the victim becomes unresponsive at any point. Treating an Unconscious Victim As stated before, if a choking victim has fallen unconscious or become unresponsive at any point, make sure that an ambulance or 911 has been called. After that: Lay the unconscious victim on their back on the ground. If the obstruction is visible in their mouth, you may try to use your finger to remove it. However, be careful to not push the object further into the airway. If the object is not visible, do not try to reach for it. Perform CPR on the victim. Perform 2 rescue breaths, followed by 30 chest compressions. For more detailed information on how to perform CPR, click here. Periodically check the victim ' s mouth to see if the obstruction has become visible. Standard of practice review revealed rescuers are not supposed to utilize suction to blindly attempt to retrieve a food bolus in a choking victim because there is a risk of causing impaction. A review of the clinical documentation from the hospital revealed Resident #2 had suffered from a food bolus impaction which had to retrieved with the use of forceps in the emergency room . Resident #2 never recovered from the choking incident and returned to the facility on hospice. Resident #2 died on [DATE] in the facility.

This Citation Pertains to MI 259 Based on observation, interview, and record review, the facility failed to prevent mental abuse through intimidation and coercion, rising to level of immediate jeopardy, in 3 of 6 residents reviewed for abuse (Resident #23, #47, #48), and failed to prevent physical abuse and neglect in 3 of 6 residents reviewed for abuse (Resident #55, #90 & #48) resulting in fears of reprisal (Resident #48), frustration (Resident #47, #90), anxiety (Resident #47), pain (Resident #55 and #48) and feelings of decreased self-worth (Resident #23). Findings include: Resident #47 (R47) R47 was observed sitting in his wheelchair in his room on 3/22/21 at 2:37 PM. During an interview, R47 stated that the staff treated him like crap and the staff threaten him; they tell him they are going to get in in trouble. R47 stated in the same interview, he had seen a staff member slap a resident in room [ROOM NUMBER] because her bed was cranked all the way up. R47 did not recall the staff members name but described her as frequently complaining that she was going to quit her job. R47 stated that he had reported the incident to the ombudsman and to Nursing Home Administrator (NHA) A. R47 stated NHA A had told him the staff member he saw slap another resident, would not provide care for him. R47's Comprehensive Minimum Data Set (MDS) 3.0 dated 1/07/21, indicated he was [AGE] years-old, admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 12 (08-12 Moderate Impairment). The same MDS assessment indicated R47 did not have any physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) or other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), during the 7 day look-back period. The same MDS assessment indicated R47 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of Psychiatric Consult dated 2/09/21, R47 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's Psychiatric Consult dated 3/10/21, revealed he reported continued depression due to his situation and being isolated. R47 also reported sadness and feeling frustrated. On 3/24/21 at 3:38 PM, during an interview with NHA A, he indicated he was contacted by the ombudsman regarding R47's complaint in witnessing a staff member strike another resident. NHA A did not recall the date he was notified by the ombudsman. NHA A stated he interviewed R47 following the call from the ombudsman and R47 had told him that the incident occurred 2 to 3 years ago and he saw a nurse spank a resident. NHA A stated he interviewed Licensed Practical Nurse (LPN) E and she claimed she had never hit anyone. NHA A stated LPN E had claimed there was a disagreement in R47's transfer status; R47 requested to be transferred using the sit-to-stand lift when his care plan indicated he was a total lift (Hoyer) for transfers. NHA A stated LPN E was no longer assigned to provide care for R47. NHA A stated in the same interview he did not report the allegation to the State Agency, further investigate or document the allegation because R47 stated it had happened 2 to 3 years ago. NHA A stated he did not ask LPN E if she referred R47 to therapy for a transfer evaluation. In review of R47's activities of daily living care plan dated 11/26/19, R47's transfer instructions included use of the sit-to-stand lift or the Hoyer lift as needed. On 3/24/21 at 4:30 PM NHA A stated he had contacted the ombudsman and based on the ombudsman's notes, he was notified of R47's allegation of abuse on 3/10/21. NHA A stated R47 had reported the incident occurred 2 to 3 years ago. NHA A stated he was aware that R47 was admitted to the facility on [DATE], less than 2 to 3 years ago. NHA A stated during the same interview therapy had evaluated R47 for transfers in February 2021, and they determined he was only safe for Hoyer lift transfers. NHA A stated in the same interview he did not interview other residents or staff following the abuse allegation. NHA A stated LPN E was still R47's assigned nurse, but another nurse administered his medications after she set them up. During an interview on 3/25/21 at 8:57 AM, R47 stated NHA A came into his room the day before and felt like they were storm trooping me. R47 stated he felt ambushed and had to initial something he did not read. R47 reported to this writer again that he saw LPN E slap a resident in room [ROOM NUMBER]. On 3/25/21 at 9:35 AM, NHA A stated last evening he went to talk with R47 with 2 witnesses. NHA A stated R47 did not recall the incident of LPN E slapping/spanking a resident and had him sign a questionnaire. In review of the document titled Residents Questionnaire, dated 3/24/21, R47's name was printed on top of the document. The document had 5 questions, Has anyone made you feel uncomfortable; Have you experienced or observed any type of abuse; Do you feel safe at the building; Do you have any concerns with your roommates; and Do you feel comfortable speaking with administration about any concerns. The bottom of the same document indicated NHA A and LPN Unit Manager I signed the document under the signature line. During an interview on 3/25/21 at 1:00 PM, Ombudsman FF stated she received a telephone call on 3/10/21 from R47 and he conveyed LPN E was verbally abusive to him and he had seen LPN E be physically abusive to another resident. Ombudsman FF stated 3/10/21 was the first time R47 called her. Ombudsman FF stated she notified NHA A on the same day, 3/10/21 of the allegation of abuse. Ombudsman FF stated she called R47's mother and suggested to set up a care conference. During an interview on 3/25/21 at 1:36 PM, R47's mother stated R47 has only complained of the same person at the facility, LPN E. R47's mother stated he was not good with remembering names, he has a memory deficit, and history of a closed head injury. R47's mother stated the ombudsman did suggest scheduling a care conference but was not able to get through to anyone when she called. R47's mother stated R47 has tried to set it up a care conference also and had not been successful. During an interview on 3/30/21 at 9:56 AM, LPN E stated R47 did not want her to be his nurse, that he was like a jealous husband, he yelled and then made up. LPN E stated she referred R47 to therapy because he was unsafe in his motorized wheelchair. LPN E stated she had not transferred R47 with the sit to stand lift or the Hoyer lift. LPN E denied hitting a resident and stated she wrote a statement and submitted it to NHA A. On 3/31/21 at 9:14 AM, R47 stated LPN E had parked her medication cart across the hall from his room and watched him. R47 stated he felt irritated and frustrated. R47 stated he did not know how LPN E could get away with hitting that resident. R47 stated the staff aren't treating him well, they were not answering his call light, or if they did it was after 2 hours. R47 stated he had not had a shower in 2 months. R47's call light was on during interview. An immediate jeopardy in failing to prevent mental abuse with intimidation and coercion began on 3/21/21. The immediate jeopardy was identified on 4/05/21 at 10:45 AM and an immediate jeopardy notice was presented to NHA A. Immediate Jeopardy was removed on 4/06/21, when the facility had the begun the following: -The Administrator and Unit Manager, who were present during the interview of resident #47 on 3/24/21, were suspended pending investigation at 11:30am on 4/05/21 in accordance with the facility abuse policy. -Resident # 23: additional Social Worker (SW) visit was provided on 4/05/21 and care plan was updated to monitor for psychosocial distress related to an allegation that she felt coerced when interviewed by staff. Additional SW support will continue. -Resident #47 was offered an alternative manager on 4/05/21 to address his concerns. -Resident #47 was provided an additional SW visit on 4/05/21 and care plan was updated to monitor for psychosocial distress related to an allegation that he felt coerced when interviewed by staff. Additional SW support will continue. -Resident #48 was provided an additional SW visit on 4/06/21 and care plan was updated to monitor for psychosocial distress related to an alleged event. -R48's allegation was reported to State Agency on 4/07/21. -Certified Nurse Assistant (C.N.A.) F was educated and will not have further contact with Resident #48. C.N.A. F suspended pending investigation on 4/07/21. -Beginning on 4/05/21 Residents were queried to determine if they have ever felt intimidated by a staff member or manager, been asked to sign a document that they didn't know what they signed, and if they have any concerns about abuse or mistreatment. All interviewable residents will be queried. Current number (#) of interviewable residents was 69 as identified by a BIMs score of 8 or higher: moderately impaired to cognitively intact. All non-interviewable will be assessed for abuse by resident assessment including extreme changes of behavior, aggressive or disruptive behavior towards a specific person, withdrawal, isolation, depression, and expression of fear/anxiety. A skin assessment will also be completed for non-interviewable residents to assess for any suspicious injury or injury of unknown origin. The current # of non-interviewable residents was 45 as identified by a BIMs score of 7 or lower: severe cognitive impairment. The internal Compliance Officer will review all queries and assessments and notify the Abuse Coordinator of any concerns. The Abuse Coordinator will protect, investigate and report as required by regulation and facility policy. In response to an alleged violation of abuse, neglect or mistreatment, the facility will take the following action to an alleged violation: Thoroughly investigate the alleged violation: prevent further abuse, neglect and mistreatment from occurring while the investigation was in progress and Take appropriate corrective action, as a result of the investigation findings. -Abuse policy was reviewed and determined to be appropriate. -Quality Assurance and Performance Improvement (QAPI) meeting was conducted with Management staff. They were also educated on the abuse policy and signs of psychosocial harm including fear/ anxiety that may be manifested as panic and aggressive or agitated behavior. In addition, that if any resident expresses concern about something, they signed to immediately notify social services. Management staff were educated on appropriate interview techniques, ensuring that the resident knows what they are signing and the right to refuse. Also educated on reinforcing the use of the Compliance hotline. -The Admissions Department was given Compliance hotline business cards and will issue them with education to new admissions. -Residents provided information on how to contact Corporate Compliance hotline, (including a business card) at any time they feel a concern was not being addressed or fear of intimidation or coercion. -QAPI meeting conducted with Medical Director to review immediate jeopardy notice, corrective action, and continuous compliance process. -Education continued with residents to include how to report, Ombudsman and State Agency contact information and the right to complain without fear of reprisal. -Abuse Policy education started for all staff to include that the Interim Abuse Coordinator was the Director of Nursing (DON). Abuse education includes education on the abuse policy and signs of psychosocial harm including fear/ anxiety that may be manifested as panic and aggressive or agitated behavior. No staff will have resident contact until education received. Agency/contract staff will be provided education prior to providing resident contact. Education will be incorporated into new employee orientation to ensure continuation of process. -The Admissions Department was given Ombudsman and State Agency contact information and will issue them with education to new admissions. -Ombudsman and State Agency contact information updated on resident floors. -The Compliance Officer/Assistant Director of Nursing (ADON), was responsible for compliance: to ensure that concerns are addressed timely, per regulation and without fear of reprisal. Resident #23 (R23): Per R23's Electronic Medical Record (EMR) she was admitted to the facility on [DATE]. Review of R23's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed she had a BIMS score of 15 out of 15 which indication she had no cognitive impairment. In an interview on 3/22/2021, at 10:35 AM, R23 stated she did not get her showers as she should. In another interview on 3/22/2021, at 12:41 PM, Resident # 23 stated that she was supposed to have two showers per week, however stated that she had been only getting bed baths. In an interview on 3/25/2021, at 1:48 PM, R23 stated that she only received a bed bath on this day. In an interview on 3/31/2021, at 10:27 AM, Administrator A stated that he had a statement that R23 had signed for the months of January, February, and March 2021 that she had received her shower. Administrator A said he had a witness when R23 was asked to sign the statement. Review of the letter signed by R23 revealed she signed a letter that stated, I (R23) have been receiving snacks, receiving showers/baths and my needs are being met. I also feel safe at the facility. The letters were dated January 31, 2021, February 28, 2021, and March 30, 2021. In an interview on 3/31/2021, at 10:49 AM, R23 stated that she signed the letter in January and February, and said that within the last hour Licensed Practical Nurse (LPN) X, who was the Unit Manager for the second floor, had entered her room and had her sign the letter dated 3/30/2021. R23 stated that LPN X came in to her room alone, and Administrator A was not with her. R23 said LPN X told her that the letter she was signing was her stating that she received a shower on Tuesday 3/30/2021. R23 said she did not want to lie by not signing it because she did received a shower the day before on 3/30/2021. With the letter dated 3/30/2021 in hand it was given to R23 to read. R23 was not able to read what the letter stated. R23 said that she just trusted what LPN X told her the letter said. The letter was then read in full detail to R23 by this surveyor. R23 stated that what this surveyor read to her was not not LPN X had read to her. R23 said LPN X only told her the letter she was signing was that she received her shower on 3/30/2021 and nothing more. During this interview R23 stated that she was told that she was signing this document because it would be needed for the state surveyors. In an interview on 3/31/2021, at 11:01 AM, LPN X said she had R23 sign the yesterday, 3/30/2021, right after her shower. LPN X said she asked Administrator A for the paperwork, which he gave to her, and then went into R23's room by herself and had R23 sign the letter. On 3/31/2021, at 11:09 AM, R23 was asked again when she signed the latter that is dated 3/30/2021. R23 stated twice, without hesitation, that she signed it today, 3/31/2021 and it was within the last hour, and then stated again that it was not yesterday but today. In another interview on 4/01/2021, at 10:10 AM, R23 stated that with staff having her sign the letter that she received her showers made her feel that people thought she was lying when she would report that she did not have a shower. R23 stated that she did not know why she signed the letters. In an interview on 4/01/2021, at 10:17 AM, Administrator A stated that he was not in the room when R23 signed the letter on 3/30/2021, but only signed that he saw the signed letter by R23. Record review of a progress note documented by Social Worker (SW) L, dated 4/5/2021, at 3:51 PM revealed, .She (R23) reports that she does feel neglected at times. Resident #48(R48) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R48 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R48 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired, and he required one person physical assist with bed mobility, transfers, toileting, dressing, hygiene, and bathing. R48's MDS reflected no behaviors including, physical, verbal or refusal of care. During an interview and observation on 3/24/21 at 11:05 AM R48 stated, I was assaulted by (named Certified Nurse Assistant((CNA F)) on 3/4/21 and told (named Administrator((NHA A)) on 3/5/21. R48 reported CNA F was rough during care on 3/4/21 and hurt his neck. R48 reported after speaking with NHA A on 3/5/21 was told CNA F would not care for him again and an x-ray would be ordered. R48 reported he continues to have neck pain and had not yet received neck x-ray and CNA F worked with him again on 3/21/21. R48 reported did not feel safe here and began to cry and tears noted. R48 reported NHA A lied to him and reported fear of, reprisal. During an interview on 3/25/21 at 11:04 a.m. NHA A reported R48 did not have any abuse allegations in past three months. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . UM reported that resident was very agitated when CENA tried to provide care. Resident seen in bed awake and alert. Resident stated he was not wet when CENA came in to change his brief. He said the CENA attempted to check to see if he was wet and he reach out to block the CENA and now his neck hurts and will like X-Ray of neck. Resident assessed. No signs of trauma or bruises noted. Resident able to turn his neck from left to right but states it hurts when he turn. Of note resident has a history of chronic pain secondary to [CONDITION(S)]. Was started on antibiotic yesterday for UTI. X-Ray of neck ordered, pain meds given. Will monitor. During an interview on 3/25/21 at 1:51 p.m. CNA F reported working at the facility for nine years and usually day shift and often works double shifts(7a-10p) four days per week. CNA F reported was familiar with R48. After this surveyor asked CNA F to describe R48, CNA F reported R48 sometimes was incontinent of urine and thought he didn't and stated, he was wet that morning. This surveyor asked, what morning was CNA F referring too? CNA F reported the day that R48 became verbally upset with CNA F and began physically swinging at CNA F. CNA F reported R48 did not believe he was wet and became physically and verbally agitated during care on 3/4/21 around 9:30 a.m. CNA A reported smell of urine but R48 argued he was not wet. CNA F reported she said, let me change you. CNA F she turned R48 on side who grabbed bar while linens were changed and R48 started swinging arms and cussing calling CNA F names. CNA F reported no physical contact was made. CNA F reported collected items, exited room and informed agency nurse but unsure of name and reported completed statement and gave to NHA A the next day. CNA F reported worked next day 7:00 a.m. to 10:00 p.m. and was assigned to R48 and R48 told her he did not want CNA F in room because she had tried to through him out of bed day prior. CNA F informed nurse and they spoke to R48 and was then told by NHA A she would no longer be assigned to R48 care. CNA F reported she recalled R48 complained of neck pain during care on 3/4/21 and an X-ray was ordered. CNA F reported worked Sunday 3/21/21 on 4th floor south and had told nurse could not go in R48 room because NHA A had told her not to care for R48. CNA F reported nurse told CNA F assignments could not be switched to other aid and told CNA F to address roommates needs and nurse would address R48 needs. CNA F reported as soon as she entered R48 room and said name to R48 roommate, R48 became agitated, started calling her names and yelling. CNA F reported had not been required to be off work related to event. CNA F reported last abuse training at facility was last week and everyone received abuse training after event. During an interview on 3/25/21 at 2:37 p.m. CNA J reported working at the facility for four months and received abuse training at that time and again 2 weeks ago. CNA J reported all abuse allegations should be reported to supervisor who was often the nurse who would then reports to NHA A. During an interview on 3/25/21 at 4:25 p.m. NHA A reported there was not an investigation for R48 for 3/4/21 incident because R48 did not report why he did not want CNA F back in the room. NHA A reported was told by CNA F that she had provided R48 care on 3/4/21 and after shower R48 started swinging at CNA F and calling racial slurs and being combative. NHA A reported he spoke with R48 on 3/5/21 who complained of a sore neck. After this surveyor asked, what did R48 report to him? NHA A stated, nothing except missing items and sore neck. (named R48)did not mention anyone hitting or abusing him so I did not do investigation. NHA A reported was aware of one incident that CNA F entered R48 room after 3/4/21 event and was again told not to go in R48 room. NHA A reported CNA F did provided written statement because of incident and would try to locate statement. Review of the Medication Administration Record(MAR), dated 3/1/21 through 3/31/21, reflected R48 had 0 out of 10 pain on pain scale(0=no pain, 10=highest pain) on 3/3/21 and 7 to 8 out of 10 on pain scale 3/4/21 through 3/6/21. Review of Kardex, dated 3/31/21, reflected no documentation that reflected resident and NHA request related to caregivers. Review of the Nursing Progress Notes, dated 3/12/2021 at 10:53 p.m., reflected, Patient AOX3 able to make needs known, no respiratory discomfort noted, no c/o sob, c/o pain [MEDICATION(S)] prn as ordered . During an interview on 4/05/21 at 12:19 p.m., Social Worker (SW) L reported R48 had requested to speak with Social Worker on 3/5/21. SW L reported R48 informed her that CNA F was rough during care on 3/4/21 and did not want CNA F performing any further care for him. SW L reported CNA F reported R48 was wet and needed to be changed so CNA F changed R48 soiled brief and R48 became agitated. SW L reported CNA F was told by NHA A not to provided care or enter R48 room. SW L reported when made aware of information from R48 about CNA F care she would report to Abuse Coordinator, NHA A. SW L reported R48 incident on 3/4/21 had been reported to NHA A by RNUM prior to SW L interview with R48. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Seen by (named physician), rheumatologist as a f/u on 3/31/2021. No evidence of [CONDITION(S)], serologies were negative for [CONDITION(S)]. Recommends referral to see neurologist. Appt scheduled for 4/14/2021 . During an interview on 4/06/21 at 3:30 PM Registered Nurse Unit Manager (RNUM) II verified R48 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/6/21 at 3:30 p.m., observed CNA F working on fourth floor, talking with staff near nurse station. During an interview on 4/07/21 at 10:45 a.m., Director of Operations, Acting NHA (DO) EE reported R48's abuse allegation was reported 4/6/21, and CNA F was not suspended because was more of a handling concern and not abuse. During an interview on 4/07/21 at 1:28 p.m. Director of Nursing (DON) B reported was current interim Abuse Coordinator with history of Abuse Coordinator title. When asked to name seven elements of abuse was unable to recall all 7 elements of abuse. When asked when abuse allegation should be reported? DON B reported abuse allegation were required to be reported within 24 hours and (DO) corrected DON B by answering, two hours. During an interview on 4/07/21 at 3:50 p.m. DON B provided R48 neck X-ray dated 3/27/21. DON B verified R48 neck X-ray was ordered 3/5/21 and verified no documentation to reflect delay of X-ray performed on 3/27/21. Resident #90(R90) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R90 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R90 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers and one person physical assist with locomotion on unit, toileting, dressing, hygiene, and bathing. During an observation and interview on 3/23/21 at 11:41 a.m., signs were located on R90 closed door that reflected isolation precautions and call light was on. Staff at nurse station reported all rooms on floor required use of full Personal Protective Equipment (PPE), gown, mask, eye protection and gloves to enter. This surveyor donned appropriate PPE, knocked on R90 door and obtained permission to enter from R90. R90 was sitting in bed with hospital gown on and call light on above door in hall, light indicator at call light plug in did not appear to be functioning. R90 reported currently waiting for staff to answer call light because of need to use bathroom. R90 request to have this surveyor wait in room. R90 reported frequent long call light response greater than one hour and had been waiting since 11:20 a.m. at that time. R90 appeared calm and pleasant, hair appeared greasy and unkept with moderate amount long facial hair observed on R90 chin area. R90 reported she felt embarrassed to have facial hair but required assistance from staff because of being blind and staff had not provided assistance. CNA J entered R90 room with full PPE on and R90 reported need to be changed. CNA J reported need to get fitting sheet from hall and removed PPE and exited R90 room. CNA J returned to R90 room with no gown. CNA J asked R90 if it was ok for surveyor to observe person care and R90 verbalized permission for this surveyor to observe care. At 11:56 a.m. CNA J assisted R90 turn on side with gloves, eye protection and mask in place and no gown. CNA J performed peri care and used call light at 12:09 p.m. for additional assistance. CNA J reported at that time had forgot to put on gown prior to entering R90 room. At 12:13 p.m. RNUM II entered R90 room to assist with boosting R90 up in the bed. This surveyor heard R90 report to CNA J that CNA P will not wash peri area when changing R90 brief because it was against CNA P religion and was always short with her, what do you want? During an interview on 3/25/21 at 2:37 p.m. CNA J reported had worked at the facility for four months and received abuse training at that time and again two weeks ago. CNA J reported if abuse is allegation of abuse was suspected it was CNA J job to report to supervisor immediately. This surveyor asked CNA J if R90 had reported any care concerns to CNA J at the time this surveyor was observing care on 3/23/21? CNA J reported R90 had reported CNA P did not perform peri care because it was against her religion. CNA J reported that was an example of neglect and reported to the nurse Licensed Practical Nurse (LPN) JJ that day. CNA J reported was not asked to complete witness statement. CNA J reported it was her job to report and she did. During an interview on 3/25/21 at 11:04 a.m. NHA A reported R90 did not have any abuse allegations in past month. During an interview on 3/25/21 at 4:35 p.m. NHA A reported again not aware of abuse allegation from 3/23/21 for R90. NHA A reported was not notified of R90 being mistreated by staff or anything like that. NHA A reported would expect staff to report any abuse allegations to him or supervisor immediately. During an interview on 3/31/21 at 10:05 a.m. NHA A reported completed investigation related to R90 on 3/25/21. NHA A stated, (named R90) only complained about one CNA staff that did not perform pericare cleaning center of peri area. NHA A reported R90 reported feeling safe. NHA J reported CNA J was present during interview with R90. This surveyor asked why R90 investigation reflected this surveyor had informed NHA A about care concerns when R90 had reported care concerns to CNA J while this surveyor was present? NHA J verified that it was reported that this surveyor was present when R90 reported care concerns to CNA J on 3/23/21. NHA A reported all allegation are expected to be reported to supervisor or NHA immediately. NHA A reported did not feel this situation was abuse. According to the facility Investigation, dated 3/25/21, reflected an interview with R90 with NHA A, DON B, and CNA J present was done on 3/25/21. The investigation reflected R90 was asked directly if she felt abused or neglected. According to the investigation R90 reported, she(R90) voiced to the Surveyor and CNA that she felt one CENA did not clean the center of her vagina very well. Also informed the surveyor how the 1 CENA had informed her how it was against her religion to clean the center of her vagina .but stated the 1 CENA did clean her buttocks and side of her vagina very well.