Every finding on record at The Villa at the Park

This citation pertains to Incident 2688332 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff, affecting one resident (R701) of two reviewed for abuse. Findings include An allegation of staff to resident abuse on 11/28/25 involving Certified Nursing Assistant (CNA) A and R701 was submitted to the state agency.On 12/10/25 at 11:49 AM, R701 was observed sitting on the side of their bed in their room. When asked about the purplish bruise under their left eye, R701 stated, don't want to talk and shook their head side to side. R701's medical record was reviewed and revealed the resident was admitted to the facility on [DATE] and had diagnoses of: Paranoid Schizophrenia; Encephalopathy; Anxiety Disorder; and Depressive Disorder. R701's Brief Interview for Mental status assessment dated [DATE] was a 11/15 indicating impaired cognition.On 12/10/25 at 12:50 PM, CNA A was interviewed via telephone. CNA A was asked to describe what happened on 11/28/25 the incident involving R701. CNA A indicated they had worked the midnight shift and they were finishing their check and changes, when R701 came out of the room swinging and punching them in the face. CNA confirmed they hit R701 in the face due to a reflexive action. CNA A confirmed they had received training on abuse and how to handle aggressive resident behaviors and admitted not implementing the training.On 12/10/25 at 2:00 PM, the Director of Nursing (DON) was interviewed. The DON stated an awareness of the alleged incident between CNA A and R701 and confirmed her expectation is that residents will be free from abuse and neglect from staff.A review of the Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy dated 9/11/2020 revealed, 'it is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion . Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.' During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1) Staff was acting in self-defense but did not display abuse prevention techniques when dealing with the aggressive resident.2) Audit was immediately implemented to identify physical abuse towards residents who display aggressive behaviors. None was identified. 3) No additional residents were identified.4) Concierge staff will conduct weekly interviews with residents to identify abusive behaviors.5) a. Audit implemented to be conducted 2x weekly X 4 weeks then monthly to identify staff who may respond aggressively to behavior incidents. b. new hires will receive additional training on how to handle residents who are aggressive with them prior to receiving assignment on the floor. c. Staff received reeducation on abuse which included how to respond safely to aggressive residents. d. Town Hall meeting monthly to remind staff regarding the abuse policy. This will be a required agency item.The administrator will be responsible to sustain compliance.Date of completion of plan of correction 12/3/25The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to properly assess one resident (R1) out of one reviewed for self-administration of medications. Findings include:On 9/15/2025 at 9:00 AM, R1 was observed in their room, sitting in a wheelchair and eating breakfast. R1 was observed to have two Albuterol Sulfate inhalers at their bedside, as well as eye drops. R1 was asked if they use the inhalers, and they stated yes, I use them as prescribed.A review of the medical record revealed R1 admitted into the facility on 9/5/2025 with the following diagnoses, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R1 also required staff assistance with bed mobility and transfers.On 9/17/2025 at 8:51 AM, a medication observation was completed with Licensed Practical Nurse (LPN) E. LPN E was asked about the inhalers at R1's bedside. LPN E grabbed the inhalers and asked R1 where they got them from. R1 stated they gave the inhalers to them at the hospital and brought them back when they returned on 9/5/2025. LPN E stated the inhalers were empty and discarded of them at their cart.On 9/17/2025 at 10:45 AM, an interview was conducted with the Director of Nursing (DON). The DON stated to have medications at bedside they have to obtain a physician's order and an education form depending on the medication, as well as the person.A review of a facility policy titled, Self-Administration of Medication noted the following, .2.If a resident requests self-administration of respiratory inhalant only, complete the Self-Administration Evaluation of Respiratory Inhalants form. 3. Determination of the residents' ability to self-administer medication by the IDT (Interdisciplinary Team) will be documented in the resident's medical record and on the care plan. The documentation will also include the participation of the resident and resident representative, if applicable, in the assessment and care plan process.