(no dates included on investigation). According to CNA J interview, dated 3/25/21, reflected, just CNA don't clean her(R90) privacy area but , does clean her inner thighs and buttocks. According to CNA J second interview, dated 3/26/21, reflected, (named R90) was complaining about care when I was doing her ADL. Talking to the state. She felt that it wasn't good care .After care I reported to nurse. The NHA A statement, dated 3/25/21, with no incident dates, reflected, Director of nursing will reeducate CNA (named CNA P) on ensuring that proper Peri-Care and update care plan as needed. The investigation did not include any interviews with like residents. Review of the facility Perineal Care Policy and Procedure, undated, provided by DON B on 3/31/21 at 10:35 a.m., reflected, PURPOSE 1. To cleanse the perirectal area. 2. To prevent infection and odor. 3. To maintain skin integrity .PROCEDURE .c. Use one gloved hand to stabilize and separate the labia, with the other hand wash from front to back on one side, reposition the mitt using a clean area of the mitt cleanse the other side, and lastly reposition the mitt to cleanse the middle moving front to back . During an interview on 4/06/21 at 9:15 a.m. DON B reported expected peri care to be perform according to the facility Policy and Procedure. DON B reported provided CNA P one on one verbal inservice on 3/30/21 on facility Perineal Care Policy and Procedure because she wanted to make sure CNA P was aware of proper policy. DON B reported did not observe CNA P perform peri care. During an interview on 4/06/21 at 10:47 a.m. DON B reported reliace(training program) had skills check off for observations including peri care. DON B reported CNA P did not have pericare skills check in past yea [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide restorative nursing services, rising to level of immediate jeopardy for 2 residents (Resident #55 and #90) and failed to provide restorative nursing for 6 of 9 residents reviewed for range of motion and mobility (Resident #23, #33, #57, #69, #80, #84), resulting in a facility acquired contracture (Resident #55) and likelihood of pain, and decreased mobility (#23, #33, #57, #69, #80, #84, #90). Findings include: Resident #33 (R33) Resident #33's Minimum Data Set (MDS) assessment dated [DATE], revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 13 (Cognitively Intact 13-15). Restorative Nursing Program Recommendations dated 1/20/21 revealed R33 required active range of motion (AROM, without assistance) to both lower extremities for 2 sets of 20, 3 times a week for 16 weeks. R33's Restorative Nursing Programs Recommendations were not added to her care plan. During an interview on 4/06/21 at 3:26 PM, Certified Nurse Assistant (CNA) JJ stated she had just completed restorative nursing education at the facility. CNA JJ stated she completed passive (Not Active as recommended) ROM of exercise with R33 the day prior with her hands and lower legs. Resident #84 (R84) On 3/29/21 at 10:00 AM, R84 was observed lying in bed wearing a hospital-type gown. R84's hair was not brushed and appeared greasy. R84's Admission MDS dated [DATE], indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 05 (00-07 Severe Impairment). The same MDS assessment indicated R84 had limitations in functional range of motion (limited ability to move a joint that interfered with daily function or placed resident at risk for injury) in both her upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). In review of Physician's Progress Note dated 2/25/21, R84 was a [AGE] year-old female with history of multiple Stage IV pressure ulcers, [CONDITION(S)] (bone infection) of coccyx (tailbone), and diarrhea. R84 underwent multiple debridement's of wounds and completed a six-week course of antibiotic therapy prior to admission. R84's past medical history included septic shock (infection throughout body causing organ injury/damage), [CONDITION(S)] (lack of red blood cells), chronic [CONDITION(S)], dementia, stroke, and right femoral vein deep vein [CONDITION(S)] (DVT, blood clot). R84 had a tube feeding due to protein calorie malnutrition. Physical Therapy (PT) Note dated 2/20/21 through 3/05/21, revealed R84 reported pain during therapy with range of motion exercises. The same note revealed R84 was unable to rate pain but would scream/yell STOP during mobility training. PT note signed 3/12/21 revealed R84's treatment plan included lower extremity passive range of motion exercise in supine (back) position including Hip Flex with knee Flex, Hip Flex with knee extension, Hip Adduction (ADD, toward midline of body)/Abduction (ABD, away from midline of body), Ankle Stretches, 2 sets of 20 in order to improve limb stability and facilitate safety during bed mobility tasks. PT Discharge Summary note signed 3/20/21 revealed R84 was discharged from skilled therapy on 3/19/21. R84 did not meet all set therapy goals, including to increase strength of her lower extremities; and it was recommended she receive restorative nursing for lower extremity range of motion exercises. Restorative Nursing Program Recommendations dated 3/27/21 revealed R84 required passive range of motion (PROM, with assistance) to both lower extremities for 2 sets of 20, 3 times a week for 16 weeks. R84's Restorative Nursing Programs Recommendations were not added to her care plan. During an interview on 3/31/21 at 11:00 AM, Physical Therapist (PT) T stated R84 had been discharged from therapy due to her insurance. PT T stated when R84 was discharged from therapy, she recommended to continue range of motion exercises, however, the facility did not have a restorative therapy program. PT T stated during the same interview that R84 had pain during her therapy sessions, she would wince and cry in pain. PT T stated in the same interview, R84's nurses were aware of her pain. Rehabilitation Therapy Director (RTD) U was interviewed on 3/31/21 at 11:58 AM and stated when she started her position 4 years ago, there was a restorative program, but the facility had and issue with staffing the program. RTD U stated the therapists still made recommendations for restorative nursing onto a form, and that the forms were placed in a folder in her office. RTD U expressed without a restorative program, many residents would decline and return to therapy, it was a vicious cycle. RTD U stated R84 was weak, but therapy would complete a quarterly assessment to see if she could be placed back on therapy services. RTD U stated during the same interview that therapy had worked with residents for oral hygiene, ambulation, sitting on side of bed, their mental state (someone paying attention), and had seen a decline in a week or two after discharge from therapy services. RTD U stated a restorative program would help nurse assistants because residents would require less assistance for resident care. Pain Management Policy dated 11/28/17 indicated suggestive signs and symptoms of pain included resisting cares, groans, crying, and facial grimacing. The same policy indicated non-pharmacological interventions to alleviate pain included exercises to address stiffness and prevent contractures. An immediate jeopardy in failing to provide restorative services after discharge from physical and/or occupational therapy began on 1/12/21. On 4/05/21 at 10:45 AM an immediate jeopardy notice was presented to NHA A. The date the immediate jeopardy was identified was 4/05/21. Immediate Jeopardy was removed on 4/06/21, when the facility had the begun the following: Residents who currently reside in facility with restorative therapy recommendations that had not been implemented were reviewed. 27 residents were identified, 8 are currently on skilled therapy caseload and restorative will resume following completion. Care plans were updated to include the interventions as recommended. -Restorative program implemented. -Resident #55 plan of care plan/ Kardex was updated to include restorative nursing interventions. -Resident # 90 was discharged to hospital on 4/01/2021, the orthotic boot was located by the therapy department on 4/02/2021 and would be implemented upon her return from the hospital. -Restorative Nursing guideline and Restorative Nursing Program Manager Essential Functions were reviewed and determined to be appropriate. Therapy staff were educated on the process for providing the Restorative nursing Program recommendations to the Restorative Nursing Program Manager. -Nursing and activity staff educated on the Restorative Nursing Program Guideline to include process for implementation of a restorative program, ongoing monitoring of program efficacy and any refusals. Staff will enter actual minutes that resident participated in restorative program in Point of Care (POC) program. -Quality Assurance and Performance Improvement (QAPI) meeting was conducted with Management staff. -MDS Registered Nurse (RN) designated as the Restorative Nursing Program Manager. Restorative Nursing Program Manager Essential Functions reviewed with MDS RN. Education provided regarding the daily communication of participation, refusals, or necessary modifications. Interdisciplinary (IDT) team educated on the need to hold monthly meeting, conducted by the Restorative Nursing Program Manager to discuss caseload, need for referral back to skilled therapy for any declines, review of any resident who been discharged from restorative to ensure the resident has maintained or improved function. -QAPI meeting conducted with Medical Director to review immediate jeopardy notice, corrective action, and continuous compliance process. -Regional Directors of Therapy initiated training with CNA's nurses and activities on restorative therapy to include active, passive ROM, use of therabands or weights if ordered. -Skills competency check list for active and passive ROM will be completed by CNA. Return demonstration with therapy department will be completed for braces, splints, weights, therabands when recommended as a restorative intervention by therapy. -Activity staff will be educated on activities that can provide restorative functions, fishing, ball toss, bowling etc. - Director of Nursing (DON) and Restorative Nursing Program Manager are responsible for sustained compliance. -Continued education plan -Nursing staff on duty were educated on the restorative guideline. -Therapy staff were educated on the process for providing restorative referrals to the nursing department for follow up. -No staff will provide resident care until education has been received. -Agency staff will be provided education prior to providing care. -Education will be incorporated into new employee orientation to ensure continuation of process. Resident #23 (R23): Per R23's EMR she was admitted to the facility on [DATE]. Review of R23's BIMS assessment dated [DATE] revealed she had a BIMS score of 15 out of 15 which indication she had no cognitive impairment. No restorative care plan Record Review of a therapy evaluation, dated 3/10/2020, revealed R23 was able to stand. Review of a therapy Evaluation and Treatment, dated 5/30/2020, had a listed goal for R23 to get stronger and be able to walk again. Review of a therapy note, dated 6/13/2020, revealed R23 was not ambulatory and required a mechanical lift device for transfers. Record Review of a Physical Therapy (PT) recommendation, dated 3/25/2020, revealed R23 was recommended to receive restorative services. Review of a PT note revealed R23 had therapy services from 5/30-6/28/2020. The notes revealed, under Discharge Recommendations, R23 was recommended to have a restorative program established and a range of motion program. Record review of R23's Electronic Medical Record (EMR) as of 04/01/21, at 12:00 PM, revealed no documentation that R23 had received any restorative therapy treatment services. Record review of a Minimal Data Set (MDS), dated [DATE], revealed R23 was assessed to require physical assist only with self-performance in bathing. Review of an MDS dated [DATE] revealed R23 had become totally dependent on staff for self-performance in bathing. In an interview on 4/01/2021, at 12:33 PM, Director of Rehab U (DOR) said R23 was referred to and recommended to have restorative services when PT discharged her in June of 2020. DOR U said R23 was picked again for PT on 3/5/2021. DOR U said R23 did not receive any of the recommended restorative services, and said it because there was no restorative services or program at the facility. DOR U said R23 would not have had a decline in her ability to self bath if she would have had restorative services. Resident #57 (R57): Per R57's EMR he was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a PT recommendation, dated 12/18/2020, revealed R57 was recommended by therapy to have restorative services three times per week for 16 weeks. Review of an MDS assessment, dated 7/14/2020, revealed R57 was coded a 2 (assistance needed) for his ability to self perform for transfers, a 1 (independent) for eating, and used a walker for ambulation. Review of an MDS, dated [DATE], revealed R57 was coded a 7 (did not occur) for transfers, a 2 for eating, and required a wheelchair for ambulation. Review of R57's EMR revealed no documentation that R57 had received the PT recommended restorative services three times per week for 16 weeks. Resident #55 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 55 (R55) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 55 scored a 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. Further record review revealed R55 was totally dependent with the assistance from 2 staff for transfers, 1-person extensive assist for dressing and bed mobility, and 1-person physical assist for eating. On 02/04/2021, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The left knee contracture was diagnosed on [DATE]. On 03/23/21 09:55 AM, R55 was observed resting in bed, his legs were observed to be drawn upwards. R55 reported he can't move like he used to and was not currently in therapy. Record review revealed the Physical therapy evaluation dated 09/26/2020 and reflected Functional limitations Present d/t [due to] Contractures=No Physical Therapy Notes dated 9/26/20 and 10/23/20 reflected R55 showed an improvement in bed mobility and transfers with Physical Therapy services. Physical therapy notes dated 11/03/2020 reflected R55 was able to ambulate inside parallel bars 8 feet. Upon the discontinuation of Physical Therapy services (11/03/2020), the Physical Therapist wrote Restorative Nursing Program Recommendations R55's program was to include active range of motion for R55's right lower extremity and active assisted range of motion for R55's left lower extremity. These recommendations were to be completed 3 times a week and to have 2 sets of 20 for 6 weeks. These recommendations made by the Physical Therapist were never implemented. Review of the Physical Therapy evaluation dated 01/12/2021 reflected R55 had a left knee contracture and was no longer able to reposition himself in bed, was no longer able to ambulate and could only move left knee to 120 degrees. It was noted R55's prior level of functioning the left knee was at 90 degrees. The 1/12/2021 Physical Therapy evaluation had the same question as the September 2020 Physical Therapy evaluation did i.e.; Functional limitations Present d/t Contractures , however the 01/12/2021 Physical Therapy evaluation reflected Yes. R55's Physical Therapy evaluation dated 01/12/2021 identified that rolling, propelling the wheel chair, interacting in the environment, repositioning self and transfers had all been negatively impacted by the left knee contracture. On 03/25/21 at 12:29 PM, during an interview with the Director of Rehab (DOR) U, she reported that R55 was evaluated for Physical Therapy in January 2021 as part of their routine quarterly screening and discovered R55's overall decline and contracted left knee, which therapy had ordered a brace for. DOR U reported R55 was managed care and they were waiting for approval from his insurance company for Physical Therapy to begin. On 03/31/21 at 11:05 AM, during an interview with Physical Therapist (PT) T she reported she worked with R55 in January 2021 and discovered the contracture to his left knee which was new and identified during a quarterly screen. PT T reported she was R55's therapist in the fall of 2020 and saw a decline. PT T reported R55 could stand up straight when Physical Therapy was discontinued (11/03/2020) and now R55 could not stand straight. PT T further reported R55 could walk 10 feet with the assistance of 1 staff person and could no longer do that. When queried if R55's abilities could have been preserved or the contracture prevented PT T stated yes, We write programs for them to continue exercises or whatever specific needs they have, but nobody does it. That's why he is contracted now. PT T further reported R55 yells out in pain and is guarded of the left knee area when she tries to stretch the left knee. On 03/31/21 at 11:58 AM during an Interview with DOR U she reported she had been employed at the facility for 4 years. DOR U stated the facility had a restorative program when she was originally hired but the facility had done away with the program 2018. DOR U acknowledged there was a restorative nursing program designed for R55, however since the facility had no such program in place and it was never implemented. DOR U reported several of the residents at the facility could benefit from a restorative nursing program and DOR U had brought it up to management on several occasions, but it Falls on deaf ears. DOR U further reported at this point given R55's contracture and lack of prior interventions never being implemented, He is now at his baseline, I don't see him getting better. Resident #80 Review of the medical record revealed Resident #80 (R80) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] revealed R80 scored 14 out of 15 (cognitively intact on the Brief Interview for Mental Status (BIMS). The MDS revealed R80 received Physical Therapy (PT) Services from 12/31/20 to 1/27/21 and not receiving restorative nursing services. PT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] PT Discharge Summary dated 12/31/20 to 1/27/21, Discharge Recommendations: Patient to stay in this facility after discharge. Patient to follow exercises plan. Review of the [name of therapy services company] Restorative Nursing Program Recommendations dated 1/29/21 revealed Physical Therapy recommended active range of motion (AROM to bilateral lower extremities x2x20 (sets/reps) and To maintain functional ambulation, resident may ambulate 175 feet and/or up to tolerance with a [2 wheeled walker] . Review of R80's care plans revealed no mention of restorative nursing services or a plan. The medical record failed to reveal that the restorative plan was implemented. Resident #69 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R69 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R69 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with bed mobility, dressing, toileting, hygiene and bathing and two person physical assist with transfers and set up assist with locomotion on unit and eating. The MDS reflected R104 did not have any behaviors including rejection of care. The MDS revealed R69 received Physical Therapy (PT) Services starting 9/2/2020 and again on 1/20/21 and did not receive restorative nursing services. During an interview on 03/31/21 at 11:58 a.m., Director of Rehab (DOR) U reported she had been employed at the facility for 4 years. DOR U stated the facility had a restorative program when she was originally hired but the facility had not had restorative program for past three years. DOR U reported several residents have therapy recommendation for restoritive program but facility no longer offers, therefore, restoritive programs were never implemented. During an observation and interview on 4/1/21 at 2:23 p.m., R69 was observed in hall in motorized wheel chair outside room and appeared calm and pleasant. R69 moved to room and reported concerns about lack of therapy services at facility. R60 appeared to have bilateral hand contractures and reported no use of bilateral legs. R69 reported facility staff have never performed passive range of motion or exercise with him or given exercises to perform with exception of short time R69 was seen by therapy staff several months ago. R69 reported concern that without therapy contractures will worsen and could develop new contractures. According to the, [name of therapy services company] Restorative Nursing Program Recommendations, dated 6/4/2020 and 2/3/21 reflected, R69 had recommendations for Passive Range of Motion to maintain Range of motion and prevent contractures. Review of R69's care plans revealed no mention of restorative nursing services or a plan. The medical record failed to reveal that the restorative plan was implemented. Resident #90 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R90 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R90 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers and one person physical assist with locomotion on unit, toileting, dressing, hygiene, and bathing. The MDS revealed R90 received Physical Therapy (PT) Services starting 2/9/21 and did not receive restorative nursing services including splint or brace assistance. During an observation and interview on 3/23/21 at 11:41 a.m., signs were located on R90 closed door that reflected isolation precautions and call light was on. Staff at nurse station reported all rooms on floor required use of full Personal Protective Equipment (PPE), gown, mask, eye protection and gloves to enter. This surveyor donned appropriate PPE, knocked on R90 door and obtained permission to enter from R90. R90 was sitting in bed with hospital gown on and call light on above door in hall, light indicator at call light plug in did not appear to be functioning. R90 appeared calm, pleasant and alert and oriented times three. R90 did not have any braces or splints in place. Review of the Base Line Care Plan, dated 11/4/21, for R90 reflected, Focus: The resident has an alteration in musculoskeletal status (SPECIFY) r/t, Goal: The resident will remain free of injuries or complications related to (SPECIFY) review date. Intervention: (SPECIFY: Encourage/supervise/assist) the resident with the use of supportive devices (SPECIFY: splints, braces, canes, crutches etc.) as recommended. Care plans did not appear to be individualized. Review of the Care Plans dated 1/11/21 through 5/3/21, for R90 revealed no mention on contracture splint for right ankle. During an interview on 4/1/21 at 10:17 a.m. Director of Rehab (DOR) U reported R90 had been evaluated and recommendation for Right ankle splint. DOR U reported no decline in R90 right ankle contracture, however, splint had been missing for about a month since R90 moved rooms related to COVID and reported to NHA A and was sill missing. DOR U reported R90 splint was ordered to help reduce pain. Review of the [named therapy] Rehabilitation Screen form, dated 12/12/20, reflected R90 was assessed by Physical Therapy and comments included, Resident could benefit form contracture splint for Rt. ankle. Referral placed with [names supplier], paperwork pending Dr's signatures .Resident will be reevaluated upon receipt of Rt ankle contracture splint. Review of the [named therapy] Rehabilitation Screen form, dated 2/9/21, reflected R90 was assessed by Physical Therapy and comments included, Resident received her Rt. ankle contracture splint(PRAFO) from [named supplier] in [DATE]. PT evaluation & Tx warranted to establish wearing schedule, [arrow up] ROM & reduce severity of contracture. Review of the Nursing Progress Notes, dated 3/7/2021 at 9:29 p.m., for R90, reflected, Resident was moved to room .on the COVID side of the unit. Review of the Immediate Jeopardy Removal plan, dated 4/6/21, reflected, Resident # 90 was discharged to hospital on 4/1/2021, the orthotic boot was located by the therapy department on 04/02/2021 and will be implemented upon her return from the hospital. Review of the Restorative Nursing Program Progress Note, dated 4/4/21 at 9:21 p.m., reflected R90 Resident has been admitted to the Restorative Nursing Program for AAROM 2 sets/20 reps on 4/4/21. Restorative services are indicated to maintain functional strength plan is to initiate program and monitor residents progress and adjust interventions and goals as indicated. R90 was currently admitted to hospital. During an interview on 4/07/21 at 12:41 p.m., Regional Therapy Manager(RTM) LL reported no knowledge of R90 splint located and reported DOR U not working that day. During an interview on 4/07/21 at 1:59 p.m., RTM LL reported R90's right ankle contracture splint was located on 4/2/21 in the facility basement by Physical Therapist T. RTM LL reported was by facility to educate nurse staff, cna, activity staff on restoritive program and how to do proper and safe Range of Motion (ROM) and splint placement and monitoring and safe use of assistive devices. RTM LL reported education included return demonstration. RTM LL reported Restoritive orders go to MDS department. During an interview on 4/7/21 at 2:11 p.m. Certified Nurse Assistant(CNA) N reported performed restoritive services after receiving education from DON B recently and document times. CNA N reported was unsure what passive ROM was and reported did not received education from rehab staff yesterday or current day(4/7/21). During an interview on 4/7/21 at 2:29 PM CNA N reported no training from therapy department related to restoritive program. CNA N reported received phone call with and was provided education related to restoritive program on 4/6/21. The Immediate Jeopardy was removed on 4-6-21, however the deficient practice continued at isolated with actual harm that is not immediate jeopardy as sustained compliance could not be validated by the state agency.

This Citation Pertains to MI 259. Based on observation, interview, and record review, the facility failed to thoroughly investigate and prevent further potential abuse in 4 of 6 residents reviewed for abuse (Resident #47, #48, #55, #90), resulting in fears of reprisal (Resident #48, #55) and frustration (Resident #47, #90). Findings include: Resident #47 (R47) R47 was observed sitting in his wheelchair in his room on 3/22/21 at 2:37 PM. During an interview, R47 stated that the staff treated him like crap and the staff threaten him; they tell him they are going to get in in trouble. R47 stated in the same interview, he had seen a staff member slap a resident in room [ROOM NUMBER] because her bed was cranked all the way up. R47 did not recall the staff members name but described her as frequently complaining that she was going to quit her job. R47 stated that he had reported the incident to the ombudsman and to Nursing Home Administrator (NHA) A. R47 stated NHA A had told him the staff member he saw slap another resident, would not provide care for him. R47's Comprehensive Minimum Data Set (MDS) 3.0 dated 1/07/21, indicated he was [AGE] years-old, admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 12 (08-12 Moderate Impairment). The same MDS assessment indicated R47 did not have any physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) or other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), during the 7 day look-back period. The same MDS assessment indicated R47 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of Psychiatric Consult dated 2/09/21, R47 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's Psychiatric Consult dated 3/10/21, revealed he reported continued depression due to his situation and being isolated. R47 also reported sadness and feeling frustrated. On 3/24/21 at 3:38 PM, during an interview with NHA A, he indicated he was contacted by the ombudsman regarding R47's complaint in witnessing a staff member strike another resident. NHA A did not recall the date he was notified by the ombudsman. NHA A stated he interviewed R47 following the call from the ombudsman and R47 had told him that the incident occurred 2 to 3 years ago and he saw a nurse spank a resident. NHA A stated he interviewed Licensed Practical Nurse (LPN) E and she claimed she had never hit anyone. NHA A stated LPN E had claimed there was a disagreement in R47's transfer status; R47 requested to be transferred using the sit-to-stand lift when his care plan indicated he was a total lift (Hoyer) for transfers. NHA A stated LPN E was no longer assigned to provide care for R47. NHA A stated in the same interview he did not report the allegation to the State Agency, further investigate or document the allegation because R47 stated it had happened 2 to 3 years ago. NHA A stated he did not ask LPN E if she referred R47 to therapy for a transfer evaluation. In review of R47's activities of daily living care plan dated 11/26/19, R47's transfer instructions included use of the sit-to-stand lift or the Hoyer lift as needed. On 3/24/21 at 4:30 PM NHA A stated he had contacted the ombudsman and based on her notes, was notified of R47's allegation of abuse on 3/10/21. NHA A stated R47 had reported the incident occurred 2 to 3 years ago. NHA A stated he was aware that R47 was admitted to the facility on [DATE], less than 2 to 3 years ago. NHA A stated during the same interview therapy had evaluated R47 for transfers in February 2021, and they determined he was only safe for Hoyer lift transfers. NHA A stated in the same interview he did not interview other residents or staff following the abuse allegation. NHA A stated LPN E was still R47's assigned nurse, but another nurse administered his medications after she set them up. During an interview on 3/25/21 at 8:57 AM, R47 stated NHA A came into his room the day before and felt like they were storm trooping me. R47 stated he felt ambushed and had to initial something he did not read. R47 reported to this writer again that he saw LPN E slap a resident in room [ROOM NUMBER]. On 3/25/21 at 9:35 AM, NHA A stated last evening he went to talk with R47 with 2 witnesses. NHA A stated R47 did not recall the incident of LPN E slapping/spanking a resident and had him sign a questionnaire. In review of the document titled Residents Questionnaire, dated 3/24/21, R47's name was printed on top of the document. The document had 5 questions, Has anyone made you feel uncomfortable; Have you experienced or observed any type of abuse; Do you feel safe at the building; Do you have any concerns with your roommates; and Do you feel comfortable speaking with administration about any concerns. The bottom of the same document indicated NHA A and LPN Unit Manager I signed the document under the signature line. During an interview on 3/25/21 at 1:00 PM, Ombudsman FF stated she received a telephone call on 3/10/21 from R47 and he conveyed LPN E was verbally abusive to him and he had seen LPN E be physically abusive to another resident. Ombudsman FF stated 3/10/21 was the first time R47 called her. Ombudsman FF stated she notified NHA A on the same day, 3/10/21 of the allegation of abuse. Ombudsman FF stated she called R47's mother and suggested to set up a care conference. During an interview on 3/25/21 at 1:36 PM, R47's mother stated R47 has only complained of the same person at the facility, LPN E. R47's mother stated he was not good with remembering names, he has a memory deficit, and history of a closed head injury. R47's mother stated the ombudsman did suggest scheduling a care conference but was not able to get through to anyone when she calls. R47's mother stated R47 has tried to set it up a care conference also and had not been successful. During an interview on 3/30/21 at 9:56 AM, LPN E stated R47 did not want her to be his nurse, that he was like a jealous husband, he yells and then makes up. LPN E stated she referred R47 to therapy because he was unsafe in his motorized wheelchair. LPN E stated she had not transferred R47 with the sit to stand lift or the Hoyer lift. LPN E denied hitting a resident and stated she wrote a statement and submitted it to NHA A. Resident #55 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident # 55 (R55) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 55 scored a 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. On 03/23/21 at 10:07 AM, R55 reported Certified Nursing Assistant (CNA) yelled at him to sit up straight and pushed him in the side of his head, R55 stated he could not remember her name, but was convinced he could Pick her out of a crowd, R55 further stated he reported it to the Physician Assistant (PA) R yesterday. On the same day, at approximately 10:15am, this surveyor met with Administrator A who stated he had no allegations of abuse had been reported to him related to R55. R55's allegation of abuse was conveyed to Administrator A at that time. On 3/23/21 at approximately 1:00PM, Administrator A and Licensed Practical Nurse /Unit Manager (LPN/UM) I stopped surveyor at 3rd floor nursing station, to inform writer that R55 conveyed to LPN/UM I that he said he was touched upside the head and told to sit up straight but then he started talking about [MEDICATION(S)] trees and stuff, ya know he is confused. Administrator A stated he too interviewed resident and he (R55) denied being abused, just that the CNA was rough. Administrator A reported he did not suspend any staff pending investigation. On 03/24/2021 at 4:36pm, during a phone interview with PA R he reported he did in fact see and held a conversation with R55 on Monday 3/22/2021 but did not recall R55 making an allegation of abuse. PA R stated The Administrator already made me sign a statement to that affect. On 03/30/21 at 02:44 PM, review of Administrator A's facility reported incident and 5- day investigation of the alleged abuse reflected the alleged perpetrator was CNA N. The written interview Administrator A had with Resident # 55 reflected in part . He said she was a little ruff (sic) with adjusting him. Further review of the 5-day facility reported incident reflected CNA N was educated on proper handling of patients when adjusting them in bed. The facility reported incident was reviewed in its entirety and did not include one interview from any other residents, including R55's roommate at the time, who was documented to be alert and oriented times three. On 03/31/21 at 08:55 AM, during an interview with Administrator A, the facility reported incident was reviewed. Administrator A acknowledged and agreed R55 told Administrator A that CNA N was rough when caring for him. Administrator A was queried if he had probed further as to what R55 meant by rough or gave an example. Administrator A did not. When queried if rough was considered abuse, Administrator A stated no, that CNA N just moved too fast and R55 was already in pain. Administrator A reiterated that CNA N received training for proper handling. The training given to CNA N was requested at that time. Administrator A reported he completed his investigation on 3/30/2021 and did not substantiate abuse. When queried if CNA N was suspended during the investigation in order to protect R55 (as directed per facility policy), Administrator A stated CNA N was suspended at the end of the day on 3/23/21 and allowed to return to work 3/24/21, despite the investigation that was not completed until 3/30/2021. Administrator A was asked what was the put in place to protect R55 until his investigation was completed. Administrator A did not respond. When queried why the investigation did not include any interviews from any other residents, Administrator A did not respond. Resident #48(R48) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R48 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R48 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired, and he required one person physical assist with bed mobility, transfers, toileting, dressing, hygiene, and bathing. R48's MDS reflected no behaviors including, physical, verbal or refusal of care. During an interview and observation on 3/24/21 at 11:05 AM R48 stated, I was assaulted by (named Certified Nurse Assistant((CNA F)) on 3/4/21 and told (named Administrator((NHA A)) on 3/5/21. R48 reported CNA F was rough during care on 3/4/21 and hurt his neck. R48 reported after speaking with NHA A on 3/5/21 was told CNA F would not care for him again and an x-ray would be ordered. R48 reported he continues to have neck pain and had not yet received neck x-ray and CNA F worked with him again on 3/21/21. R48 reported did not feel safe here and began to cry and tears noted. R48 reported NHA A lied to him and reported fear of, reprisal. During an interview on 3/25/21 at 11:04 a.m. NHA A reported R48 did not have any abuse allegations in past three months. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . UM reported that resident was very agitated when CENA tried to provide care. Resident seen in bed awake and alert. Resident stated he was not wet when CENA came in to change his brief. He said the CENA attempted to check to see if he was wet and he reach out to block the CENA and now his neck hurts and will like X-Ray of neck. Resident assessed. No signs of trauma or bruises noted. Resident able to turn his neck from left to right but states it hurts when he turn. Of note resident has a history of chronic pain secondary to [CONDITION(S)]. Was started on antibiotic yesterday for UTI. X-Ray of neck ordered, pain meds given. Will monitor. During an interview on 3/25/21 at 1:51 p.m. CNA F reported working at the facility for nine years and usually day shift and often works double shifts(7a-10p) four days per week. CNA F reported was familiar with R48. After this surveyor asked CNA F to describe R48, CNA F reported R48 sometimes was incontinent of urine and thought he didn't and stated, he was wet that morning. This surveyor asked, what morning was CNA F referring too? CNA F reported the day that R48 became verbally upset with CNA F and began physically swinging at CNA F. CNA F reported R48 did not believe he was wet and became physically and verbally agitated during care on 3/4/21 around 9:30 a.m. CNA A reported smell of urine but R48 argued he was not wet. CNA F reported she said, let me change you. CNA F she turned R48 on side who grabbed bar while linens were changed and R48 started swinging arms and cussing calling CNA F names. CNA F reported no physical contact was made. CNA F reported collected items, exited room and informed agency nurse but unsure of name and reported completed statement and gave to NHA A the next day. CNA F reported worked next day 7:00 a.m. to 10:00 p.m. and was assigned to R48 and R48 told her he did not want CNA F in room because she had tried to through him out of bed day prior. CNA F informed nurse and they spoke to R48 and was then told by NHA A she would no longer be assigned to R48 care. CNA F reported she recalled R48 complained of neck pain during care on 3/4/21 and an X-ray was ordered. CNA F reported worked Sunday 3/21/21 on 4th floor south and had told nurse could not go in R48 room because NHA A had told her not to care for R48. CNA F reported nurse told CNA F assignments could not be switched to other aid and told CNA F to address roommates needs and nurse would address R48 needs. CNA F reported as soon as she entered R48 room and said name to R48 roommate, R48 became agitated, started calling her names and yelling. CNA F reported had not been required to be off work related to event. CNA F reported last abuse training at facility was last week and everyone received abuse training after event. During an interview on 3/25/21 at 2:37 p.m. CNA J reported working at the facility for four months and received abuse training at that time and again 2 weeks ago. CNA J reported all abuse allegations should be reported to supervisor who was often the nurse who would then reports to NHA A. During an interview on 3/25/21 at 4:25 p.m. NHA A reported there was not an investigation for R48 for 3/4/21 incident because R48 did not report why he did not want CNA F back in the room. NHA A reported was told by CNA F that she had provided R48 care on 3/4/21 and after shower R48 started swinging at CNA F and calling racial slurs and being combative. NHA A reported he spoke with R48 on 3/5/21 who complained of a sore neck. After this surveyor asked, what did R48 report to him? NHA A stated, nothing except missing items and sore neck. (named R48)did not mention anyone hitting or abusing him so I did not do investigation. NHA A reported was aware of one incident that CNA F entered R48 room after 3/4/21 event and was again told not to go in R48 room. NHA A reported CNA F did provided written statement because of incident and would try to locate statement. Review of the Medication Administration Record(MAR), dated 3/1/21 through 3/31/21, reflected R48 had 0 out of 10 pain on pain scale(0=no pain, 10=highest pain) on 3/3/21 and 7 to 8 out of 10 on pain scale 3/4/21 through 3/6/21. Review of Kardex, dated 3/31/21, reflected no documentation that reflected resident and NHA request related to caregivers. Review of the Nursing Progress Notes, dated 3/12/2021 at 10:53 p.m., reflected, Patient AOX3 able to make needs known, no respiratory discomfort noted, no c/o sob, c/o pain [MEDICATION(S)] prn as ordered . During an interview on 4/05/21 at 12:19 p.m., Social Worker (SW) L reported R48 had requested to speak with Social Worker on 3/5/21. SW L reported R48 informed her that CNA F was rough during care on 3/4/21 and did not want CNA F performing any further care for him. SW L reported CNA F reported R48 was wet and needed to be changed so CNA F changed R48 soiled brief and R48 became agitated. SW L reported CNA F was told by NHA A not to provided care or enter R48 room. SW L reported when made aware of information from R48 about CNA F care she would report to Abuse Coordinator, NHA A. SW L reported R48 incident on 3/4/21 had been reported to NHA A by RNUM prior to SW L interview with R48. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Seen by (named physician), rheumatologist as a f/u on 3/31/2021. No evidence of [CONDITION(S)], serologies were negative for [CONDITION(S)]. Recommends referral to see neurologist. Appt scheduled for 4/14/2021 . During an interview on 4/06/21 at 3:30 PM Registered Nurse Unit Manager (RNUM) II verified R48 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/6/21 at 3:30 p.m., observed CNA F working on fourth floor, talking with staff near nurse station. During an interview on 4/07/21 at 10:45 a.m., Director of Operations, Acting NHA (DO) EE reported R48's abuse allegation was reported 4/6/21, and CNA F was not suspended because was more of a handling concern and not abuse. During an interview on 4/07/21 at 1:28 p.m. Director of Nursing (DON) B reported was current interim Abuse Coordinator with history of Abuse Coordinator title. When asked to name seven elements of abuse was unable to recall all 7 elements of abuse. When asked when abuse allegation should be reported? DON B reported abuse allegation were required to be reported within 24 hours and (DO) corrected DON B by answering, two hours. During an interview on 4/07/21 at 3:50 p.m. DON B provided R48 neck X-ray dated 3/27/21. DON B verified R48 neck X-ray was ordered 3/5/21 and verified no documentation to reflect delay of X-ray performed on 3/27/21. Resident #90(R90) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R90 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R90 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers and one person physical assist with locomotion on unit, toileting, dressing, hygiene, and bathing. During an observation and interview on 3/23/21 at 11:41 a.m., signs were located on R90 closed door that reflected isolation precautions and call light was on. Staff at nurse station reported all rooms on floor required use of full Personal Protective Equipment (PPE), gown, mask, eye protection and gloves to enter. This surveyor donned appropriate PPE, knocked on R90 door and obtained permission to enter from R90. R90 was sitting in bed with hospital gown on and call light on above door in hall, light indicator at call light plug in did not appear to be functioning. R90 reported currently waiting for staff to answer call light because of need to use bathroom. R90 request to have this surveyor wait in room. R90 reported frequent long call light response greater than one hour and had been waiting since 11:20 a.m. at that time. R90 appeared calm and pleasant, hair appeared greasy and unkept with moderate amount long facial hair observed on R90 chin area. R90 reported she felt embarrassed to have facial hair but required assistance from staff because of being blind and staff had not provided assistance. CNA J entered R90 room with full PPE on and R90 reported need to be changed. CNA J reported need to get fitting sheet from hall and removed PPE and exited R90 room. CNA J returned to R90 room with no gown. CNA J asked R90 if it was ok for surveyor to observe person care and R90 verbalized permission for this surveyor to observe care. At 11:56 a.m. CNA J assisted R90 turn on side with gloves, eye protection and mask in place and no gown. CNA J performed peri care and used call light at 12:09 p.m. for additional assistance. CNA J reported at that time had forgot to put on gown prior to entering R90 room. At 12:13 p.m. RNUM II entered R90 room to assist with boosting R90 up in the bed. This surveyor heard R90 report to CNA J that CNA P will not wash peri area when changing R90 brief because it was against CNA P religion and was always short with her, what do you want? During an interview on 3/25/21 at 2:37 p.m. CNA J reported had worked at the facility for four months and received abuse training at that time and again two weeks ago. CNA J reported if abuse is allegation of abuse was suspected it was CNA J job to report to supervisor immediately. This surveyor asked CNA J if R90 had reported any care concerns to CNA J at the time this surveyor was observing care on 3/23/21? CNA J reported R90 had reported CNA P did not perform peri care because it was against her religion. CNA J reported that was an example of neglect and reported to the nurse Licensed Practical Nurse (LPN) JJ that day. CNA J reported was not asked to complete witness statement. CNA J reported it was her job to report and she did. During an interview on 3/25/21 at 11:04 a.m. NHA A reported R90 did not have any abuse allegations in past month. During an interview on 3/25/21 at 4:35 p.m. NHA A reported again not aware of abuse allegation from 3/23/21 for R90. NHA A reported was not notified of R90 being mistreated by staff or anything like that. NHA A reported would expect staff to report any abuse allegations to him or supervisor immediately. During an interview on 3/31/21 at 10:05 a.m. NHA A reported completed investigation related to R90 on 3/25/21. NHA A stated, (named R90) only complained about one CNA staff that did not perform pericare cleaning center of peri area. NHA A reported R90 reported feeling safe. NHA J reported CNA J was present during interview with R90. This surveyor asked why R90 investigation reflected this surveyor had informed NHA A about care concerns when R90 had reported care concerns to CNA J while this surveyor was present? NHA J verified that it was reported that this surveyor was present when R90 reported care concerns to CNA J on 3/23/21. NHA A reported all allegation are expected to be reported to supervisor or NHA immediately. NHA A reported did not feel this situation was abuse. According to the facility Investigation, dated 3/25/21, reflected an interview with R90 with NHA A, DON B, and CNA J present was done on 3/25/21. The investigation reflected R90 was asked directly if she felt abused or neglected. According to the investigation R90 reported, she(R90) voiced to the Surveyor and CNA that she felt one CENA did not clean the center of her vagina very well. Also informed the surveyor how the 1 CENA had informed her how it was against her religion to clean the center of her vagina .but stated the 1 CENA did clean her buttocks and side of her vagina very well.(no dates included on investigation). According to CNA J interview, dated 3/25/21, reflected, just CNA don't clean her(R90) privacy area but , does clean her inner thighs and buttocks. According to CNA J second interview, dated 3/26/21, reflected, (named R90) was complaining about care when I was doing her ADL. Talking to the state. She felt that it wasn't good care .After care I reported to nurse. The NHA A statement, dated 3/25/21, with no incident dates, reflected, Director of nursing will reeducate CNA (named CNA P) on ensuring that proper Peri-Care and update care plan as needed. The investigation did not include any interviews with like residents. Review of the facility Perineal Care Policy and Procedure, undated, provided by DON B on 3/31/21 at 10:35 a.m., reflected, PURPOSE 1. To cleanse the perirectal area. 2. To prevent infection and odor. 3. To maintain skin integrity .PROCEDURE .c. Use one gloved hand to stabilize and separate the labia, with the other hand wash from front to back on one side, reposition the mitt using a clean area of the mitt cleanse the other side, and lastly reposition the mitt to cleanse the middle moving front to back . During an interview on 4/06/21 at 9:15 a.m. DON B reported expected peri care to be perform according to the facility Policy and Procedure. DON B reported provided CNA P one on one verbal inservice on 3/30/21 on facility Perineal Care Policy and Procedure because she wanted to make sure CNA P was aware of proper policy. DON B reported did not observe CNA P perform peri care. During an interview on 4/06/21 at 10:47 a.m. DON B reported (name of training program) had skills check off for observations including peri care. DON B reported CNA P did not have pericare skills check in past year.