Based on interview and record review, the facility failed to review the pharmacist's identified irregularities and document the action taken or not taken to address the irregularities for two residents (R2 and R6) out of three reviewed for Medication Regiment Reviews (MRRs). Findings include: R2 A review of the medical record revealed R2 admitted into the facility on 8/14/2020 with the following medical diagnoses, Paranoid Schizophrenia and Neuroleptic Induced Parkinsonism. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 5/15 indicating an impaired cognition. R2 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed the following progress note from the pharmacist, Effective date: 4/16/2025 10:59:00.MRR completed.See report for comment. On 9/16/2025 at 11:35 AM, a request for the full MRR report was requested from the facility. On 9/17/2025 at 8:24 AM and 1:16 PM, a second and third request was made for the full MRR and not received by the end of survey. R6 A review of R6's medical record revealed they were admitted into the facility on 8/21/24 with diagnosis which included Dementia, Anxiety, and Adult Failure to Thrive. Further review revealed the resident was cognitively impaired and required extensive assistance with activities of daily living. A review of MRRs completed for R6 on 3/14/25 and 4/16/25 revealed the following recommendation, Recommend a Valproic Acid Level every 6 months secondary to Valproic Acid therapy. Both recommendations did not reveal a response from the prescriber, nor did the medical record reveal lab results for Valproic Acid levels. Further review of R6's medical record revealed the resident had the following order initiated on 12/12/24, Valproic Acid Oral Solution 250 MG (milligrams)/5ML (milliliters) (Valproate Sodium). Give 3.5 ml every morning and at bedtime for Mood disorder. This order was discontinued on 4/25/25. On 9/17/25 at 10:40 AM, the Director of Nursing (DON) was asked about the pharmacy recommendations not being addressed and explained they would look into. No further information was provided by the end of survey. A review of the facility's Drug Remine Review policy revealed, .3. Irregularities identified will be documented on a separate, written report and sent to the attending physician, medical director, and director of nursing, listing the resident name, relevant drug and irregularity the pharmacist has identified. If in the professional judgement of the pharmacy consultant that an irregularity requires urgent action, the pharmacy consultant will immediately report the irregularity to the Director of Nursing and/or Unit Charge Nurse and the attending physician by phone .5. The attending physician will document in the resident record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record

Based on interview and record review, the facility failed to ensure behavioral services were provided for one sampled resident (R42) of eight residents reviewed for behavioral services.Findings include:A review of the clinical record revealed R42 was admitted into the facility on 11/1 9/24 with the following diagnoses Epilepsy, Depressive Disorder, Dementia and Focal Traumatic Brain Injury. A review of the clinical record showed that the resident was cognitively intact.A review of R42's clinical record revealed that on 11/20/24 a physician order for psych to evaluate and treat and on 6/29/25 another order was written for psychiatry consult to re-evaluate and treat bipolar/mood disorder and competency evaluation. Further review of R42 Clinical record revealed the following behavioral narrative notes:-11/25/24 -verbally aggressive towards staff.-12/7/24 - Resident confused refuses to stay in bed, puts self in wheelchair.-1/4/25 -Resident was seen throwing themself on the floor intentionally attempting to hurt/harm themself.-1/18/25 - Resident refused activities of daily living (ADL) care and to be put in bed.-3/1 5/25 - Resident calling staff out of their names because they didn't want another resident to get any coffee.-3/22/25 - Resident verbally aggressive with staff after dinner.-5/23/25- Resident was yelling and cursing at staff while they were assisting them because they stated they don't need help and can walk by themself.-7/5/25 - Resident cursed and shouted at staff unprovoked.-9/7/25 - R42 was involved in a resident-to-resident incident stemming from calling another resident out their name.Further review of the clinical record failed to show any follow up notes or consultations from psychology or behavioral services to address resident behaviors.On 9/16/25 at 10:00 AM a request was made for the most recent psychology evaluation and behavioral service notes for R42.At 2:30 PM, the Social Service Director (SSD) stated that there were no psychology notes or behavioral notes available.On 9/17/2025 at 11:03 AM, an interview with SSD occurred and they were queried about the behavioral services orders not being followed and missing services. The SSD stated that behavioral services and psychology services should have been implemented.On 9/17/25 at 12:43 PM, an interview with Director of Nursing (DON) was held and they were queried about the expectations of completion of physician orders to evaluate and treat and follow up behavioral services. They reported the expectation is for all physician orders to be followed.At 2:16 PM, the facility's Behavioral Services policy was requested and not received by the end of the survey.