Based on observation, interview, and record review the facility failed to update and or revise care plans for 6 residents (Resident #43, #55, #69, #80, #84, and #90) of 24 residents reviewed for care plan revisions resulting in the potential for increased depression for R43, no restorative therapy deemed necessary by the Physical Therapy Department for Resident #55, #69, #80, #84 and #90, resulting in a contracture of the left knee and decreased functional status for Resident #55, and the potential for decline in functional status for Resident #69, #80, and #84. Findings include: Resident #43 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], Resident 43 (R43) was a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS revealed R43 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview Mental Status (BIMS). Further review of the clinical record revealed care conference notes dated 12/22/2020 with a concern that R43 was experiencing increased depression related to her upcoming divorce. Review of the Social Work (SW) progress notes dated 3/31/2021 reflected SW was made aware of behavior change for R43 and that a comment was made in relation to her signing her divorce papers, Mood reported different than usual. There was no explanation to how R43's mood was different or what R43's behavior change was. Review of R43's care plan had no updates, interventions or acknowledgment of the psychosocial struggle endured by R43 due to her impending divorce. Resident #55 According to the clinical record, including the Minimum Data Set (MDS), dated [DATE], Resident # 55 (R55) was a [AGE] year old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 55 scored a 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status. Further record review revealed R55 was totally dependent with the assistance from 2 staff for transfers, 1-person extensive assist for dressing and bed mobility, and 1-person physical assist for eating. On 02/04/2021, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The left knee contracture was diagnosed on [DATE]. On 03/23/21 09:55 AM, R55 was observed resting in bed, his legs were observed to be drawn upwards. R55 reported he can't move like he used to and was not currently in therapy. Record review revealed the Physical therapy evaluation dated 09/26/2020 reflected Functional limitations Present d/t [due to] Contractures=No. Physical Therapy Notes dated 9/26/20 and 10/23/20 reflected R55 showed an improvement in bed mobility and transfers with Physical Therapy services. Physical therapy notes dated 11/03/2020 reflected R55 was able to ambulate inside parallel bars 8 feet. Upon the discontinuation of Physical Therapy services (11/03/2020), the Physical Therapist wrote Restorative Nursing Program Recommendations R55 's program was to include active range of motion for R55's right lower extremity and active assisted range of motion for R55's left lower extremity. These recommendations were to be completed 3 times a week and to have 2 sets of 20 for 6 weeks. These recommendations made by the Physical Therapist were never implemented. Review of R55's care plans did not reflect that Therapy's recommendations were ever implemented on a care plan. Review of the Physical Therapy evaluation dated 01/12/2021 reflected R55 had a left knee contracture and was no longer able to reposition himself in bed, was no longer able to ambulate and could only move his left knee to 120 degrees. It was noted R55's prior level of functioning the left knee was at 90 degrees. The 1/12/2021 Physical Therapy evaluation had the same question as the September 2020 Physical Therapy evaluation did i.e.; Functional limitations Present d/t Contractures , however the 01/12/2021 Physical Therapy evaluation reflected Yes. R55's Physical Therapy evaluation dated 01/12/2021 identified that rolling, propelling the wheel chair, interacting in the environment, repositioning self and transfers had all been negatively impacted by the left knee contracture. On 03/31/21 at 11:05 AM, during an interview with Physical Therapist (PT) T she reported she worked with R55 in January 2021 and discovered the contracture to R55's left knee which was new and identified during a quarterly screen. PT T reported she was R55's therapist in the fall of 2020 and saw a decline. PT T reported R55 could stand up straight when Physical Therapy was discontinued (11/03/2020) and now R55 could not stand straight. PT T further reported R55 could walk 10 feet with the assistance of 1 staff person and can no longer do that. When queried if R55's abilities could have been preserved or the contracture prevented PT T stated yes, We write programs for them to continue exercises or whatever specific needs they have, but nobody does it. That's why he is contracted now. PT T further reported R55 yells out in pain and is guarded of the left knee area when she tries to stretch the left knee. On 03/31/21 at 11:58 AM during an Interview with Director of Rehab (DOR) U she reported she had been employed at the facility for 4 years. DOR U stated the facility had a restorative program when she was originally hired but the facility had done away with the program in 2018. DOR U acknowledged there was a restorative nursing program designed for R55, however since the facility had no such program in place it was never implemented. Further review of R55's kardex (a tool utilized by Certified Nursing Assistants on how to provide care) dated 04/01/2021 did not reflect recommendations for restorative program designed by Physical Therapy. Resident #84 (R84) On 3/24/21 at 9:22 AM, R84's family member stated during an interview concerns that R84 looked terrible during a face time visit she had with her earlier in the same week. R84's family member stated when talking to the staff earlier, the nurse assistant stated R84 was always asking for water, R84's family member stated she told the nurse assistant to give her some water. On 3/29/21 at 10:00 AM, R84 was observed lying in bed wearing a hospital-type gown. R84's hair was not brushed and appeared greasy. There was no water glass observed in R84's area of the room. R84's Admission MDS dated [DATE], indicated she was admitted to the facility on [DATE] and had a BIMS score of 05 (00-07 Severe Impairment). R84 was totally dependent (full staff performance every time during entire 7-day look-back period) for transfers, eating, toilet use, personal hygiene, and bathing. The same MDS assessment indicated R84's Functional Range of Motion (limited ability to move a joint that interfered with daily functioning or placed resident at risk of injury) was impaired on both sides of her upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). The same MDS assessment indicated R84 was admitted to the facility with 2 stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle), 1 stage III pressure ulcer (full thickness tissue loss without bone, tendon or muscle exposed), and 1 stage II pressure ulcer(partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed). The same MDS assessment, under skin and ulcer treatments, indicated R84 did not have a turning/repositioning program (program that specified the intervention (e.g., reposition on side, pillows between knees) and frequency of position change (e.g., every 2 hours). A physicians order dated 3/18/21 at 2:55 PM indicated R84 was ordered a pleasure tray for meals consisting of a pureed texture, thin consistency, one to one assist when alert, 90 degree positioning, small bites/sips, alternate liquids and solids, and to monitor for signs and symptoms of aspiration and/or pneumonia. This order was not added to R84's care plans. R84's Activities of Daily Living care plan dated 2/23/21 indicated an intervention dated 3/18/21 the resident is NPO [nothing by mouth, solids and liquids] and receives a tube feeding by nursing. The same care plan did not include order or instructions for pleasure feedings. R84's Tube Feeding care plan dated 2/23/21, revealed she required a tube feeding related to NPO status. R84's Nutrition care plan dated 2/22/21 indicated diet was NPO. In review of R84's pleasure tray tickets, dated 3/25/21, she had yogurt, mashed potatoes, pudding/ice cream for meals that day. Feeding instructions were not included on the tray tickets. On 3/25/21 at 3:37 PM, Unit Manager I stated she updated the ADL care plans and dietary updated the tube feeding care plan for R84. UM I stated in the same interview, R84's pleasure foods just started 3/25/21. When the order for R84's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Unit Manager (UM) I was interviewed on 3/30/21 at 9:18 AM and stated she did not know why R84 did not have drinking water in room. R84's Skin Integrity impairment care plan dated 2/23/21 indicated to use a draw sheet or lifting device to move resident. A draw sheet was not observed during incontinence care on 3/30/21at 10:29 AM or when repositioning R84 on 3/30/21 at 11:12 AM during wound care. Resident #80 Review of the medical record revealed Resident #80 (R80) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] revealed R80 scored 14 out of 15 (cognitively intact on the Brief Interview for Mental Status (BIMS). The MDS revealed R80 received Physical Therapy (PT) Services from 12/31/20 to 1/27/21 and did not receive restorative nursing services. Review of the PT Evaluation & Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PT Discharge Summary dated 12/31/20 to 1/27/21 revealed Discharge Recommendations: Patient to stay in this facility after discharge. Patient to follow exercises plan. Review of the [name of therapy services company] Restorative Nursing Program Recommendations dated 1/29/21 revealed Physical Therapy recommended active range of motion (AROM to bilateral lower extremities 2x20 (sets/reps) and To maintain functional ambulation, resident may ambulate 175 feet and/or up to tolerance with a [2 wheeled walker] . Review of R80's care plans revealed no mention of restorative nursing services or a plan. The medical record failed to reveal that the restorative plan was implemented. Resident #69 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R69 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R69 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with bed mobility, dressing, toileting, hygiene and bathing and two person physical assist with transfers and set up assist with locomotion on unit and eating. The MDS reflected R104 did not have any behaviors including rejection of care. The MDS revealed R69 received Physical Therapy (PT) Services starting 9/2/2020 and again on 1/20/21 and did not receive restorative nursing services. During an interview on 03/31/21 at 11:58 a.m., Director of Rehab (DOR) U reported she had been employed at the facility for 4 years. DOR U stated the facility had a restorative program when she was originally hired but the facility had not had restorative program for past three years. DOR U reported several residents have therapy recommendation for restoritive program but facility no longer offers, therefore, restoritive programs were never implemented. During an observation and interview on 4/1/21 at 2:23 p.m., R69 was observed in hall in motorized wheel chair outside room and appeared calm and pleasant. R69 moved to room and reported concerns about lack of therapy services at facility. R60 appeared to have bilateral hand contractures and reported no use of bilateral legs. R69 reported facility staff have never performed passive range of motion or exercise with him or given exercises to perform with exception of short time R69 was seen by therapy staff several months ago. R69 reported concern that without therapy contractures will worsen and could develop new contractures. According to the, [name of therapy services company] Restorative Nursing Program Recommendations, dated 6/4/2020 and 2/3/21 reflected, R69 had recommendations for Passive Range of Motion to maintain Range of motion and prevent contractures. Review of R69's care plans revealed no mention of restorative nursing services or a plan. The medical record failed to reveal that the restorative plan was implemented. Resident #90 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R90 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R90 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers and one person physical assist with locomotion on unit, toileting, dressing, hygiene, and bathing. The MDS revealed R90 received Physical Therapy (PT) Services starting 2/9/21 and did not receive restorative nursing services including splint or brace assistance. During an observation and interview on 3/23/21 at 11:41 a.m., signs were located on R90 closed door that reflected isolation precautions and call light was on. Staff at nurse station reported all rooms on floor required use of full Personal Protective Equipment (PPE), gown, mask, eye protection and gloves to enter. This surveyor donned appropriate PPE, knocked on R90 door and obtained permission to enter from R90. R90 was sitting in bed with hospital gown on and call light on above door in hall, light indicator at call light plug in did not appear to be functioning. R90 appeared calm, pleasant and alert and oriented times three. R90 did not have any braces or splints in place. Review of the Base Line Care Plan, dated 11/4/21, for R90 reflected, Focus: The resident has an alteration in musculoskeletal status (SPECIFY) r/t, Goal: The resident will remain free of injuries or complications related to (SPECIFY) review date. Intervention: (SPECIFY: Encourage/supervise/assist) the resident with the use of supportive devices (SPECIFY: splints, braces, canes, crutches etc.) as recommended. Care plans did not appear to be individualized. Review of the Care Plans dated 1/11/21 through 5/3/21, for R90 revealed no mention on contracture splint for right ankle. During an interview on 4/1/21 at 10:17 a.m. Director of Rehab (DOR) U reported R90 had been evaluated and recommendation for Right ankle splint. DOR U reported no decline in R90 right ankle contracture, however, splint had been missing for about a month since R90 moved rooms related to COVID and reported to NHA A and was sill missing. DOR U reported R90 splint was ordered to help reduce pain. Review of the [named therapy] Rehabilitation Screen form, dated 12/12/20, reflected R90 was assessed by Physical Therapy and comments included, Resident could benefit form contracture splint for Rt. ankle. Referral placed with [names supplier], paperwork pending Dr's signatures .Resident will be reevaluated upon receipt of Rt ankle contracture splint. Review of the [named therapy] Rehabilitation Screen form, dated 2/9/21, reflected R90 was assessed by Physical Therapy and comments included, Resident received her Rt. ankle contracture splint(PRAFO) from [named supplier] in [DATE]. PT evaluation & Tx warranted to establish wearing schedule, [arrow up] ROM & reduce severity of contracture. Review of the Nursing Progress Notes, dated 3/7/2021 at 9:29 p.m., for R90, reflected, Resident was moved to room .on the COVID side of the unit. Review of the facility plan, dated 4/6/21, reflected, Resident # 90 was discharged to hospital on 4/1/2021, the orthotic boot was located by the therapy department on 04/02/2021 and will be implemented upon her return from the hospital. During an interview on 4/07/21 at 12:41 p.m., Regional Therapy Manager(RTM) LL reported no knowledge of R90 splint located and reported DOR U not working that day. During an interview on 4/07/21 at 1:59 p.m., RTM LL reported R90's right ankle contracture splint was located on 4/2/21 in the facility Physical Therapist T.

Based on observation, interview, and record review, the facility failed to report abuse in 3 of 6 residents reviewed for abuse (Resident #47, #48, #90), resulting in fears of reprisal (Resident #48) and frustration (Resident #47, #90). Findings include: Resident #47 (R47) R47 was observed sitting in his wheelchair in his room on 3/22/21 at 2:37 PM. During an interview, R47 stated that the staff treated him like crap and the staff threaten him; they tell him they are going to get in in trouble. R47 stated in the same interview, he had seen a staff member slap a resident in room [ROOM NUMBER] because her bed was cranked all the way up. R47 did not recall the staff members name but described her as frequently complaining that she was going to quit her job. R47 stated that he had reported the incident to the ombudsman and to Nursing Home Administrator (NHA) A. R47 stated NHA A had told him the staff member he saw slap another resident, would not provide care for him. R47's Comprehensive Minimum Data Set (MDS) 3.0 dated 1/07/21, indicated he was [AGE] years-old, admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 12 (08-12 Moderate Impairment). The same MDS assessment indicated R47 did not have any physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) or other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), during the 7 day look-back period. The same MDS assessment indicated R47 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of Psychiatric Consult dated 2/09/21, R47 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's Psychiatric Consult dated 3/10/21, revealed he reported continued depression due to his situation and being isolated. R47 also reported sadness and feeling frustrated. On 3/24/21 at 3:38 PM, during an interview with NHA A, he indicated he was contacted by the ombudsman regarding R47's complaint in witnessing a staff member strike another resident. NHA A did not recall the date he was notified by the ombudsman. NHA A stated he interviewed R47 following the call from the ombudsman and R47 had told him that the incident occurred 2 to 3 years ago and he saw a nurse spank a resident. NHA A stated he interviewed Licensed Practical Nurse (LPN) E and she claimed she had never hit anyone. NHA A stated LPN E had claimed there was a disagreement in R47's transfer status; R47 requested to be transferred using the sit-to-stand lift when his care plan indicated he was a total lift (Hoyer) for transfers. NHA A stated LPN E was no longer assigned to provide care for R47. NHA A stated in the same interview he did not report the allegation to the State Agency, further investigate or document the allegation because R47 stated it had happened 2 to 3 years ago. NHA A stated he did not ask LPN E if she referred R47 to therapy for a transfer evaluation. In review of R47's activities of daily living care plan dated 11/26/19, R47's transfer instructions included use of the sit-to-stand lift or the Hoyer lift as needed. On 3/24/21 at 4:30 PM NHA A stated he had contacted the ombudsman and based on her notes was notified of R47's allegation of abuse on 3/10/21. NHA A stated R47 had reported the incident occurred 2 to 3 years ago. NHA A stated he was aware that R47 was admitted to the facility on [DATE], less than 2 to 3 years ago. NHA A stated during the same interview therapy had evaluated R47 for transfers in February 2021, and they determined he was only safe for Hoyer lift transfers. NHA A stated in the same interview he did not interview other residents or staff following the abuse allegation. NHA A stated LPN E was still R47's assigned nurse, but another nurse administered his medications after she set them up. During an interview on 3/25/21 at 8:57 AM, R47 stated NHA A came into his room the day before and felt like they were storm trooping me. R47 stated he felt ambushed and had to initial something he did not read. R47 reported to this writer again that he saw LPN E slap a resident in room [ROOM NUMBER]. On 3/25/21 at 9:35 AM, NHA A stated last evening he went to talk with R47 with 2 witnesses. NHA A stated R47 did not recall the incident of LPN E slapping/spanking a resident and had him sign a questionnaire. In review of the document titled Residents Questionnaire, dated 3/24/21, R47's name was printed on top of the document. The document had 5 questions, Has anyone made you feel uncomfortable; Have you experienced or observed any type of abuse; Do you feel safe at the building; Do you have any concerns with your roommates; and Do you feel comfortable speaking with administration about any concerns. The bottom of the same document indicated NHA A and LPN Unit Manager I signed the document under the signature line. During an interview on 3/25/21 at 1:00 PM, Ombudsman FF stated she received a telephone call on 3/10/21 from R47 and he conveyed LPN E was verbally abusive to him and he had seen LPN E be physically abusive to another resident. Ombudsman FF stated 3/10/21 was the first time R47 called her. Ombudsman FF stated she notified NHA A on the same day, 3/10/21 of the allegation of abuse. Ombudsman FF stated she called R47's mother and suggested to set up a care conference. During an interview on 3/25/21 at 1:36 PM, R47's mother stated R47 has only complained of the same person at the facility, LPN E. R47's mother stated he was not good with remembering names, he has a memory deficit, and history of a closed head injury. R47's mother stated the ombudsman did suggest scheduling a care conference but was not able to get through to anyone when she calls. R47's mother stated R47 has tried to set it up a care conference also and had not been successful. During an interview on 3/30/21 at 9:56 AM, LPN E stated R47 did not want her to be his nurse, that he was like a jealous husband, he yells and then makes up. LPN E stated she referred R47 to therapy because he was unsafe in his motorized wheelchair. LPN E stated she had not transferred R47 with the sit to stand lift or the Hoyer lift. LPN E denied hitting a resident and stated she wrote a statement and submitted it to NHA A. Resident #48(R48) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R48 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R48 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired, and he required one person physical assist with bed mobility, transfers, toileting, dressing, hygiene, and bathing. R48's MDS reflected no behaviors including, physical, verbal or refusal of care. During an interview and observation on 3/24/21 at 11:05 AM R48 stated, I was assaulted by (named Certified Nurse Assistant((CNA F)) on 3/4/21 and told (named Administrator((NHA A)) on 3/5/21. R48 reported CNA F was rough during care on 3/4/21 and hurt his neck. R48 reported after speaking with NHA A on 3/5/21 was told CNA F would not care for him again and an x-ray would be ordered. R48 reported he continues to have neck pain and had not yet received neck x-ray and CNA F worked with him again on 3/21/21. R48 reported did not feel safe here and began to cry and tears noted. R48 reported NHA A lied to him and reported fear of, reprisal. During an interview on 3/25/21 at 11:04 a.m. NHA A reported R48 did not have any abuse allegations in past three months. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . UM reported that resident was very agitated when CENA tried to provide care. Resident seen in bed awake and alert. Resident stated he was not wet when CENA came in to change his brief. He said the CENA attempted to check to see if he was wet and he reach out to block the CENA and now his neck hurts and will like X-Ray of neck. Resident assessed. No signs of trauma or bruises noted. Resident able to turn his neck from left to right but states it hurts when he turn. Of note resident has a history of chronic pain secondary to [CONDITION(S)]. Was started on antibiotic yesterday for UTI. X-Ray of neck ordered, pain meds given. Will monitor. During an interview on 3/25/21 at 1:51 p.m. CNA F reported working at the facility for nine years and usually day shift and often works double shifts(7a-10p) four days per week. CNA F reported was familiar with R48. After this surveyor asked CNA F to describe R48, CNA F reported R48 sometimes was incontinent of urine and thought he didn't and stated, he was wet that morning. This surveyor asked, what morning was CNA F referring too? CNA F reported the day that R48 became verbally upset with CNA F and began physically swinging at CNA F. CNA F reported R48 did not believe he was wet and became physically and verbally agitated during care on 3/4/21 around 9:30 a.m. CNA A reported smell of urine but R48 argued he was not wet. CNA F reported she said, let me change you. CNA F she turned R48 on side who grabbed bar while linens were changed and R48 started swinging arms and cussing calling CNA F names. CNA F reported no physical contact was made. CNA F reported collected items, exited room and informed agency nurse but unsure of name and reported completed statement and gave to NHA A the next day. CNA F reported worked next day 7:00 a.m. to 10:00 p.m. and was assigned to R48 and R48 told her he did not want CNA F in room because she had tried to through him out of bed day prior. CNA F informed nurse and they spoke to R48 and was then told by NHA A she would no longer be assigned to R48 care. CNA F reported she recalled R48 complained of neck pain during care on 3/4/21 and an X-ray was ordered. CNA F reported worked Sunday 3/21/21 on 4th floor south and had told nurse could not go in R48 room because NHA A had told her not to care for R48. CNA F reported nurse told CNA F assignments could not be switched to other aid and told CNA F to address roommates needs and nurse would address R48 needs. CNA F reported as soon as she entered R48 room and said name to R48 roommate, R48 became agitated, started calling her names and yelling. CNA F reported had not been required to be off work related to event. CNA F reported last abuse training at facility was last week and everyone received abuse training after event. During an interview on 3/25/21 at 2:37 p.m. CNA J reported working at the facility for four months and received abuse training at that time and again 2 weeks ago. CNA J reported all abuse allegations should be reported to supervisor who was often the nurse who would then reports to NHA A. During an interview on 3/25/21 at 4:25 p.m. NHA A reported there was not an investigation for R48 for 3/4/21 incident because R48 did not report why he did not want CNA F back in the room. NHA A reported was told by CNA F that she had provided R48 care on 3/4/21 and after shower R48 started swinging at CNA F and calling racial slurs and being combative. NHA A reported he spoke with R48 on 3/5/21 who complained of a sore neck. After this surveyor asked, what did R48 report to him? NHA A stated, nothing except missing items and sore neck. (named R48)did not mention anyone hitting or abusing him so I did not do investigation. NHA A reported was aware of one incident that CNA F entered R48 room after 3/4/21 event and was again told not to go in R48 room. NHA A reported CNA F did provided written statement because of incident and would try to locate statement. Review of the Medication Administration Record(MAR), dated 3/1/21 through 3/31/21, reflected R48 had 0 out of 10 pain on pain scale(0=no pain, 10=highest pain) on 3/3/21 and 7 to 8 out of 10 on pain scale 3/4/21 through 3/6/21. Review of Kardex, dated 3/31/21, reflected no documentation that reflected resident and NHA request related to caregivers. Review of the Nursing Progress Notes, dated 3/12/2021 at 10:53 p.m., reflected, Patient AOX3 able to make needs known, no respiratory discomfort noted, no c/o sob, c/o pain [MEDICATION(S)] prn as ordered . During an interview on 4/05/21 at 12:19 p.m., Social Worker (SW) L reported R48 had requested to speak with Social Worker on 3/5/21. SW L reported R48 informed her that CNA F was rough during care on 3/4/21 and did not want CNA F performing any further care for him. SW L reported CNA F reported R48 was wet and needed to be changed so CNA F changed R48 soiled brief and R48 became agitated. SW L reported CNA F was told by NHA A not to provided care or enter R48 room. SW L reported when made aware of information from R48 about CNA F care she would report to Abuse Coordinator, NHA A. SW L reported R48 incident on 3/4/21 had been reported to NHA A by RNUM prior to SW L interview with R48. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Seen by (named physician), rheumatologist as a f/u on 3/31/2021. No evidence of [CONDITION(S)], serologies were negative for [CONDITION(S)]. Recommends referral to see neurologist. Appt scheduled for 4/14/2021 . During an interview on 4/06/21 at 3:30 PM Registered Nurse Unit Manager (RNUM) II verified R48 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/6/21 at 3:30 p.m., observed CNA F working on fourth floor, talking with staff near nurse station. During an interview on 4/07/21 at 10:45 a.m., Director of Operations, Acting NHA (DO) EE reported R48's abuse allegation was reported 4/6/21, and CNA F was not suspended because was more of a handling concern and not abuse. During an interview on 4/07/21 at 1:28 p.m. Director of Nursing (DON) B reported was current interim Abuse Coordinator with history of Abuse Coordinator title. When asked to name seven elements of abuse was unable to recall all 7 elements of abuse. When asked when abuse allegation should be reported? DON B reported abuse allegation were required to be reported within 24 hours and (DO) corrected DON B by answering, two hours. During an interview on 4/07/21 at 3:50 p.m. DON B provided R48 neck X-ray dated 3/27/21. DON B verified R48 neck X-ray was ordered 3/5/21 and verified no documentation to reflect delay of X-ray performed on 3/27/21. Resident #90(R90) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R90 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R90 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers and one person physical assist with locomotion on unit, toileting, dressing, hygiene, and bathing. During an observation and interview on 3/23/21 at 11:41 a.m., signs were located on R90 closed door that reflected isolation precautions and call light was on. Staff at nurse station reported all rooms on floor required use of full Personal Protective Equipment (PPE), gown, mask, eye protection and gloves to enter. This surveyor donned appropriate PPE, knocked on R90 door and obtained permission to enter from R90. R90 was sitting in bed with hospital gown on and call light on above door in hall, light indicator at call light plug in did not appear to be functioning. R90 reported currently waiting for staff to answer call light because of need to use bathroom. R90 request to have this surveyor wait in room. R90 reported frequent long call light response greater than one hour and had been waiting since 11:20 a.m. at that time. R90 appeared calm and pleasant, hair appeared greasy and unkept with moderate amount long facial hair observed on R90 chin area. R90 reported she felt embarrassed to have facial hair but required assistance from staff because of being blind and staff had not provided assistance. CNA J entered R90 room with full PPE on and R90 reported need to be changed. CNA J reported need to get fitting sheet from hall and removed PPE and exited R90 room. CNA J returned to R90 room with no gown. CNA J asked R90 if it was ok for surveyor to observe person care and R90 verbalized permission for this surveyor to observe care. At 11:56 a.m. CNA J assisted R90 turn on side with gloves, eye protection and mask in place and no gown. CNA J performed peri care and used call light at 12:09 p.m. for additional assistance. CNA J reported at that time had forgot to put on gown prior to entering R90 room. At 12:13 p.m. RNUM II entered R90 room to assist with boosting R90 up in the bed. This surveyor heard R90 report to CNA J that CNA P will not wash peri area when changing R90 brief because it was against CNA P religion and was always short with her, what do you want? During an interview on 3/25/21 at 2:37 p.m. CNA J reported had worked at the facility for four months and received abuse training at that time and again two weeks ago. CNA J reported if abuse is allegation of abuse was suspected it was CNA J job to report to supervisor immediately. This surveyor asked CNA J if R90 had reported any care concerns to CNA J at the time this surveyor was observing care on 3/23/21? CNA J reported R90 had reported CNA P did not perform peri care because it was against her religion. CNA J reported that was an example of neglect and reported to the nurse Licensed Practical Nurse (LPN) JJ that day. CNA J reported was not asked to complete witness statement. CNA J reported it was her job to report and she did. During an interview on 3/25/21 at 11:04 a.m. NHA A reported R90 did not have any abuse allegations in past month. During an interview on 3/25/21 at 4:35 p.m. NHA A reported again not aware of abuse allegation from 3/23/21 for R90. NHA A reported was not notified of R90 being mistreated by staff or anything like that. NHA A reported would expect staff to report any abuse allegations to him or supervisor immediately. During an interview on 3/31/21 at 10:05 a.m. NHA A reported completed investigation related to R90 on 3/25/21. NHA A stated, (named R90) only complained about one CNA staff that did not perform pericare cleaning center of peri area. NHA A reported R90 reported feeling safe. NHA J reported CNA J was present during interview with R90. This surveyor asked why R90 investigation reflected this surveyor had informed NHA A about care concerns when R90 had reported care concerns to CNA J while this surveyor was present? NHA J verified that it was reported that this surveyor was present when R90 reported care concerns to CNA J on 3/23/21. NHA A reported all allegation are expected to be reported to supervisor or NHA immediately. NHA A reported did not feel this situation was abuse. According to the facility Investigation, dated 3/25/21, reflected an interview with R90 with NHA A, DON B, and CNA J present was done on 3/25/21. The investigation reflected R90 was asked directly if she felt abused or neglected. According to the investigation R90 reported, she(R90) voiced to the Surveyor and CNA that she felt one CENA did not clean the center of her vagina very well. Also informed the surveyor how the 1 CENA had informed her how it was against her religion to clean the center of her vagina .but stated the 1 CENA did clean her buttocks and side of her vagina very well.(no dates included on investigation). According to CNA J interview, dated 3/25/21, reflected, just CNA don't clean her(R90) privacy area but , does clean her inner thighs and buttocks. According to CNA J second interview, dated 3/26/21, reflected, (named R90) was complaining about care when I was doing her ADL. Talking to the state. She felt that it wasn't good care .After care I reported to nurse. The NHA A statement, dated 3/25/21, with no incident dates, reflected, Director of nursing will reeducate CNA (named CNA P) on ensuring that proper Peri-Care and update care plan as needed. The investigation did not include any interviews with like residents. Review of the facility Perineal Care Policy and Procedure, undated, provided by DON B on 3/31/21 at 10:35 a.m., reflected, PURPOSE 1. To cleanse the perirectal area. 2. To prevent infection and odor. 3. To maintain skin integrity .PROCEDURE .c. Use one gloved hand to stabilize and separate the labia, with the other hand wash from front to back on one side, reposition the mitt using a clean area of the mitt cleanse the other side, and lastly reposition the mitt to cleanse the middle moving front to back . During an interview on 4/06/21 at 9:15 a.m. DON B reported expected peri care to be perform according to the facility Policy and Procedure. DON B reported provided CNA P one on one verbal inservice on 3/30/21 on facility Perineal Care Policy and Procedure because she wanted to make sure CNA P was aware of proper policy. DON B reported did not observe CNA P perform peri care. During an interview on 4/06/21 at 10:47 a.m. DON B reported (name of training program) had skills check off for observations including peri care. DON B reported CNA P did not have pericare skills check in past year.

Based on observation, interview, and record review, the facility failed to identify and assess for pain in one of three residents reviewed for pain (Resident #84), resulting in crying out in pain during therapy, position changes, and wound care. Findings include: Resident #84 (R84) On 3/29/21 at 10:00 AM, R84 was observed lying in bed wearing a hospital-type gown. R84's hair was not brushed and appeared greasy. Podiatry Consult dated 2/23/21 revealed R84 had foot and ankle pain affecting both legs; the pain rating was 4 out of 10, with 0 being no pain and 10 being the worst pain ever. R84's Admission MDS dated [DATE], indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 05 (00-07 Severe Impairment). The same MDS assessment indicated R84 did not have indicators of pain or possible pain in the last 5 days. R84's MDS indicated she did not receive scheduled pain medications, as needed medications, or non-pharmacological medications during the 5-day look-back period. In review of Physician's Progress Note dated 2/25/21, R84 was a [AGE] year-old female with history of multiple Stage IV pressure ulcers, [CONDITION(S)] (bone infection) of coccyx (tailbone), and diarrhea. R84 underwent multiple debridement's (removal of dead/infected tissue) of wounds and completed a six-week course of antibiotic therapy prior to admission. R84's past medical history included septic shock (infection throughout body causing organ injury/damage), [CONDITION(S)] (lack of red blood cells), chronic [CONDITION(S)], dementia, stroke, and right femoral vein deep vein [CONDITION(S)] (DVT, blood clot). R84 had a tube feeding due to protein calorie malnutrition. The same noted indicated R84's plan for care included wound care and pain management. Physical Therapy Note dated 2/20/21 through 3/05/21, revealed R84 reported pain during therapy with range of motion exercises. The same note revealed R84 was unable to rate pain but would scream/yell STOP during mobility training. R84's March 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R84's February and March 2021 MAR, no Acetaminophen was administered between 2/20/21 through 3/05/21. There were no other medications ordered for pain. R84's March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, revealed pain could cause suffering and was associated with inactivity, social withdrawal, depression, functional decline, and could interfere with participation in rehabilitation. The same source indicated pain management interventions must be included as part of a care plan that aimed to prevent or relieve pain and included monitoring for effectiveness and revision of care plan if stated goals were not met. R84's Potential for Acute Pain care plan dated 3/15/21, indicated her goal was to not have an interruption in normal activities through next review. The same care plan indicated to review effectiveness of pain interventions. On 3/31/21 at approximately 9:15 AM, R84 was observed lying on her back in bed. Wound Nurse D rolled R84 from her back to her left side; R84 grimaced. Catheter Care was observed on 3/30/21 at 10:29 AM with Certified Nurse Assistant (CNA) JJ. R84 voiced discomfort during catheter care. R84 did not have a catheter strap securing her catheter. On 3/30/21 at 11:12 AM, Wound Nurse D and Physician's Assistant (PA) GG were observed during a dressing change to R84's sacrum. PA GG provided bowel incontinence care; R84 cried ouch, ouch, be careful man during procedure. PA GG removed two stitches from R84's sacral wound area with scissors; R84 cried out in pain when the stitches were removed. Wound Nurse D explained to R84 they were almost done. In review of R84's MAR, no additional doses of Acetaminophen were given on 3/30/21. R84 had received the scheduled Acetaminophen at 8:30 AM, approximately 2 1/2 hours prior to the dressing change. On 3/31/21 at 9:20 AM Unit Manager I stated she could get R84 a catheter strap. During an interview on 3/31/21 at 11:00 AM, Physical Therapist (PT) T stated R84 had been discharged from therapy due to her insurance. PT T stated when R84 was discharged from therapy, she recommended to continue range of motion exercises, however, the facility did not have a restorative therapy program. PT T stated during the same interview that R84 had pain during her therapy sessions, she would wince and cry in pain. PT T stated in the same interview, R84's nurses were aware of her pain. Wound Care Progress Note dated 3/30/21 revealed R84 was not pre-medicated for pain and no pain was documented. During an interview with Wound Nurse D on 4/01/21 at 2:18 PM, she agreed R84 had pain during the wound care treatment on 3/30/21, R84 had cried out in pain when two stitches were removed from the sacral wound area; but she had documented R84 had no pain during the procedure. R84's pain care plan dated 3/15/21 revealed an intervention to identify, record and treat the resident's existing conditions which may increase pain and or discomfort including ulcers, contractures, paresthesia (tingling or prickling) related to stroke. Pain Management Policy dated 11/28/17 indicated suggestive signs and symptoms of pain included resisting cares, groans, crying, and facial grimacing. The same policy indicated non-pharmacological interventions to alleviate pain included showers, music therapy, and exercises to address stiffness and prevent contractures.

This citation pertains to intake: MI 091 Based on observation, interview and record review, the facility failed to provided necessary monitoring and treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer and prevent infection for 1 of 2 residents (Resident #12) reviewed for pressure ulcers, resulting in non-healing facility acquired stage 4 pressure ulcer and wound infection. Findings include: According to the facility, Skin Management Guideline, dated 11/28/17, reflected, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown .treatment of [REDACTED]. The Weekly Wound Documentation Observation in PCC should only have one wound per observation .When a pressure ulcer is present, daily wound monitoring should include: an evaluation of the ulcer, if no drainage is present, an evaluation of the dressing, if present, the status of the area surrounding the ulcer .the presence of the possible complication, such as signs of infections .Consult with a Physician/NP, Family and Supervisor/Designee if the ulcer(s) has not shown progress in two weeks . According to the facility, Guideline: Weekly Skin/Wound Documentation and Reporting, dated 1/7/16, reflected, Purpose: To provide a centralized form for documentation and reporting of all resident skin concerns within the facility. Guideline: The facility treatment nurse and/or designee will complete the weekly skin observation. Responsibility: It is the responsibility of the DON/ADON to ensure that the weekly skin/wound documentation is timely and complete. Procedure: 1. The treatment nurse or designee will designate a day in which the wound documentation will be completed. 2. Once this day is established, it's recommended that this day remain consistent .3. Weekly documentation must be reported within 7 days of the prior documentation. Documentation completed beyond the 7 day period is considered out of compliance . Resident #12 (R12) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R12 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R12 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required one person physical assist with dressing, toileting, hygiene and bathing and two person physical assist with bed mobility and transfers and set up assist with locomotion on unit and eating. The MDS reflected R12 did not have any behaviors including rejection of care. According to the complaint intake received on 11/23/20, reflected, Complainant states by being left wet/soiled for extended periods and not being turned or repositioned as doctor ordered he has developed 2 wounds on his butt. Complainant states the lack of care has led to numerous infections [MEDICAL CONDITION] and UTI . During an observation and interview on 1/20/21 at 1:24 p.m. R12 was noted sitting in a motorized chair in a private room visiting with another resident. R12 door appeared to have isolation supplies hanging on door. R12 reported isolation was no longer needed. During an interview on 1/20/21 at 1:25 p.m. Unit Manager (UM) DD reported R12 had current droplet precautions in place that included surgical mask over N95 mask, goggles, gown and gloves to enter the room related to frequent appointments outside the facility. During an interview on 1/20/21 at 1:30 p.m., R12 reported he spoke to managers, who frequently changed, about care concerns including being left wet and soiled for long periods of time, not being repositioned timely, and not being showered/bathed as ordered. R12 reported history of pressure ulcers that had worsened and had history of wound infections. R12 reported he also reported concerns to administrator (ADM) who was no longer at the facility. R12 reported being aware of grievance process at the facility, however, reported had not been able to locate grievance forms for several months and had not complete related to care concerns. R12 verified no shower 1/4/21, 1/6/21, 1/7/21 as documented. R12 reported had been getting weekly showers recently but would prefer two weekly as ordered. R12 reported was being seen at wound clinic on regular basis. During an interview on 1/20/21 at 2:50 p.m. Licensed Practical Nurse Treatment Nurse (LPNTN) Q reported R12 was seen by wound clinic either weekly or every other week. LPNTN Q reported R12 had a stage 4 facility acquired pressure ulcer to left ischial tuberosity since she came in July 2020. LPNTN Q reported the current treatment was [MEDICATION NAME] foam daily and reported treatment changed 2-3 weeks ago from wound clinic. LPNTN Q reported R12 refuses off loading and is often up in chair and reported documentation can be found in Progress Notes and Care Plans. LPNTN Q reported she monitors R12's wound at least weekly. LPNTN Q reported she was the only treatment nurse at the facility and performed all the weekly skin assessments. During an observation on 1/20/21 at 3:10 p.m. this surveyor toured 1st, 2nd, and 3rd floors with empty concern form baskets noted on walls on each floor (not available to residents). Review of the Physician orders, dated 1/15/21 through current (1/20/21), reflected, L Ischial Tuberosity Wound: Cleanse area with antibacterial soap and water, rinse and pat dry. Pack Tunnel at 12 o'clock and area of undermining with [MEDICATION NAME]. Cover with [MEDICATION NAME] Border Dressing. Change daily or if soiled. every night shift for Wound Care. Review of the Physician orders, dated 11/25/20 through 1/15/21, reflected, Wound Care: cleanse L ischial tuberosity apply Santyl to wound bed and pack tunneling at 12 O'clock with Calcium Alginate rope twice daily and PRN every evening and night shift for wound care. Review of the Physician orders, dated 10/13/20 through 11/25/20, reflected, Wound Care: cleanse L ischial tuberosity apply Santyl to wound bed and pack tunneling at 12 O'clock with Calcium Alginate rope twice daily and PRN every day and evening shift for wound care. Review of the Treatment Administration Records(TAR), dated 11/1/20 through current(1/20/21), reflected 17 blank entries(not documented as completed) and three times R12 refused wound care. Review of the facility, Wound Assessment Details- Wound Rounds, dated 11/11/20 through current (1/20/21), reflected R12 had no wound assessment between 11/14/20 and 11/25/20 (11 days), no wound assessments between 11/25/20 and 12/10/20 (15 days), no wound assessments between 12/10/20 and 12/31/20 (21 days), and no wound assessments between 12/31/20 and 1/20/21 (20 days). Review of the completed Wound Rounds dated 11/11/20 through 12/31/20 all reflected 8/10 pain, 30% slough (non viable tissue), moderate serosangenous drainage and macerated peri wound area. Review of the Wound Rounds dated 11/25/20 through 12/31/20 reflected R12 L ischial wound facility acquired (6/8/19) stage 4 pressure wound measured 2.5cm by 2.5cm by 0.2cm. Review of the Wound Rounds reflected no attempt to assess R12 stage 4 pressure ulcer between 12/31/20 and 1/11/21(11 days) with no documented refusals noted. Review of the facility Electronic Medical Record, reflected no wound clinic visits documents between 11/1/20 to current. During a telephone interview on 1/21/21 at 12:00 p.m., LPNTN Q verified she had last seen/assessed R12's pressure ulcer on 12/31/20 (three weeks prior). LPNTN Q reported if resident refused wound care will attempt the following week and document as refused on Wound Rounds. During a telephone interview on 1/21/21 at 2:50 p.m. Director of Nursing (DON) B reported would expect staff to follow facility policy and procedures for wound care including assessments, monitoring and treatments. DON B reported would expect nursing staff to assess and monitor wounds at minimum of weekly and if resident refused would expect staff to re-attempt every day, document and notify physician. DON B reported would expect wound clinic communication to be in R12 medical record. Review of the facility, Wound Assessment Details- Wound Rounds, dated 1/22/21, reflected 8/10 pain, 30% slough(non viable tissue), moderate serosangenous drainage and macerated periwound area. Review of the pictured wound reflected no change in size with increased peri wound maceration compared to 12/31/20 wound appearance. Review of Wound Clinic visits, provided by the DON B on 1/25/21, reflected R12 was seen in the Wound Clinic on 1/7/21 with orders to discontinue Santyl, Cleanse L tuberosity wound with antibacterial soap and water, rinse and pat dry. Pack Tunnel at 12 O'clock and area of undermining with [MEDICATION NAME]. Cover with [MEDICATION NAME] Border Dressing. Change daily or if soiled. (According to R12 TAR not started until 1/5/21). R12 Wound Clinic visit notes reflected R12 had follow up appointments 1/11/21, 1/18/21 and 1/25/21. DON B provided this surveyor with R12 ,dated 1/18/21, that included 3 of 5 pages with no orders included and reported the facility had not had R12 Wound Clinic visits in R12 medical record prior to surveyor request. Review of the facility Care Plans, dated 4/29/20 through current (1/19/21), reflected, The Resident is resistive to care (history of refused skin treatments despite encouragement from staff members) .Interventions: Allow the resident to make decisions about treatment regimen, to provide sense of control . Review of the facility Care Plans, dated 6/30/20 through current (1/19/21), reflected The Resident has pressure ulcer (Left Ischial) Stg 4 rt limited mobility r/t Hx of ulcers .Interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing weekly Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD .If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods .weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . During a telephone interview on 1/25/21 at 11:56 a.m. DON B reported that R12 had reported to her recently he had gone to wound clinic several times. DON B verified facility did not have wound clinic visits notes in R12 medical record because they did not have them. DON B reported would expect facility to collaborate with wound clinic. DON B reported would expect documented wound assessment at least weekly and if refused would expect continued attempts daily with communication with physician and documentation. DON B verified R12 did not have would assessment since 12/31/20.

This intake pertains to MI 084. Based on interview and record review, the facility failed to provide treatment and services based on the comprehensive assessment in one of three reviewed for quality of care (Resident #81), resulting in unmet goals and readmission to the hospital. Findings include: Resident #81 (R81) R81's hospital History and Physical dated [DATE], indicated he was a [AGE] year-old with a history of mental impairment and [MEDICAL CONDITION] disorder who presented to the emergency room from the group home where he previously lived, after a four and a half minute [MEDICAL CONDITION] on this same day and multiple [MEDICAL CONDITION] the day prior. The same note had conveyed R81 was very particular in who could feed him, that he had contractures in the lower extremities, and would need to discuss a Percutaneous Endoscopic Gastrostomy (PEG, feeding tube) tube with his power of attorney (POA). R81's hospital transfer progress notes dated [DATE], revealed he had the [DIAGNOSES REDACTED]. R81's hospital Physical Therapy (PT) evaluation dated [DATE] indicated he could potentially benefit from passive range of motion or a splinting program for his contractures. Hospital Case Manager note dated [DATE] indicated hospice was discussed with R81's power of attorney (POA), but she declined initiation. physician progress notes [REDACTED]. The same note indicated his POA indicated R81 was more compliant with medications if given up waking, instead of waking him up at 7:00 AM, as well as give medications with fruit. R81's Activities of Daily Living (ADL) care plan dated [DATE], revealed he was admitted to the nursing home on [DATE], and did not include a PT referral for passive range of motion exercises or splinting program, to give medications upon rising and with fruit. These instructions were not included in any care plan, physician orders, or on the medication record. Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE], revealed R81 had a cognitive communication deficit, dysphasia (difficulty in swallowing), dehydration, and failure to thrive diagnoses. R81 presented coughing after swallowing thin liquids. ST recommendations included 1:1 feeding assistance with close supervision for safety, alternation of liquids and solids, bolus size modifications, general swallow techniques/precautions, lingual sweep/re-swallow, rate modification and second swallow, upright posture during meals and at least 30 minutes after meals. ST's recommendations were not added to R81's care plan. R81's medical record included a Do Not Resuscitate Order, signed by the POA on [DATE], that indicated in the event his heart and breathing should stop, no person should attempt to resuscitate him. R81's wishes were not transferred onto his care plan. R81's physician orders [REDACTED]. R81's [DATE] Medication Administration Record [REDACTED]. During an interview on [DATE] at 11:45 AM, Certified Nurse Assistant (CNA) F stated on [DATE] at lunch, she noticed R81 had regular food on his lunch tray and should have had pureed. CNA F stated she reported R81's lunch tray issue to the nurse, did not feed R81 food from his lunch tray, and gave him a magic cup (frozen supplement). CNA F stated during the same interview R81 coughed when he was fed the magic cup, and his lips started to turn purple. CNA F stated she reported R81's condition to the nurse, and everyone freaked out. On [DATE] at 3:51 PM, Registered Nurse (RN) G confirmed she initiated R81's transfer to the ED on [DATE], and she wasn't aware speech recommendations for feeding assistance. RN G stated in the same interview she felt R 81 was pocketing his food (holding food in mouth and not swallowing). RN G stated she did not listen to R81's lung sounds as part of her assessment. RN G stated she stated she initiated oxygen and suctioned R81 prior to his transfer to the ED. Situation, Background, Assessment Recommendation (SBAR) dated [DATE] indicated R81 had a change in condition, altered mental status, peripheral capillary oxygen saturation (SPO2, estimate of amount of oxygen in the blood) in the 80's, [MEDICAL CONDITION] (low levels of oxygen in blood), weakness, fatigue, labored breathing with accessory muscle use, low pulse, and signs of dehydration. There was no record of when oxygen was initiated, what R81's exact SPO2 readings were and what time. The same document indicated R81's SPO2 was last obtained at 7:55 AM, 96 percent (%) on room air. The Skilled Nursing Facility (SNF) to ED Handoff form dated [DATE], indicated R81's medication sheet was sent to the ED, specifying he was a full code. Emergency Department (ED) records titled Pre-hospital Care Report Summary, dated [DATE], revealed a call was received at 2:34 PM, emergency medical services (EMS) arrived on the scene to find R81 lying in bed, the nurse reported he had choked on some food that morning, had to be suctioned, oxygen was initiated and he had been having difficulty breathing since. R81 was transferred to the ED. ED records dated [DATE] revealed under chief complaint that R81 was lethargic and had choked at lunch around 12:00 PM. The same notes indicated EMS had stated R81 was a full code. The same notes indicated shortly after R81 arrived, he underwent Cardiac [MEDICAL CONDITION] Restitution (CPR), and endotracheal intubation (tube placed into the windpipe to maintain open airway). The same records revealed after multiple rounds of CPR, R81's POA was called and stated she did not want life support measures to be provided. Hospital Emergency Department Records dated [DATE] revealed R81 was pronounced dead at 5:42 PM and suspect patient died from hypoxic [MEDICAL CONDITION] (inadequate gas exchange by the respiratory system) secondary to aspiration (fluid entering airway or lungs). Director of Nursing (DON) B was interviewed on [DATE] at 4:00 PM and stated she was not aware of R81 choking during lunch on [DATE], was not sure if an intravenous line (IV) or PEG tube was discussed with his POA, and wasn't sure if his POA was previously contacted to come in the facility to assist in feeding R81. In a follow-up to the interview, DON B sent an electronic mail (email) on [DATE] at 3:08 PM indicating there was not an accident report related to R81 choking, as no choking incident was documented in the facility. Occupational therapy screened R81 but did not pick him up because he was not a candidate for rehabilitation and was unable to follow demands. The same email indicated R81's DNR was signed by community primary care physician, not by facility physician; and the unit manager contacted the family to determine care wishes.