Based on interview and record review, the facility failed to develop comprehensive care planned interventions to reflect the resident's current status for two residents, (R6 and R13) of two residents reviewed for care plans. Findings include:R6A review of R6's medical record revealed they were admitted into the facility on 8/21/24 with diagnoses which included Dementia, Anxiety, and Adult Failure to Thrive. Further review revealed the resident was cognitively impaired and required extensive assistance with activities of daily living. Further review of the medical record revealed a document titled, (Name of department of correction) Parole Order revealing R6 was under the supervision of the department of corrections as a parolee until 8/21/26. A review of the resident's care plan did not address the resident's current status as a parolee. R13A review of R13's medical record revealed they were admitted into the facility on 6/20/25 with diagnoses which included BI-Polar Disorder, Post-Traumatic Stress Disorder (PTSD), Schizoaffective Disorder, and Acute Cystitis with Hematuria. Further review revealed the resident had a significantly impaired cognition and required assistance for activities of daily living. Further review of the resident's medical record revealed a care plan outlining the following, Focus: The resident has a mood problem r/t (related to) Bipolar disorder, PTSD, Schizoaffective disorder, Bipolar. Date Initiated: 06/20/2025 Interventions: SLEEP: Evaluate resident for possible sleeping pattern changes and intervene as appropriate. Date Initiated: 06/20/2025 . Further review of the care plan did not reveal any additional interventions related to the resident's behavioral needs. On 9/17/25 at 1:08 PM, the Nursing Home Administrator (NHA) was asked about social work services being addressed in Quality Assurance and acknowledged that social work services is an area which has been identified as an area needing improvement. On 9/17/25 at 2:16 PM, the facility's Care Plan policy was requested and not received by the end of the survey.

Based on interview and record review, the facility failed to provide follow-up to the PASARR (preadmission screening/annual resident review-Form 3877) for one sampled resident (R42) of four reviewed for PASARR concerns, resulting in the potential for unmet care needs. Findings include: A review of the clinical record revealed R42 was admitted into the facility on [DATE] with the following diagnoses Epilepsy, Depressive Disorder, Dementia and Focal Traumatic Brain Injury. A review of the clinical record showed that the resident was cognitively intact. A review of R42's PASARR Level I Screening form, indicated Yes was checked in section two for questions one through four and included, The person screened shall be determined to require a comprehensive Level II OBRA (Omnibus Budget Reconciliation Act) evaluation if any of the above items are 'Yes' unless a physician, nurse practitioner or physician's assistant, certifies on form DCH-3878 that the person meets at least one of the exemption criteria. The form indicated, If any answer to items 1-6 in section II is 'Yes' send ONE copy to the local Community Mental Health Services Program (CMHSP) with a copy of form DCH-3878 if an exemption is requested . The 3877 was incomplete and there was no 3878 or referral for a level II evaluation. On 9/17/25 at 2:20 PM, the Social Service Director was queried regarding the 3877/3878's for R42 and stated, The previous Social Worker completed the 3877, but it is unknown about the 3878. No further explanation was provided.On 9/17/25 at 2:16 PM, the facility's PASARR policy was requested and not received by the end of the survey.

Based on observation, interview, and record review, the facility failed to formulate an accurate advance directive for one resident (R70) of four residents reviewed for advance directives. Findings include:A review of R70's medical record revealed they were initially admitted into the facility on 7/10/20 and readmitted on [DATE] with diagnoses of End Stage Renal Disease, Diabetes, and Muscle Weakness. Further review revealed the resident was cognitively intact and required extensive assistance for activities of daily living. Further review of R70's medical record's face sheet revealed the resident's code status was Do Not Resuscitate (DNR, an order which instructs medical professionals not to attempt cardiopulmonary resuscitation). Further review of R70's medical record revealed a document dated for 3/25/25 and titled, Code Status Elective Form which outlined the following, In the event I experience pulseless, cardiopulmonary arrest, (witnessed or unwitnessed), I request the following. The space for Do Not Resuscitate was checked and circled. In addition, the document was signed by the resident's previous guardian, whose guardianship was terminated on 2/10/23 per documentation located in the resident's medical record. In addition, the form was signed by the facility's previous social worker, and the space available for two witnesses were blank. Also noted on the document was the following statement, For residents in (name of state) .please proceed to DNR order form.Further review of the medical record did not reveal any additional documentation or orders for the resident having a code status of DNR. On 9/17/25 at 12:18 PM, R70 was observed laying in their bed and asked if anyone had ever spoken to them about an advance directive, in which they stated no.On 9/17/25 at 1:08 PM, the Nursing Home Administrator (NHA) was asked about social work services being addressed in Quality Assurance and acknowledged that social work services is an area which has been identified as an area needing improvement. On 9/17/25 at 2:52 PM, Social Services Director C was asked about the advance directive for R70, and explained the process and documentation needed for a DNR order. Social Services Director C further explained she would look further into R70's advance directive.A review of the facility's Advance Directive and Care Planning policy revealed the following, C. Facility staff will provide the resident and/or resident representative with written description of the facility's practice to implement an advance directive. (Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements are met). The facility will identify the primary decision-maker (e.g. assess the resident's decision-making capacity and identify or arrange for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions). i. If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility will provide advance directive information to the individual's resident representative in accordance with State law. ii. In the event that the resident condition changes, based on regular comprehensive assessment or change in resident status review, and theresident is able to receive such information; the resident will be provided with written description of the facility's practice to implement an advance directive.