This citation has two Deficient Practice Statements (DPS A and DPS B). DPS A) Based on interview, and record review, the facility failed to establish and implement proper infection prevention and control policies and procedures to prevent development and transmission of Coronavirus Disease 2019 (COVID-19), resulting in Immediate Jeopardy when the facility failed to properly clean and disinfect resident rooms placing all 108 residents and staff at risk for contracting Covid-19 and at least 40 residents with current Covid-19 infection. Findings include: On 5/7/20 the survey team requested the facility's Covid-19 Infection Control and Housekeeping/cleaning Policies and Procedures. Documents were provided by facility NHA A via email, review of the document received titled, Environmental Cleaning and Disinfection COVID-19 with an effective date March 19, 2020 revealed, CDC (Centers for Disease Control and Prevention) has provided recommendations .Current evidence suggest that novel coronavirus may remain viable for hours to days on surfaces made from a variety of materials. Cleaning of visibly dirty surfaces followed by disinfection is a best practice measure for the prevention of COVID-19 and other [MEDICAL CONDITION] respiratory illness in community settings .Routine cleaning and disinfection procedures (e.g. using cleaners and water to pre-clean surfaces prior to applying an EPA (Environmental Protection Agency)-registered, hospital grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 (severe acute respiratory syndrome coronavirus 2) in healthcare settings, including those patient-care areas . Also included with this request was a document titled, Isolation Room Cleaning Procedures, which was undated. Review of this document revealed, 4) Disinfect High Touch and Flat Surfaces. Work your way clockwise around the room and disinfect flat surfaces and high-touch items using EPA approved solution. This includes, but is not limited to doorknobs, light switches, call lights, TV remotes, bed siderails, bed frame, footboard and headboard, bedside tables, closet handles, window sills, chairs, heating unit, and any flat surfaces. Be sure to follow manufacturers' directions for contact times .Disinfect Restroom. Using the EPA approved solution, clean disinfect all hard, nonporous bathroom surfaces, including the sink area, mirrors, grab bars and shower fixtures . According to CMS (Centers for Medicare and Medicaid) Covid-19 focused survey protocol, Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare setting (effective against the organism identified if known) at least daily and when visibly soiled. Review of the CDC's Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 revealed, Disinfectants used at a facility should be EPA-registered, hospital-grade disinfectants with an emerging [MEDICAL CONDITION] pathogens claim against [DIAGNOSES REDACTED]-CoV-2. List N on the EPA website lists products that meet EPA's criteria for use against [DIAGNOSES REDACTED]-CoV-2 (https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2) .All EPA-registered, hospital-grade disinfectants have a contact time which is required to kill or inactivate pathogens. Environmental surfaces must remain wet with the product for the entire contact time duration to work appropriately. Contact times range from 30 seconds to 10 minutes. Keeping a surface wet for 10 minutes is seldom accomplished with a single application. It is important for facilities to know that their product is appropriate (List N as above) and is being used for the entire contact time. Also, it is helpful for the facility to assign responsibility for cleaning and disinfection of specific surfaces and equipment (who cleans what). According to the EPA's website (https://www.epa.gov/coronavirus/disinfectant-use-and-coronavirus-covid-19), How does EPA know that the products on List N work on [DIAGNOSES REDACTED]-CoV-2? While surface disinfectant products on List N have not been tested specifically against [DIAGNOSES REDACTED]-CoV-2, the cause of COVID-19, EPA expects them to kill [MEDICAL CONDITION] because they: Demonstrate efficacy (e.g. effectiveness) against a harder-to-[MEDICAL CONDITION]; or Demonstrate efficacy against another type of human coronavirus similar to [DIAGNOSES REDACTED]-CoV-2. All surface disinfectants on List N can be used to [MEDICAL CONDITION] on surfaces such as counters and doorknobs. Because [DIAGNOSES REDACTED]-CoV-2 is a new virus, this pathogen is not readily available for use in commercial laboratory testing to see if a certain disinfectant product is effective at killing [MEDICAL CONDITION]. EPA reviews and registers antimicrobial pesticides, which include disinfectants for use on pathogens like [DIAGNOSES REDACTED]-CoV-2, the novel human coronavirus that causes COVID-19 .In early March, EPA released its initial List N: Disinfectants for Use Against [DIAGNOSES REDACTED]-CoV-2 (List N). This list continues to be updated on a weekly basis. It is searchable and sortable, comes with helpful tips on how to use disinfectants properly, and features frequently asked questions to ensure correct product usage. As with any EPA-registered product, carefully read the label and only use the product as described in its directions . According the EPA's Frequently Asked Questions page (https://www.epa.gov/coronavirus/frequent-questions-related-coronavirus-covid-19), What does the column Follow the disinfection directions and preparation for the following virus mean? Why [MEDICAL CONDITION] other than the human coronavirus listed in that column? This column shows the harder-to-[MEDICAL CONDITION] than the human coronavirus. Products qualify for the emerging [MEDICAL CONDITION] pathogen claim by showing that it works against the listed harder-to-[MEDICAL CONDITION]. Therefore, if the contact time for this harder-to-[MEDICAL CONDITION] is followed, EPA expects the product to be effective against [DIAGNOSES REDACTED]-CoV-2 on surfaces. You can also find this information on the product label. During a telephone interview on 5/8/20 at 11:36 a.m., when asked what product the facility was using as a disinfectant agent, Environmental Services Director (ESD) L stated that they were using Brand X (name of brand with EPA registration number of 1839-83) for that purpose. ESD L further stated, Right now we are strictly using Brand X for disinfecting. Review of Brand X's label revealed EPA registration number 1839-83. Further review of the label revealed, Virucidal Activity - (Brand X) kills on hard, non-porous inanimate surfaces when allowed to remain wet for 10 minute contact time against: Canine Parvovirus . Review of EPA's List N information (retrieved on 5/8/20) revealed that this product was on List N. It further stated, Products with Emerging [MEDICAL CONDITION] Pathogens AND Human Coronavirus claims for use against [DIAGNOSES REDACTED]-CoV-2 .Follow the disinfection directions and preparation for the following virus: Canine Parvovirus .Contact time in minutes: 10. During a telephone conversation on 5/8/20 at 3:00 p.m., NHA A was made aware of the Immediate Jeopardy. On this same day at 3:43 p.m., NHA A forwarded an email to the State Agency which was from the facility's contracted environmental services company's vice president. Attached to this email was an informational pamphlet regarding Brand X cleaner and disinfectant. Review of the document revealed that this product was registered with the EPA with a registration number of 1839-83 and it was a, one step cleaner and disinfectant for use in hospitals, nursing homes, schools, etc., where infection control is of prime importance . Further review of the document revealed, (Brand X -EPA Reg # 1839-83-XXX) has demonstrated effectiveness [MEDICAL CONDITION] similar to [DIAGNOSES REDACTED]-CoV-2 on hard non-porous surfaces. Therefore, this product can be used against [DIAGNOSES REDACTED]-CoV-2 when used in accordance with the directions for use against [MEDICAL CONDITION] virus, [MEDICATION NAME] Type 1, and Canine Parvovirus on hard, non-porous surfaces .*VIRUCIDAL ACTIVITY: .10 MINUTE CONTACT TIME [MEDICAL CONDITION] Virus (HAV), Canine Parvovirus, [MEDICATION NAME] Type 1 . On 5/11/20 at 9:00 a.m., the State Agency received an email from the Facility's contracted environmental services company's vice president, which stated, I've attached supporting documentation for the Brand X - which will help clarify the 2-minute contact time for [DIAGNOSES REDACTED]-CoV-2. These attachments included a document titled, Efficacy Bulletin (Brand X) which had a date of 6/18. Highlighted on this document was the Test Organism Human Coronavirus (ATCC VR-740 strain 229E) Contact time 2 minutes. This Test Organism is not the same as [DIAGNOSES REDACTED]-Coronavirus-2. According the Journal of Virology article dated 10/12/16 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 81), ATCC VR-740 strain 229E, is a causative agent of the common cold . During a telephone interview on 5/8/20 at 11:36 a.m., when asked how resident rooms were being disinfected, Environmental Services Director (ESD) L stated that we are doing sanitation on each unit daily. We are spraying the Brand X on all the high touch areas, which are the most important areas. When asked if the housekeeping staff had been educated on Covid-19 and proper cleaning and disinfecting, ESD L stated that yes, we did education to the staff on the whole process of the covid. When asked if any procedures changed when Covid-19 became a concern, ESD L stated no. When asked about the proper use of Brand X, ESD L stated that it had a 2 minute contact time, we spray it on, let it set for 2 minutes and then wipe it off. When asked if there were any other products being used for disinfecting resident rooms, ESD L stated that they do have a backup product but, Right now we are strictly using the Brand X. When asked how staff have been instructed to clean resident rooms, ESD L stated we have a 10 step process which included disinfecting high touch items then walls and shelfs, then to the bathroom and then the floors and then exit the room. When asked how many housekeepers work during a day, ESD L stated that there is a housekeeper for each of the three resident floors. ESD L stated that for the past couple of days, he was working the 2nd floor, which was the facility's designated Covid-19 positive floor. ESD L confirmed that he was using the Brand X and that it had a contact time of 2 minutes. During telephone interview on 5/8/20 at 1:09 p.m., when asked how resident rooms were being cleaned and disinfected, Housekeeper (HK) H stated that we are spraying Brand X on every surface and waiting 2 minutes before wiping it off. During a telephone interview on 5/8/20 at 2:24 p.m., when asked how resident rooms were being cleaned and disinfected, HK M stated that she had been working at the facility for 5 years. HK M further stated Brand X. That is what we are using. We spray it on and let it set for like two minutes and then wipe it down. When asked what items were being disinfected this way, HK M stated, Like the bedside tables, bed rails, call lights .all the high touch areas. When asked if there was any other product that was being used to disinfect resident rooms, HK M stated, No, right now just that one. During a telephone interview on 5/8/20 at 3:13 p.m., when asked how resident rooms were being cleaned and disinfected, HK N stated that she has worked at the facility for [AGE] years. Right now, we are using Brand X, and what we are doing now is spraying all the surfaces down and then we wipe it. We are pretty much using it everywhere; I am in the rooms all day long. We spray it on everything, call lights, doorknobs, bed side tables, bed rails everything. HK N was not aware the Brand X required a 10-minute contact time for [DIAGNOSES REDACTED]-CoV-2. On 5/11/2020 it was verified that the facility implemented the following to remove the Immediate Jeopardy: 100% of Environmental Services Employees were immediately educated on the EPA recommendation of use of Brand X solution; to include the 10-minute sanitation contact time for hard surfaces. Remaining facility staff were contacted via telephone and educated on the updated guidance regarding contact sanitation of hard surfaces prior to reporting the workstation; no facility employee will report to duty without receiving updated guidance. On 5-11-20 the State Agency completed verification that the Immediate Jeopardy was removed on 5/8/2020. However, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that all staff had not been confirmed to have been educated and sustained compliance had not yet been verified by the State Agency. DPS B) Based on interview and record review, the facility failed to establish and implement a surveillance plan, for identifying, tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 and failed to have a plan that included early detection and management of a potentially infectious, symptomatic residents, resulting in the failure of early detection, and inadvertent spread of Covid-19 to all 108 residents and staff. Findings include: On 5/7/20 the survey team requested the facility's Covid-19 Infection Control and Housekeeping/cleaning Policies and Procedures. On 5/7/20 NHA A provided the surveyors documents via an email. It was confirmed by NHA A and Director of Nursing (DON) B that these were the only policies the facility had regarding Infection Control Procedures associated with Covid-19 The only document that pertained to Infection Control was titled, Infection Prevention and Control Guideline with an effective date of 11/28/17. Review of the document failed to reveal a surveillance plan, for identifying, tracking, monitoring and/or reporting of fever, respiratory illness, and/or other signs/symptoms of COVID-19 and failed to have a plan that included early detection and management of a potentially infectious, symptomatic residents. Further review of this document revealed, Written standards, practices, and procedures for the Infection Prevention and Control program, include: Surveillance: A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; Reporting: When and to whom possible incidents of communicable disease or infections should be reported . Further review of the documents provided failed to reveal any written standards or procedures on the surveillance of Covid-19. According to the CDC (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html); Actively monitor all residents upon admission and at least daily for fever (T=100.0 oF) and symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, muscle aches) .If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any with new symptoms. During a telephone interview on 5/12/20 at 11:35 a.m. with Infection Control (IC) nurse K and DON B, this surveyor asked if daily surveillance for Covid-19 was being completed for the residents, DON B stated, We started everyone in the building back in March, it included any respiratory symptoms, fever, cough and vital signs. When asked if these assessments were documented, DON B stated, I think the previous DON was putting them on a line listing, then DON B stated, I don't know, I don't know what she was doing. I am not sure, as of right now, I don't see where she was putting anything. When asked how the surveillance was being completed, DON B stated, The nurses were doing that, and then reporting that to the managers and then the managers were reporting to the DON. When asked if the floor nurses were documenting these assessments, DON B stated, No, they were documenting the vitals. If they had a fever we monitored and then we would swab .that should have been the process, to write assessments in the chart. If there was some type of change in condition, we would assess them .everybody is getting vital signs every shift and everyone that tested positive for Covid-19 were getting vital signs every 4 hours. When asked if positive residents were being assessed more frequently DON B stated, They were being monitored more frequently. When asked if the facility implemented documented assessments DON B stated, there are orders in their now for respiratory assessments for the positive, it was up to the nurses to report any change in condition .the assessments are done by the nurses .no there were no actual assessments being documented by the nurses .We are going by what the nurses tell us. They are supposed to be assessing the residents and letting us know if there is a change in condition. When asked if the nurses are documenting their assessments, DON B stated, Let's say they are not the best at it. Review of the medical records are residents that have tested positive for Covid-19 revealed that orders for a complete respiratory assessment were put into the charts on 5/7/19, but failed to reveal that this was being completed prior to 5/7/19. Further review of resident medical records failed to reveal that any type of Covid-19 assessment was being completed of the residents. During a telephone interview on 5/12/20 at 2:46 p.m., when asked if routine respiratory assessments were being completed on residents, Licensed Practical Nurse (LPN) D stated, Temps were a big thing, and the O2 stats (oxygenation levels) because that was a big part of it, we all knew that, checking temps and O2 levels. When asked about a respiratory assessments being completed, LPN D stated, Yes, if we saw something we would do something. When asked what the respiratory assessment entailed, LPN D stated that they would listen to their lungs, watch them breath and see if there was anything else going on. When asked if these assessments were documented anywhere, LPN D stated, They should be filled out in an evaluation. When asked if this was completed on every resident every time, LPN D stated, No we would just put vital sings in and if there was abnormal, then we would further assess, there was not a documented assessment for every resident every shift. We are not staffed well enough for that. When asked if she was educated on how and when to assess residents, LPN D stated, I don't remember that no, being told to complete a respiratory assessment .we would keep an eye on everyone, and if you saw something different then you would call the doctor and let them know what was going. During a telephone interview on 5/12/20 at 3:30 p.m., when asked about routine assessments of the resident for Covid-19, LPN P stated, In March they had us getting vitals for every resident it started 1 time a day, then eventually it was every shift, and we documented in the VS. When asked about completing a respiratory assessment, LPN P stated, That included it there, we have the finger thing we put on the finger (the pulse oximeter-an electronic device that clips onto a patient's finger to measure heart rate and oxygen saturation). When asked if there was anything else, they assessed for, LPN P stated, That was all we were supposed to do. When asked if they were supposed to assess for breath sounds or cough or sore throat, LPN P: stated, No they were not having us do any of that. When asked how they were monitoring resident for possible Covid-19 infections, LPN P stated, Basically temperature, that is what we were focusing on, basically that is what they had us focusing on was the temperature. On 5/13/2020 at 8:45 am, during a phone interview with Registered Nurse/Unit Manager (RN/UM) G, she reported that she was the Unit Manager for the facility's 2nd floor. The 2nd floor had a census of 40, all of which are positive for Covid 19. RN/UM G further stated she was a contracted employee and had worked at the facility for approximately 2 weeks. When queried on how the facility monitors and assess's residents for signs and symptoms of Covid 19, she reported they do respiratory assessments every shift, which started about a week ago. When queried what was done prior to a week ago, RN/UM G stated she was uncertain. When asked about the Facility's policy and procedures as it relates to Covid 19, RN/UM G stated she did not know and did not want to speculate.

Based on interview and record review, the facility failed to thoroughly assess, monitor, document characteristics, and implement timely interventions prior to and after the development of a pressure ulcer for one (#701) of two residents reviewed for pressure ulcers, resulting in an intact blister worsening to a necrotic pressure ulcer. Findings include: A complaint was submitted to the State Agency that alleged R#701 acquired a bed sore on the left side of her buttock while she was a resident at the facility. On 5/6/19 and 5/7/19, an onsite investigation into the complainant's allegation was conducted. R#701's clinical record was reviewed and revealed the following: R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#701 had intact cognition, no behaviors, and required extensive to total physical assistance from two staff members for bed mobility, transfers, and all activities of daily living (ADLs) except eating. The MDS documented R#701 was frequently incontinent of stool, had an indwelling urinary catheter, and did not have any pressure ulcers upon admission into the facility. A progress note dated 3/16/19 documented, .Resident presented with excoriation to buttocks and on back of amputated leg. Resident buttocks was ladened with skin barrier and had to be washed off; skin red and angry, Vit D ointment applied to soothe area. Resident was advised to desist from laying on her back all day and to lay on her side from time to time. Foley was leaking and was last changed 6 wks ago, per resident's report . A progress note dated 3/18/19 documented, Resident found to have several [MEDICAL CONDITION], documentation completed, (Physician C)notified for orders. A progress note dated 3/30/19 documented, Resident presented with wound on Ischial tuberosity (IT- lower and back part of the hip bone), RT (right) trochanter (hip) and Lt (left) trochanter. Wound on Lt IT presented with dead tissue, wound cleansed with NS (normal saline) foam border gauze applied to all affected areas. Resident tolerated wound dressing. A Skin/Wound Note dated 3/30/19 documented, .contacted (Physician C) describing areas as an update, treatment changed to [MEDICATION NAME] AG with silver (a anti-microbial wound gel) an every 2 day change and prn (as needed), wound bed to inferior with yellow slough (Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed)., edges attached and distinct .superior wound has dark tissue with scant area of yellow slough to wound bed noted .moderate drainage serosanguineous .due to her obesity resident has stated she has difficulty lying on either side . A Daily Skilled Note dated 3/30/19 documented, .Resident will only allow a couple times this shift to be slightly adjust on the left side to attempt to offload pressure to left side on ischial area due to continued treatment, due to positioning of left leg chronically rotated laterally and resident refusing to be propped off from left side slightly healing to areas is low in healing, new treatment implemented to promote healing of areas . A progress note dated 4/4/19 documented, .later this after noon cna (certified nursing assistant) notified nurse that resident had large loose stool and her left ischial wound tx's (treatments) needed to be changed, nurse removed old dressings that had large amount of serosanguineous (clear yellow liquid mixed with blood) drainage from both wounds, inferior (lower) wound observed with yellow slough (dead tissue that may have a yellow or white appearance) to the superior aspect (upper) of wound with necrotic (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) tissue present laterally and inferiorly (to the side and below) to yellow slough and depth present, periwound with scant [DIAGNOSES REDACTED] blanchable, edges adherent and distinct, superior ischial wound is elongated with dark yellow slough to wound bed which is loosely adherent to wound bed, edges attached indistinct, periwound with [DIAGNOSES REDACTED] present and blanchable, both wounds with large amounts of serosanguineous malodorous (foul odor) drainage, both wounds cleaned and dressings reapplied . Care plans revealed no care plan for the wound on R#701's left hip. physician's orders [REDACTED]. On 5/7/19 at 10:00 A.M., Nurse A and Nurse B (identified as the wound treatment nurses) were interviewed and R#701's clinical record was reviewed. Nurse A and Nurse B were asked what the facility's protocol was when new wounds were identified on residents. It was reported that if new areas develop, the wounds would be assessed, measured, seen by the wound doctor who came into the facility on Fridays, and in the meantime, the attending physician would be contacted for a treatment order to begin immediately. When queried about who was responsible for assessing and identifying the type of wound, such as pressure versus vascular, or what stage, etc., Nurse A and Nurse B reported that the consulting wound care doctor would be responsible. Nurse A and Nurse B stated, We assess the wounds, but we cannot stage them. It was further reported that characteristics of wounds were documented by nurses and would be found in the progress notes of the electronic medical record or in another electronic system. When queried about R#701 and whether or not she was admitted with any pressure ulcers, it was reported that she had a vascular ulcer on her toe and had some redness and excoriation for which skin protectant was ordered to treat that area. When queried about the documented excoriation on 3/16/19 to R#701's buttocks, Nurse A reported the resident was admitted with excoriation and was received a barrier cream to the area (there was no order for lotion to the buttocks, only lower extremities). Nurse A and Nurse B were queried about the [MEDICAL CONDITION] documented in the progress notes on 3/18/19. Nurse A reviewed the notes, including notes in the wound documentation record and stated, The left hip started out as a blister. Nurse A stated, Wound care (contracted agency) should be contacted for any skin changes. When queried about what was put in place for R#701 after the development of the blister, Nurse A reported a foam dressing was ordered on [DATE] to be done every two days and as needed. The Treatment Administration Record (TAR) was reviewed at that time and indicated (by not being signed out by the nurse) the above treatment was not administered on 3/25/19 (which indicated the dressing had not been changed in four days). When queried about the progress note 3/30/19 that documented the wound on the left hip presented with dead tissue, Nurse A reported the attending physician (Physician C) changed the treatment to a hydrogel dressing based on the nurse's description of the wound. A progress note written by Physician C on 4/1/19 documented, .She does have this bilateral pressure sores on the buttock area. She has exogenous obesity and is at very high risk and we are trying to get her a pressure relief mattress .Pressure ulcer to the buttock area. I did review these with a nurse. Please see their description. She does have these ulcers especially in the upper buttock area, which will only get worse because of her exogenous obesity and she constantly lays on the right side. We will see an air pressure mattress is possible . When queried about interventions that were put in place prior to the development of the pressure ulcer due to resident's obesity, being bed bound, and preference of only laying one way, Nurse A reported that a bariatric bed and pressure relief mattress would be typical interventions for a resident in this condition and stated, She had been bed bound for years. When queried about why R#701 had not had a pressure relief mattress or bariatric bed ordered prior to 4/1/19 and 4/4/19 (her day of discharge to the hospital), Nurse A and Nurse B did not offer a response. Wound consultation notes were reviewed for R#701 with Nurse A and Nurse B at that time and did not document that R#701's pressure ulcer to the left hip had ever been assessed by the contracted wound care agency (they were treating her for vascular wounds on her foot). When asked about where any assessment of the characteristics or measurements of the pressure ulcer to R#701 would be documented, Nurse B reported it would be in the electronic wound software. These notes were reviewed with Nurse B at that time and revealed the following: On 3/18/18 it was documented that R#701's Left trochanter was assessed by Nurse B. The Wound Assessment Details documented, .Blister .Facility Acquired .Partial Thickness .Intact Skin 65% .Blood Filled Blister: 35% .Length - 12.5cm (centimeter) Width - 12.00cm Depth 0.00cm . (A Stage 2 Pressure Ulcer is defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present.) On 3/20/18 R#701's Left trochanter was assessed by Nurse A. The assessment documented, .Clinical Stage Partial Thickness .Intact Skin: 50% Blood Filled Blister: 30% Deep Maroon: 20% .Length 12.60cm Width 12.40cm Depth- 0.00cm .Blisters are draining and opening .Offloading pressure routinely to promote healing resident unable to completely lay off from left side due to pain and respiratory compromise . On 3/27/19, Nurse B assessed R#701's left trochanter and documented the same assessment as 3/20/17 (despite the photograph of the wound having a change in appearance (A progress note written by Nurse B on 3/30/19 documented that the wound had dead tissue). On 4/1/19, Nurse B assessed R#701's left trochanter and despite a photograph of the wounds which one appeared black in color and the other appeared covered with a white/yellow colored area, was assessed the same as 3/27/19 and 3/20/19. The progress notes documented above noted slough and dark and dead tissue. (A Stage 3 Pressure Ulcer is defined as Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. An Unstageable Pressure Ulcer is defines as Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar.) Nurse B explained that along with Nurse A they were trying to get a consistent system in place to document wounds. Nurse B reported that the nurses did not stage the wounds in the facility and that it was done by the wound care doctor. On 5/7/19 at approximately 12:00 P.M., the Director of Nursing (DON) was interviewed. The DON reported that the wound doctor does not have to see all residents with pressure sores and that the attending physician in the facility could also see the resident to assess the wounds. When queried about who was responsible for assessing residents' wounds and determining the type of wound, stage of wound, etc., the DON stated, The PCP (attending physician) can do that. Staging is not the only part of assessing a wound. Just because there is no stage does not mean it wasn't assessed. When queried about why R#701, who was bed bound, did not tolerate repositioning, and was morbidly obese did not get an order for [REDACTED].#701 if there was no staging of the pressure sore, the DON did not offer a response. Further review of R#701's clinical record revealed there was no care plan developed for the pressure ulcer on R#701's left hip, no care plan that addressed preventative measures to prevent skin breakdown (there was only a care plan that addressed the vascular skin impairment to R#701's left foot dated 2/22/19 prior to the development of the pressure ulcer to R#701's left hip). A facility policy titled, Skin Management Guideline effective 11/28/17 documented the following: .All residents admitted to the facility will be evaluated for actual and potential skin integrity issues .A complete evaluation is essential for an effective skin prevention and treatment program. A comprehensive individual evaluation guides the identification of residents at risk .identification of the presence of skin impairment .Provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs .Identify interventions to stabilize, reduce or remove underlying risk factors .Evaluate the effectiveness of interventions .Modify interventions as appropriate . .An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors .Interventions for prevention, removing and reducing predicting factors and treatment for [REDACTED]. .Weekly skin observation .will be performed by a Licensed Nurse .If a skin concern is noted, refer to the skin and wound care formulary .The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident .The physician will be consulted with changes suggesting impairment in skin integrity . .If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following is to be implemented .Review the wound formulary for guidance .Update the care plan for skin integrity .Initiate the Wound Initial Documentation Observation in (electronic medical record) which will include: type of wound, location, date, stage (pressure ulcers only) .length, width and depth; wound base description, wound edge description and id present: drainage, odor, undermining, tunneling, and/or pain . .When a pressure ulcer is present, daily wound monitoring should include: An evaluation of the ulcer, if no drainage is present .An evaluation of the status of the dressing, if present .The status of the area surrounding the ulcer .The presence of complications >Whether pain, if present, is being adequately controlled .Document any changes or concerns in the nurses notes and re-evaluate prior steps .Consult with a Physician .if the ulcer has not shown progress in two weeks .if the wound is deteriorating or increases in size. Re-evaluate plan of care as appropriate .

This citation pertains to intake# MI 655 Based off interview and record review the facility failed to ensure a safe transfer was performed for one resident (R#902) of three residents reviewed for accidents of a total sample of 4 resulting in R#902 receiving a skin laceration requiring hospitalization and receiving 27 stitches. Findings include: On 7/9/18 at approximately 3:39 p.m., a review of the medical record for R#902 was completed and revealed the following: R#902 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#902's MDS (minimum data set) with an ARD (assessment reference date) of 4/9/18 indicated R#902 needed extensive assistance from facility staff with activities of daily living. A Health status progress note dated 6/23/18 revealed the following: Resident was injured on L (left) leg during transfer to bed. Skin tear/Laceration to previously injured area assessed and treated. 5-6 inch open area which required further attention was informed to ADON (assistant director of nursing) and MD (medical doctor). Family member notified of transfer to hospital. A hospital Physician procedure note dated 6/24/18 revealed the following: Very pleasant elderly woman presents with a laceration to her left lateral leg after hitting a metal tab on her bed per her bedside nurse. On presentation today she was afebrile and hemodynamically stable. She had an 8 cm long curvilinear laceration of her left leg on exam .ED course: Patient had a very clean appearing laceration of the left leg which apparently was accidentally obtained from a metal bracket on her bed. This was anesthetized with local [MEDICATION NAME] washed and stapled with 27 staples with good wound approximation I did speak with her nurse over the phone and recommended staple removal in 10 days time. A health status progress note dated 6/24/18 revealed the following: Resident returned to facility at 0130 (military time) from (A name of local hospital), resident in stable condition. Resident has 27 stitches in Lt lateral leg, clean and wrapped, continue to monitor. A Physician order [REDACTED]. Cleanse with normal saline and leave open to air every day shift for staple area. A Care conference note dated 4/24/18 revealed the following: Quarterly care conference held with all disciplines and resident in attendance .Care Plans reviewed and updated A review of R#902's current careplans revealed the following: Focus-The resident requires staff assist to complete her daily ADL (activities of daily living) performance deficit r/t (related to) Dementia and impaired mobility .Goal-The resident will maintain current level of function through the review date .Interventions-TRANSFER: The resident requires assistance by 2 staff to move between surfaces as necessary .Transfers:Resident requires Sit to Stand Mechanical Lift. A review of the current Kardex (a quick guide to direct the certified nursing assistants on the plan of care) for R#902 revealed the following: Transferring-Resident requires Sit to Stand mechanical lift. On 6/23/18 at approximately 3:50 p.m., an investigation file completed by the facility pertaining to the laceration incident on 6/23/18 for R#902 was reviewed and revealed the following: A facility document titled Verification of Investigation stated Summary of Factual Investigative Findings- During attempt to transfer pt (patient); on duty CNA (certified nursing assistant) attempting one person transfer from wheelchair to bed; pt received laceration to left lower lateral/frontal side of leg: pt has fragile skin with dx (diagnosis) of [DIAGNOSES REDACTED]; Investigative findings support that care plan/Kardex not followed as indicated-as care plan/Kardex-shows 2 person assist with sit to stand mechanical lift-no intent to harm/cause laceration-staff received written documentation; Bed frame with some noted ridge/sharpened area of the center portion of frame may have contributed to the LLE (lower left extremity) laceration-Foam padding to bed frame as preventative measure. A statement by staff member B signed and dated on 6/23/18 revealed the following: At 9:30 pm, I (name of staff member B) was assigned to (A range of resident room numbers) I was getting her ready for bed and as I was transferring her from the wheelchair to the bed she received a skin tear on her left leg. I notified the nurse immediately and they treated her leg. A facility document titled Employee Coaching Form dated 6/27/18 that was completed by staff member D and acknowledged and signed by staff member B was reviewed and revealed the following: When caring for residents, careplans must be followed at all times. Safe transfers occur when individualized care plans are followed. Prior to any resident transfer you must know how the transfer should be performed and comply with the directives. you must never use a less safe mode of transfer. Speak to your your nurse if you have any concerns with the careplan or resident. Safety is a vital part of all resident care and especially with transfers. On 7/10/18 at approximately 2:15 p.m., The Director of Nursing (DON) was queried regarding the incident involving on 6/23/18 involving the transfer for R#902. The DON was queried if he expected the staff to follow the plan of care that was indicated in the individualized care plans for the residents in the facility and they stated that they did. The DON then stated we identified the issue and we did education to all staff on transfers. The DON was then queried for a facility policy on Transfers stating the purpose and goals of safe transfers and following the individualized care plan in regards to transfers. The DON indicated that they didn't have a policy on transfers just a grid. No policy was received stating the purpose and goals of safe transfers or the importance following the individualized care plan in regards to transfers before then end of the survey. On 7/10/18 at approximately 4:45 p.m., during the exit conference, the facility was queried for any additional documentation they would like to provide. No further documentation was provided.

Based on observation, interview and record review, the facility failed to implement preventive pressure relief devices and appropriate treatment for two (#705 and #713) of two sampled residents reviewed for pressure sores from a total of 24, resulting in the development of pressure sores, delayed healing and the potential for worsening of the sores. Findings include: Resident #705- On 10/17/16 at 7:30 PM, resident #705 was observed lying in bed on her back. The resident had her eyes open and was able to respond yes or no to uncomplicated questions. The resident was blind, immobile and had a pressure relief boot on the right foot. The left heel was on the bed. At 10 PM, the resident was asleep on her back with a boot on the right foot and the left heel was on the bed. On 10/18/16 at 9:50 AM, the resident's skin was observed with wound care nurse 'D'. The resident was lying on her back with the left heel on the mattress. When asked if there was a pressure relief device for the left heel, nurse 'D' removed a pillow from underneath the resident's head, placed it under the left heel and said that a pillow should have been there. The boot was removed from the resident's right foot. There was a foam dressing on the right heel with a hard, black, necrotic (dead skin) pressure sore underneath measuring approximately 3 centimeters (cm) in diameter. When asked, nurse 'D' said that the sore developed at the facility. When asked, nurse 'D' said that the dry dressing was ordered to be changed every three days and that there was no wound treatment prescribed, such as a chemical gel to debride dead tissue to facilitate development of new tissue. When asked, nurse 'D' said that a contracted wound specialist came to the facility every two weeks and was not due until the next week, but the resident's wound was being managed by the primary care physician, not the specialist. When asked why, she said, The wound specialist is consulted when wounds get worse, indicating that consults were not requested proactively. On 10/18/16 at 5 PM, the resident's clinical record was reviewed with nurse unit manager 'B'. The resident was admitted with [DIAGNOSES REDACTED]. Minimum Data Sets ((MDS) dated [DATE] and 8/4/16 noted the resident had severe cognitive impairment, required extensive assistance for transfers and bed mobility, was non-ambulatory, had limited movement to bilateral lower extremities and had no pressure sores. Per Braden (pressure sore risk) Scales dated 4/27/16, 6/30/16, 7/28/16 and 8/25/16, the resident was at low to moderate risk for development, with scores of 14 to 16. A scale of 12 or less meant high risk. The resident was prescribed heel protectors bilateral feet at all times as tolerated. Hospital records and an Incident report noted that the resident sustained [REDACTED]. Per a hospital progress note dated 6/29/16: Continue knee immobilizer for comfort. Should be removed every shift for skin checks. Can also remove for bathing. On 8/23/16, there was an order to add [MEDICAL CONDITION] to the resident's [DIAGNOSES REDACTED].) There were no sores observed on any part of the right foot except the heel, a typical pressure point area. Nurse 'B' was asked why there was no heel protector on the left foot, considering the sore that developed on the right heel. She was asked how the pressure sore developed, if staff was diligent with pressure relief measures, particularly since the right leg was being kept immobilized and the resident had [MEDICAL CONDITION], which made the heel more vulnerable to breakdown. Nurse 'B' said that she did not know and would have to ask nurse 'D'. On 10/18/16 at 6 PM, after the chart review with nurse 'B', the resident was observed lying in bed on her back with the left heel on the bed. There was no heel protector present in the room. On 10/19/16 at 8:50 AM, the resident was lying in bed on her back with the left heel on the bed and no heel protector in sight. At that time, nurse 'D' entered the room unwrapping a new set of heel protectors. She did not respond when asked why the resident was just now getting one for the left foot. On 11/19/16 at 11 AM, per review of wound records and notes by nurse 'D' regarding the right heel pressure sore: On 8/23/16-Nurse aide) reported to this writer of a black area on resident's right heel. Eschar (dead, leathery skin) cap on right heel measures 3 cm by 4 cm Area firm to the touch heel protectors on bilateral feet at all times as tolerated. [MEDICAL CONDITIONS] added to [DIAGNOSES REDACTED]. On 9/2/16 and 9/10/16-measured 2.5 cm x 3 cm with hard eschar. On 9/24/16-measured 3.5 cm x 2 cm with hard eschar. On 10/10/16, eschar was still anchored to wound bed. There was no documented treatment to facilitate new tissue growth. A Potential for Impairment to Skin Integrity care plan, related to limited mobility (there was no mention of [MEDICAL CONDITION]) provided by nurse 'B', noted a goal: The resident will remain free of new impairment through the (next) review date (of 11/3/16). Interventions included: Ensure that heels are elevated while resident is lying in bed. Bilateral heel protectors at all times as tolerated and foam dressing to right heel every 3 days for right heel eschar. However, the care plan inaccurately noted that it, and all of the interventions, were initiated on 4/27/16. At 1:50 PM, the Director of Nursing (DON) was asked why there was no consultation or treatment for necrosis of the facility acquired right heel pressure sore and why the sore was 3 cm by 4 cm and already necrotic when first reported. The DON said, I wasn't aware of it. Where is it located? I will have to talk to (nurse 'D') about it. I can't answer that. When asked why the left heel was repeatedly observed without the prescribed heel protector, the DON said, There is no requirement to have heel protectors. Could we have put them in place to prevent? Yes. Resident #713- On 10/17/16 at 7:15 PM and at 10 PM, resident #713 was observed lying in bed in a fetal position on her right side and was wearing bilateral heel protectors. On 10/18/16 at 10:30 AM, the resident's skin was observed with nurse 'D'. The resident was lying on her right side. The heel protector and a foam dressing dated 10/17/16, was removed from the right foot and revealed a pressure sore on the right lateral ankle measuring approximately 3 cm in diameter, that nurse 'D' said had developed in the facility. The wound bed could not be seen due to slough (liquefying dead tissue), in order to determine the stage of the pressure sore. The dressing, which was changed the previous day by nurse 'D', was saturated with a large amount of beige drainage. When asked how often the dressing was to be changed, nurse 'D' said, Every three to five days. When queried about the frequency of the dressing changes, considering the amount of drainage, nurse 'D' said, There wasn't this much drainage. It looks worse than it did yesterday. When asked if the sore was a blister that had ruptured since yesterday, the nurse said, No. It wasn't a blister. It wasn't filled with fluid. When asked if the resident was being treated by the wound specialist, nurse 'D' said No. She is Hospice. I need to see how aggressive Hospice wants to be, regarding a consult or further wound care measures and that her primary care physician was managing the wound. Nurse 'D' was asked about measures implemented to prevent the pressure sore from developing and she said, She has heel protectors, referring to current measures. When asked what would have made the pressure sore unavoidable, nurse 'D' said, She favors lying on her right side. The resident was resistant to turning and immediately wanted to lay back on the right side. There were no pressure sores observed on other areas of the resident's skin except the lateral ankle, a typical pressure point area that the resident tended to lay on. On 10/18/16 at 10:50 AM, the resident's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/9/16, the resident's Braden score was 19. On 8/31/16, the resident began receiving Hospice services due to lung disease. The MDS dated [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for transfers and bed mobility and had no pressure sores. On 9/28/16, foam dressings every 3 to 5 days, were prescribed for a stage II blister on the right lateral ankle and the resident's treatment records revealed that application of the dressings began on 9/28/16. There was no documented order for heel protectors before 9/28/16. The resident's Skin Integrity care plan noted an intervention added to the care plan on 9/28/16: Ensure heels elevated while in bed. At 11 AM, per review of the resident's nurse aide electronic care plan with nurse aide 'F', there were no documented interventions for pressure relief to the resident's heels. On 10/18/16 at 12 Noon, nurse 'D' presented a new order and said, I spoke to the Hospice nurse and she changed the dressings from every 3 to 5 days, to every 3 days. When queried about the frequency practically remaining unchanged for a sore that was worsening and with increased drainage, nurse 'D' did not respond. At 12:10 PM, Hospice nurse 'C' was interviewed by phone about the pressure sore. She said, Our goal is to help maintain it, so it won't become infected and keep (the resident) comfortable. When asked if nurse 'C' had told her that the wound was worse and had a large amount of drainage, nurse 'C' said, I didn't understand that about the wound, so maybe we can change to an Alginate because of the drainage and change it (foam dressing) every three days. Alginate is a highly absorbable wound treatment cut to size, placed directly on sores with moderate to heavy drainage and forms a gel to help minimize bacterial contamination. When asked if she had experienced seeing Hospice residents, thought to be in further decline, improve and no longer require Hospice care, nurse 'C' said, Oh, yes. That happens. At 6 PM, the resident was observed lying in bed on her right side. Per review of the resident's Hospice Skin Integrity care plan, last modified 10/11/16: Goals included-Clean infection free wounds and Preventive measures utilized. On 10/19/16 at 8 AM, the resident was observed lying in bed on her right side. At 1 PM, per review of the resident's wound notes by nurse 'D': On 9/28/16, the pressure sore was a fluid-filled blister measuring 2 cm by 1.7 cm. On 10/8/16, it measured 2 cm by 2 cm. On 10/14/16, it measured 2.3 cm by 2.5 cm. There was no mention of the pressure sore in the physician's progress note dated 10/8/16. At 1:50 PM, the DON was asked if the resident's pressure sore was avoidable or unavoidable and he said, She is Hospice. She is declining and not eating. When told that the resident had a pressure sore only on the right lateral ankle, on the side that she usually slept on, but no place else and that there were no documented preventive interventions before the sore was discovered, the DON said, Well, we have things in place now. On 10/20/16 at 8 AM, per review of the facility's Prevention of Pressure Ulcers policy dated 10/2010: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure The most common site heels, ankles The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate When in bed every, attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices The facility was asked if there was additional information regarding this citation, but none was provided by survey exit. ( )

Based on observation, interview and record review, the facility failed to provide adequate supervision and failed to consistently implement or revise fall safety devices/interventions for two (#701 and #705) of four sampled residents reviewed for accidents from a total of 24, resulting in falls with bleeding, a hematoma, pain, a fracture and emergency treatment and hospitalization . Findings include: Resident, #705- On 10/17/16 at 7:30 PM, resident #705 was observed lying in bed. The resident had her eyes open and was able to respond yes or no to uncomplicated questions. The resident was blind and immobile. On 10/18/16 at 5 PM, the resident's clinical record and an Incident report were reviewed with nurse unit manager 'B'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets ((MDS) dated [DATE] and 8/4/16 noted the resident had severe cognitive impairment, required extensive assistance for transfers and bed mobility, was non-ambulatory and had limited movement of bilateral lower extremities. The Incident report dated 6/25/16 at 2 PM noted: resident complained of right knee pain PRN (as needed) Norco (narcotic pain reliever) given per daughter's request. Description of incident by person involved: Reported by Activities(staff), resident was being pushed in wheelchair to activity when foot went back a little and resident complained of right knee. (History of right knee arthroplasty (knee replacement) Result of injury: Resident admitted to (hospital) fracture femur. The corrective measure to prevent reoccurrence: monitor the knee. There were no documented comments in the Incident report regarding the circumstances of the injury, who was directly involved and no further corrective actions. Nurses noted the following: 6/25/16 at 2:19 PM-Reported to writer that resident left with some church people to take her to an activity in building but that resident complained of her right knee. 6/25/16 at 9:24 PM-Resident complained of right knee again. Right knee per (nurse aide) looks larger than usually does. Right knee noted to be very warm to touch Norco given order for STAT (immediate) X-ray to right knee 6/26/16 at 8:30 AM-Upon arrival on shift noted with abnormal STAT X-ray results as follows: .femur fracture new order to transfer resident to (hospital emergency room ). The resident was then transferred to the hospital. Per review of a hospital X-ray report of the right femur dated 6/26/16: right femur demonstrates displaced angulated fracture (two pieces of bone at an angle to one another) just above the knee prosthesis (artificial joint) significantly displaced fracture Osteopenia (weakened bone). An orthopedic report by a hospital Nurse Practitioner dated 6/29/16 noted: Surgery was not performed as the resident was not ambulatory prior to the incident, so an immobilizer was applied. The resident returned to the facility on [DATE]. When asked about the injury and whether footrests were on the resident's wheelchair during transport to prevent the leg/foot from bending backwards, nurse 'B' said that the resident was in the wheelchair without footrests and was being wheeled to an activity by a visitor when the incident occurred. When asked, she was unable to explain why this resident, who did not and could not use her feet to propel the wheelchair at the time, did not have footrests on the wheelchair when staff got her dressed and up for the day. Nurse 'B' said, She has osteopenia. There was no documented [DIAGNOSES REDACTED].' did not respond when asked why staff was not diligent, in lieu of osteopenia or osteoporosis, in providing proper wheelchair devices to ensure safety. (Earlier in the day at 4 PM, when asked about safety measures during wheelchair transports, Therapy manager 'E' said, We expect footrests on the wheelchair during transport unless the resident uses their feet to propel on their own.) On 10/19/16 at 1:50 PM, when the resident's fracture was discussed with the Director of Nursing (DON), he said, We should provide a safe transfer, like footrests. There was no available policy provided regarding use of wheelchair foot rests. Resident #701- On 10/17/16 at 7 PM, resident #701 was observed asleep in a low bed with a fall safety alarm to alert staff of unassisted attempts to transfer and a fall safety mat on the floor next to the bed. On 10/18/16 at 10:30 AM, resident's, including #701, were observed being monitored by staff that were seated in the room. At 4:15 PM, the resident's clinical record and Incident reports were reviewed with nurse unit manager 'B'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had moderate cognitive impairment and required limited assistance for transfers. The MDS dated [DATE] noted that the resident had severe cognitive impairment, was non-ambulatory, required extensive assistance for all activities of daily living and had limited movement to the left lower extremity. The resident was prescribed a bed fall safety alarm. The resident's Fall Risk Observations (assessments) dated 1/3/16, 2/11/16, 2/23/16, 2/29/16, 3/25/16, 4/7/16, 4/22/16, 4/26/16, 5/3/16, 6/6/16, 7/12/16 and 7/21/16, noted risk scores ranging 25 to 48. A score of 16 or greater meant high risk for falls. Most of these assessments were obtained on the dates that falls occurred. The resident's Incident reports revealed that on 1/3/16, the resident had a fall in her room without injury and another fall on 2/11/16 resulting in left hip fracture with surgical repair and returned back to the facility on [DATE]. Subsequent Incident reports and nursing notes revealed the following: 1. On 2/23/16 at 7:30 PM-Resident attempted to stand without seeking and asking for assistance in the day room and fell -no documented indication that staff were present, monitoring the day room and had witnessed the fall-no noted injury-corrective action: placed on one to one supervision. When asked about day room supervision, nurse 'B' said that the room was supposed to be monitored when residents were present. 2. On 2/28/16 at 1:45 PM-found on floor in day room-no noted injury-no documented indication that staff was present-corrective action: taken to an activity. 3. On 3/9/16-fall in room-found by the bed-complained of leg pain-X-ray negative for fracture-no mention bed alarm sounded. 4. On 3/25/16 at 6:25 PM-fall in the North dining room located at the end of the hallway beyond all of the resident rooms and nursing station-a wheelchair alarm sounded-no noted injury-the corrective action: monitor dining room during meals. It was unknown by nurse 'B' as to when a wheelchair alarm began to be used. Per 3/4/16 nursing notes, the resident had a wheelchair alarm in place at that time. 5. On 4/7/16 6:30 PM-slid to floor from wheelchair in hallway-no noted injury-no indication that incident was witnessed or that alarm sounded-corrective action-check alarm to ensure that it is working. Nurse 'B' did not respond when asked if the alarm was working or not. 6. On 4/22/16 at 4 PM-sitting on the floor by the bathroom doorway with water on the floor after trying to get water in a pitcher from the bathroom sink-no noted injury-alarm sounded-no indication why the resident was left alone in the room when awake. 7. On 4/26/16 at 4:45 PM-slid out of wheelchair on floor in the North dining room-bruise to left upper arm and bleeding from finger left hand-alarm sounded-no indication the dining room was being monitored-corrective action: resident placed by the nursing station. When asked if anti-slide devices were added to the wheelchair seat, such as anti-skid pads (dycem) or a pommel cushion (a wedge that elevates between the legs), nurse 'B' said no. 8. On 4/26/16 at 10 PM-on floor in hallway by North dining room-no noted injury-no indication alarm sounded. 9. On 5/3/16 at 3:30 PM-on floor by room door-complained of left hip pain-X-ray negative for fracture-no indication that wheelchair or bed alarm sounded or why resident was left alone in the room while awake. Corrective action: Continue to monitor. 10. On 6/6/16 at 3:45 PM-on floor in room-bleeding from left ear-no indication alarm sounded or why resident was left alone in the room while awake. 11. On 7/12/16 at 8 PM-slid from wheelchair on floor in day room-no indication alarm sounded or that anti-skid device was in or added to wheelchair or that the room was being supervised. 12. On 8/9/16 at 5:30 PM-observed on floor by nursing station with head against wall-hematoma to back of head-no indication that staff was present at the nursing station or that the fall was witnessed or that the alarm sounded-corrective action: Chair alarm to be connected to resident at all time while in wheelchair. Nurse 'B' could not answer when asked if the alarm was attached to the resident or not. The resident's Risk for Falls care plan related to past history, initiated 2/15/16 and on-going noted: The resident will be free of 'minor' injury There were no documented interventions regarding supervision while awake, anti-skid seat devices or bed/wheelchair alarms. On 10/19/16 at 1:50 PM, when the resident's falls, lack of proper supervision and lack of consistent and appropriate safety devices were discussed with the DON, he said, We monitor the dining room. Our falls have gone down quite a bit because of concerns with monitoring the dining room and implementing devices. He did not explain what happened in the case of resident #701. On 10/20/16 at 8 AM, per review of the facility's Falls- Clinical Protocol dated 10/2010 and Falls and Fall Risk, Managing policy dated 10/2007: -Falls should be identified as witnessed or unwitnessed events Based on assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. -The staff, with the input of the attending physician, will identify appropriate interventions to reduce risk of falls If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approaches remain relevant. The facility was asked if there was additional information but none was provided by survey exit. ( )

BASED ON OBSERVATIONS, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE USE OF TEMPORARY POWER STRIPS AND EXTENSION CORDS IN ROOM #427, FOR ONE (# 700) SAMPLED RESIDENT, RESULTING IN A FIRE. IN ADDITION, THE FACILITY FAILED TO MONITOR THE USE OF POWER STRIPS AND EXTENSION CORDS IN ROOMS: 201, 214, 226, 301, 321, 322, 325, 326, 328, 406, 410, 417, 419, 422, 424, 426), INVOLVING 38 ( #'S 1, 24, 25, 40, 41, 42, 48, 80, 81, 82, 86, 87, 88, 89, 93, 94, 99, 100, 101, 102, 103, 104, 106, 107, 108, 118, 121, 125, 126, 127, 128, 129, 130, 132, 133, 134, 136, AND 137) OFF SAMPLED RESIDENTS AND ONE (# 701) SAMPLED RESIDENT, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) TO RESIDENT'S HEALTH AND SAFETY, AND THE POTENTIAL FOR SERIOUS HARM,INJURY, OR DEATH FROM FIRE AND SMOKE INHALATION TO ALL RESIDENTS IN THE FACILITY. THE IJ WAS IDENTIFIED ON 10/29/11 AT 4:00 P.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 11/08/11 AT 2:00 PM. A PLAN OF ACTION TO REMOVE THE IJ WAS REQUESTED. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/9/11. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE DEFICIENT PRACTICE REMAINED AS WIDESPREAD, WITH NO ACTUAL HARM, WITH A POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. Findings include: A COMPLAINT INVESTIGATION WAS CONDUCTED ON 11/3/11 AT 9:45 A.M. IN RESPONSE TO AN ELECTRICAL FIRE THAT OCCURRED RELATED TO THE USE OF EXTENSION CORDS, ON 10/29/11 IN ROOM 427, WHERE RESIDENT #700 RESIDED. REVIEW OF AN "INCIDENT REPORT" DATED 10/29/11 AT APPROXIMATELY 4:00 P.M., INDICATED THAT FIRE AND SMOKE HAD BEEN IDENTIFIED BY STAFF CERTIFIED NURSE ASSISTANT (CNA) "A" IN ROOM 427, AND THE FIRE ALARM WAS ACTIVATED. ON 11/3/11 AT 10:00 A.M., THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE QUERIED REGARDING THE ELECTRICAL FIRE THAT HAD OCCURRED IN THE NURSING HOME ON 10/29/11. THE ACCOUNTS GIVEN ARE AS FOLLOWS: THE DIRECTOR OF NURSING (DON) STATED THAT SHE WAS NOTIFIED BY THE ALARM COMPANY OF A FIRE AT THE FACILITY ON 10/29/11 AT APPROXIMATELY 4:00 P.M. THE DON STATED THAT SHE CALLED THE ADMINISTRATOR, AND CALLED THE NURSING HOME AND SPOKE WITH THE RECEPTIONIST. SHE WAS TOLD THAT THE FIRE DEPARTMENT WAS ALREADY AT THE FACILITY. THE DON STATED THAT SHE ARRIVED AT THE FACILITY AT APPROXIMATELY 4:15 P.M. AND THAT THE FIRE DEPARTMENT WAS GETTING READY TO LEAVE, AND THEY HAD GIVEN THE BUILDING AN ALL CLEAR . THE DON STATED THAT THE FIRE HAD OCCURRED IN ROOM 427 ON THE FOURTH FLOOR. "WHEN I ARRIVED, MOST OF THE RESIDENTS ON THE FOURTH FLOOR WERE STILL IN THE DAY ROOM. THE FIRE DOORS WERE STILL CLOSED. I WENT INTO ROOM 427 AND OBSERVED THAT THE BED WAS PULLED AWAY FROM THE WALL. A SECTION OF THE COVE BASE MOLDING BEHIND THE BED HAD BEEN REMOVED BY THE FIRE DEPARTMENT, AND THERE WAS BLACK SOOT THAT EXTENDED ABOUT 12 INCHES UP THE WALL FROM THE FLOOR. THE FIRE DEPARTMENT HAD TAKEN A POWER STRIP AND AN EXTENSION CORD FROM THAT ROOM. I TOLD STAFF TO HAVE THE AREA CLEANED AND TO CHANGE THE LINENS. I LEFT THE FACILITY AT ABOUT 4:30 P.M., AND THE RESIDENT IN ROOM 427 WAS MOVED BACK INTO THE ROOM THAT SAME DAY." THE ADMINISTRATOR WAS INTERVIEWED AND STATED THAT HE WAS NOTIFIED BY THE ALARM COMPANY ON 10/29/11 AT APPROXIMATELY 4:00 P.M.. " I CALLED THE FACILITY AND SPOKE TO A SECOND FLOOR NURSE ABOUT THE FIRE IN ROOM 427. I SPOKE WITH THE DON AND SHE WAS ON HER WAY TO THE FACILITY TO MONITOR THE SITUATION. AFTER THE INCIDENT IN ROOM 427, ALL POWER STRIPS AND EXTENSION CORDS IN THE BUILDING WERE INSPECTED. A LOT OF THEM WERE REMOVED, AND I ESTIMATED APPROXIMATELY 9 ROOMS STILL HAD POWER STRIPS IN USE. MY GOAL IS TO ELIMINATE ALL OF THEM." THE ADMINISTRATOR WAS QUERIED ABOUT REPORTING THE INCIDENT TO THE STATE AGENCY, HE STATED THAT HE HAD TRIED TO MAKE CONTACT UNSUCCESSFULLY WITH THE LICENSING OFFICER IN DETROIT ON 10/31/11. HE STATED THAT HE WAS FINALLY ABLE TO MAKE CONTACT WITH THE LICENSING OFFICER ON 11/1/11. WHEN ASKED WHY HE DID NOT CONTACT THE LICENSING OFFICER IMMEDIATELY FOLLOWING THE DISCOVERY OF THE FIRE ON 10/29/11, HE STATED THAT " IT WAS A MELTDOWN OF A MALFUNCTIONING POWER STRIP, NOT A TRUE FIRE, AND THAT IS WHY I DID NOT REPORT IT IMMEDIATELY " . ON 11/3/11 AT 10:30 A.M., THE MAINTENANCE DIRECTOR WAS QUERIED ABOUT THE FIRE AND HE STATED THAT, " THE FIRE MARSHALL HAD BEEN to the facility on [DATE]. I WAS TOLD BY THE FIRE MARSHALL THAT SURGE PROTECTORS (POWER STRIPS) MOUNTED ON THE WALL WERE CONSIDERED A TEMPORARY POWER SOURCE, AND WERE NOT ALLOWED." THE MAINTENANCE DIRECTOR STATED THAT THERE WERE STILL SOME ROOMS WITH EXTENSION CORDS AND POWER STRIPS, AND THAT THEY WERE WORKING ON REMOVING THEM. HE STATED THAT A CONSULTATION WITH AN ELECTRICIAN WAS SCHEDULED FOR 11/7/11, TO DISCUSS ADDING NEW OUTLETS IN RESIDENT ROOMS AS NEEDED. ON 11/3/11 AT 10:45 A.M., ALL 72 RESIDENT ROOMS WERE OBSERVED FOR ANY REMAINING EXTENSION CORDS AND POWER STRIPS. ADMISSION RECORDS AND MINIMUM DATA SETS (MDS) WERE REVIEWED AND REVEALED THE FOLLOWING: SECOND FLOOR: ROOM 201: POWER STRIP IN USE, WITH A RESIDENT ON OXYGEN THERAPY. RESIDENT #1 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, AND WAS NON-AMBULATORY. ROOM 214: ONE EXTENSION CORD IN USE FOR THE TELEVISION. RESIDENT #24 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS DATED 11/4/11 NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND WAS NON-AMBULATORY. RESIDENT #25 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED SUPERVISION FOR AMBULATION. ROOM 226: ONE EXTENSION CORD IN USE. RESIDENT #40 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND WAS NON-AMBULATORY. RESIDENT #41 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED EXTENSIVE ASSISTANCE FOR AMBULATION. RESIDENT #42 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION AND WAS NON-AMBULATORY. THIRD FLOOR: ROOM 301: ONE POWER STRIP IN USE FOR THE TELEVISION, REFRIGERATOR AND PHONE. RESIDENT #48 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND WAS NON-AMBULATORY. ROOM 321: ONE POWER STRIP IN USE FOR A COMPUTER. RESIDENT #701 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD MODERATELY IMPAIRED COGNITION AND WAS NON-AMBULATORY. ROOM 322: ONE POWER STRIP IN USE FOR A BREATHING TREATMENT MACHINE. RESIDENT #80 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THE RESIDENT HAD MODERATELY IMPAIRED COGNITION, AND REQUIRED SUPERVISION FOR AMBULATION. RESIDENT #81 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED LIMITED ASSISTANCE WITH AMBULATION. RESIDENT #82 HAD [DIAGNOSES REDACTED]. A QUARTERLY M.D.S DATED 10/25/11 NOTED THAT THE RESIDENT HAD MODERATELY IMPAIRED COGNITION AND REQUIRED SUPERVISION FOR AMBULATION. ROOM 325: ONE POWER STRIP IN USE FOR THE CABLE BOX AND TELEVISION. RESIDENT #86 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, AND WAS INDEPENDENT WITH AMBULATION. ROOM 326: ONE 3-OUTLET EXTENDER IN USE. RESIDENT #87 HAD [DIAGNOSES REDACTED]. AN ANNUAL MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATION. RESIDENT #88 HAD [DIAGNOSES REDACTED]. AN ANNUAL MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED LIMITED ASSISTANCE WITH AMBULATION. RESIDENT #89 HAD [DIAGNOSES REDACTED]. AN ANNUAL MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND WAS NON-AMBULATORY. ROOM 328: ONE POWER STRIP IN USE. RESIDENT #93 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND WAS INDEPENDENT WITH AMBULATION. RESIDENT #94 HAD [DIAGNOSES REDACTED]. AN ANNUAL MDS dated [DATE] NOTED THAT THE RESIDENT HAD MODERATELY IMPAIRED COGNITION, AND REQUIRED SUPERVISION WITH AMBULATION. FOURTH FLOOR: ROOM 406: ONE BROWN EXTENSION CORD IN USE. RESIDENT #99 [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED SUPERVISION WITH AMBULATION. RESIDENT #100 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, REQUIRED LIMITED ASSISTANCE WITH AMBULATION, AND HAD OXYGEN THERAPY IN USE. RESIDENT #101 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, AND WAS NON-AMBULATORY. ROOM 407: ONE POWER STRIP IN USE. RESIDENT #102 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED LIMITED ASSISTANCE WITH AMBULATION. RESIDENT #103 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATION, AND HAD OXYGEN THERAPY IN USE. RESIDENT #104 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, WAS INDEPENDENT WITH AMBULATION, AND HAD OXYGEN THERAPY IN USE. ROOM 410: ONE LONG, ORANGE EXTENSION CORD IN USE FOR THE TELEVISION. RESIDENT #106 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND WAS NON-AMBULATORY. RESIDENT #107 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND WAS NON-AMBULATORY. RESIDENT #108 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATION. ROOM 417: ONE POWER STRIP IN USE FOR THE TELEVISION. RESIDENT #118 HAD [DIAGNOSES REDACTED]. AN ANNUAL MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATION. ROOM 419: ONE POWER STRIP IN USE FOR THE WALL MOUNTED FAN. RESIDENT #121 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND WAS INDEPENDENT WITH AMBULATION. ROOM 422: TWO WALL MOUNTED POWER STRIPS IN USE FOR TELEVISIONS. RESIDENT #125 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD MODERATELY IMPAIRED COGNITION, AND WAS NON-AMBULATORY. RESIDENT #126 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, AND WAS NON-AMBULATORY. RESIDENT #127 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, AND WAS NON-AMBULATORY. ROOM 424: ONE LONG, ORANGE EXTENSION CORD IN USE FOR A TELEVISION, AND ONE POWER STRIP IN USE FOR A TELEVISION. RESIDENT #128 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND WAS NON-AMBULATORY. RESIDENT #129 HAD [DIAGNOSES REDACTED]. RESIDENT #130 HAD [DIAGNOSES REDACTED]. AN ADMISSION MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED SUPERVISION FOR AMBULATION. ROOM 426: TWO EXTENSION CORDS IN USE FOR TELEVISIONS. RESIDENT #132 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED EXTENSIVE ASSISTANCE WITH AMBULATION. RESIDENT #133 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND REQUIRED LIMITED ASSISTANCE WITH AMBULATION. RESIDENT #134 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT, AND WAS INDEPENDENT WITH AMBULATION. ROOM 427 (THE ROOM WHERE THE FIRE OCCURRED ON 10/29/11): ONE POWER STRIP IN USE FOR 2 TELEVISIONS. THIS ROOM WAS ALSO INSPECTED FOR FIRE DAMAGE. THE COVE BASE MOLDING HAD BEEN REPLACED, THE WALL HAD BEEN RE-PAINTED AND THE FLOOR TILE HAD BEEN REPLACED. THE ROOM DID NOT HAVE ANY SMOKE ODORS LINGERING. AT THE TIME OF THE FIRE, THERE WAS ONE RESIDENT RESIDING IN THIS ROOM. THERE ARE NOW 2 OTHER RESIDENTS ALSO RESIDING IN THIS ROOM. THE RESIDENT WHO OCCUPIED ROOM 427 AT THE TIME OF THE FIRE, CONTINUES TO RESIDE IN THIS ROOM. THIS RESIDENT IS COGNITIVELY IMPAIRED, AND WAS NOT INTERVIEWABLE. THIS RESIDENT WAS OBSERVED AMBULATING IN THE HALLWAY. THE FACILITY STATED THAT THE RESIDENT SUFFERED NO INJURIES OR ILL-EFFECTS FROM THE FIRE. RESIDENT #700 HAD [DIAGNOSES REDACTED]. AN ANNUAL MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION, AND REQUIRED SUPERVISION WITH AMBULATION. RESIDENT #136 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD MODERATELY IMPAIRED COGNITION, AND WAS NON-AMBULATORY. RESIDENT #137 HAD [DIAGNOSES REDACTED]. A QUARTERLY MDS dated [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, AND WAS NON-AMBULATORY. THE YPSILANTI FIRE DEPARTMENT REPORT DATED 10/29/11 WAS REVIEWED, WITH THE FOLLOWING REMARKS NOTED: " THERE WAS ONLY A TV PLUGGED INTO THE CORD. DISPATCHED TO AN AUTOMATIC ALARM. WHILE ENROUTE DISPATCH ADVISED OF A FIRE ON THE FOURTH FLOOR SECOND BOX ALARM WAS REQUESTED. ARRIVAL WITH NOTHING SHOWING. STAFF ADVISED ROOM 427. ARRIVAL ON FOURTH FLOOR TO FIND STAFF EVACUATING THE HALL. THEY HAD PLACED TOWELS UNDER THE DOOR. CRACKED DOOR TO FIND MODERATE SMOKE IN THE ROOM. DOOR WAS KEPT CLOSED UNTIL EVACUATION WAS COMPLETED. CREWS ENTERED ROOM FULL SCBA AND INVESTIGATION FOUND THE ATTACHMENT POINT OF TWO EXTENSION CORDS HAD SHORTED OUT BURNING THE CORD BURNING A SMALL PORTION OF A LINOLEUM FLOOR AND RUBBER BASE MOLDING WITH MINOR SCORCHING TO THE WALL. PPV (POSITIVE PRESSURE VENTILATOR), WAS USED TO CLEAR ROOM AND HALL. STAFF WAS ADVISED TO CLEAN BEDDING OF OCCUPANTS AND LEAVE ROOM VACANT FOR A COUPLE HOURS CLOSE THE DOOR AND LEAVE WINDOWS OPEN. STAFF WAS ADVISED TO MONITOR THE USE OF EXTENSION CORDS AND MAKE SURE THEY ARE NOT BEING OVERLOADED ". ON 11/9/11 AT 12:15 P.M., THE MAINTENANCE DIRECTOR WAS QUERIED REGARDING MONITORING THE USE OF EXTENSION CORDS AND POWER STRIPS IN THE RESIDENT'S ROOMS. THE MAINTENANCE DIRECTOR WAS AWARE THAT RESIDENTS AND FAMILY MEMBERS WERE BRINGING EXTENSION CORDS AND POWER STRIPS INTO THE FACILITY, FOR USE IN RESIDENT ROOMS. THE MAINTENANCE DIRECTOR STATED THAT PRIOR TO THE 10/29/11 FIRE IN ROOM 427, THE FACILITY DID NOT HAVE A SYSTEM IN PLACE TO MONITOR THE USE OF EXTENSION CORDS OR POWER STRIPS IN RESIDENT ROOMS. ON 11/9/11 AT 12:27 P.M., THE ADMINISTRATOR WAS QUERIED REGARDING MONITORING THE USE OF EXTENSION CORDS AND POWER STRIPS IN THE RESIDENT'S ROOMS. THE ADMINISTRATOR WAS AWARE THAT FAMILY MEMBERS WERE BRINGING EXTENSION CORDS AND POWER STRIPS INTO THE FACILITY FOR USE IN RESIDENT ROOMS. REVIEW OF THE FACILITY'S POLICY, "GENERAL INFORMATION REGARDING FACILITY SERVICES, POLICIES, AND PROCEDURES", UNDATED, NOTED THE FOLLOWING: " ELECTRICAL APPLIANCES: THE FOLLOWING ITEMS ARE NOT ALLOWED IN THE FACILITY: E. EXTENSION CORDS...". THE FACILITY'S POLICY DID NOT ADDRESS MONITORING THE USE OF POWER STRIPS AND EXTENSION CORDS IN RESIDENT ROOMS. THE IMMEDIATE JEOPARDY WAS REMOVED ON 11/9/11, WHEN THE FACILITY IMPLEMENTED THE FOLLOWING: 1. TO ENSURE THAT FIRE IN RESIDENT ' S ROOM DOES NOT OCCUR AS A RESULT OF TEMPORARY POWER STRIPS AND EXTENSION CORDS, THE FACILITY HAS REMOVED SAID CORDS FROM ALL RESIDENT ROOMS. 2. THE FACILITY IDENTIFIED EACH ROOM THAT HAS A POWER STRIP AND EXTENSION CORD AND HAS REMOVED ALL POWER STRIPS AND EXTENSION CORDS FROM ALL RESIDENTS ' ROOMS INCLUDING ROOMS: 201,214,226,301,321,322,325,326,328,406,407,410,417,419,422,424,426 AND 427. ALL STAFF AND FAMILY MEMBERS HAVE BEEN NOTIFIED THAT POWER STRIPS AND EXTENSION CORDS ARE NOT ALLOWED IN THE FACILITY. 3. ALL RESIDENTS ROOMS HAVE BEEN QA'D BY THE FACILITIES MAINTENANCE DIRECTOR AND ADMINISTRATOR ON 11-8-2011 TO ENSURE THAT ALL POWER STRIPS AND EXTENSION CORDS HAVE BEEN REMOVED FROM ALL RESIDENTS ' ROOMS. THE MAINTENANCE DIRECTOR tested EACH ELECTRICAL OUTLET IN THE RESIDENT ' S ROOMS TO ENSURE THAT ALL OUTLETS ARE IN PROPER WORKING ORDER ON 11-9-2011. RESIDENT ROOMS HAVE BEEN ARRANGED TO ACCOMMODATE ALL PERSONAL ELECTRIC ITEMS WHICH HAVE BEEN PLUGGED DIRECTLY INTO THE WALL OUTLETS WITHIN THE CONFIGURATION OF EACH ROOM. ALL STAFF HAVE BEEN IN SERVICED ON THAT ALL POWER STRIPS AND EXTENSION CORDS ARE NOW PROHIBITED IN THE FACILITY. THE FACILITIES ' POLICY HAS BEEN REVIEWED AND UPDATED TO REFLECT THESE CHANGES. THE FIRE MARSHAL HAS BEEN CONTACTED TO IDENTIFY IF POWER STRIPS AND/OR EXTENSION CORDS ARE ALLOWABLE UNDER THE LIFE SAFETY CODE. 4. ALL ROOMS WILL BE QA'D ON A WEEKLY BASIS TO ENSURE THAT ALL EXTENSION CORDS AND POWER STRIPS REMAIN OUT OF THE RESIDENT ' S ROOMS. THIS WILL BE CONDUCTED BY THE FACILITIES MAINTENANCE DIRECTOR WHO WILL REPORT TO THE QA COMMITTEE FOR FOLLOW UP AND REVIEW. 5. THE MAINTENANCE DIRECTOR WILL QA ON A WEEKLY BASIS TO ENSURE THAT NO POWER STRIPS OR EXTENSION CORDS HAVE BEEN BROUGHT INTO THE FACILITY. THE MAINTENANCE DIRECTOR WILL REPORT ALL FINDINGS TO THE QA COMMITTEE ON A QUARTERLY BASIS FOR FOLLOW UP AND REVIEW. 6. THE QA COMMITTEE WILL REPORT ALL FINDINGS TO THE ADMINISTRATOR WHO IS RESPONSIBLE FOR COMPLIANCE, WITH REVIEW AND FOLLOW UP AS NEEDED. THE COMPLETION DATE IS 11-9-11. ( , )