This citation pertains to complaint 1310450 Based on observation, interview, and record review, the facility failed to ensure two confidential residents were treated with dignity and respect from a total census of 106. Findings include:A review of the intake 1310450 revealed that several residents had concerns about the Activity Director (AD) and their interaction with the residents. One concern stated that the AD is rude, mean, disrespectful and uses profanity towards residents, anytime the residents ask for anything, the AD gets mad and cuts off the television as punishment. On 9/15/25 at 10:00 AM, an activity was observed occurring on the second floor. The activity staff was observed setting up resident for games and preparing music for an exercise activity. On 9/15/25 at 11:05 am, a confidential meeting of residents was held in the second-floor dining room. During the meeting, nine residents spoke of dissatisfaction with the AD saying . they don't know what they are doing . they talk to us mean . talk to us inappropriate .we don't have activities for our age. We need better games . the activities can be better, and we can have more fun. During the meeting, residents also stated they have notified the administrator, and nothing has been done. On 9/17/25 while touring the facility, a resident who wished to remain confidential stated they had a problem with the AD. The resident stated, I don't like the AD, their attitude is bold, and they talk to us crazy when we go out and smoke, and they have discussed other residents' business with other residents. On 9/17/25 at 12:50 PM, an interview was held with a certified nursing assistant (CNA) who wished to remain confidential, said they had witnessed the AD to withhold cigarettes or not provide activities on both floors and speak rudely to residents. On 9/17/25 at 2:00 PM an interview was held with the AD to discuss concerns. The AD revealed they were new to the position at the building and had been working there since March. Their experience included having worked as an activity assistant at several other buildings. The AD stated the building and some of the residents are challenging, and they (the residents) were used to the prior director and now they are adjusting to changes. On 09/17/25 at 2:25 PM, the Director of Nursing (DON) was queried about the resident's concerns with the AD and indicated they were not aware of any pertinent concerns, but the Regional Director was. On 09/17/25 at 3:00 PM, the Regional Director was queried about the resident's concerns with the AD and stated that changes were coming. A review of the facility policy titled Dignity revealed the following: It is the policy of this facility to assure residents are treated in a manner that preserves the resident's dignity and promotes a quality life experience. PROCEDURE: 1. All residents will be treated with respect. 2. Resident's preferences will be taken into consideration for all aspects of care and honored to the extent practicable.

Based on observation, interview, and record review, the facility failed to provide 80 square feet of living space per bed in 21 of 36 resident rooms. Findings include:On 09/17/2025 at 01:45 PM, an environmental tour of resident room minimum square footage requirements (80 square feet per bed) was conducted by this surveyor. The following rooms were noted: 102: Three bed ward (216 square feet)103: Two bed ward (155 square feet)104: Two bed ward (149 square feet)105: Four bed ward (291 square feet)106: Four bed ward (289 square feet)107: Four bed ward (291 square feet)108: Four bed ward (288 square feet)112: Four bed ward (282 square feet)115: Four bed ward (283 square feet)119: Four bed ward (288 square feet)201: Three bed ward (220 square feet)202: Three bed ward (219 square feet)203: Two bed ward (155 square feet)204: Two bed ward (152 square feet)207: Four bed ward (291 square feet)209: Four bed ward (291 square feet)211: Four bed ward (288 square feet)212: Four bed ward (294 square feet)214: Four bed ward (289 square feet)218: Four bed ward (272 square feet)219: Four bed ward (287 square feet) On 09/17/2025 at 2:00 PM, R32 was interviewed in their room which they share with three other residents. They were asked how they felt about the available space in their room and they stated It's too tight. I've talked to them about it before but they don't do anything. R32 reported that the room does have three residents at times rather than four but described the space as essentially the same either way as the fourth bed always remains in the room whether it's occupied or not. On 09/17/2025 at 2:13 PM, the facility Administrator (NHA) and the Regional Director of Operations (RDO) were interviewed and queried regarding any plan to address the rooms requiring waivers. The RDO indicated the governing company had requested the facility submit a proposal for reduction of beds which will potentially lead to reduction or elimination of rooms requiring waivers. The RDO indicated the facility planned to submit such a proposal. The RDO indicated the facility surveys the residents intermittently regarding their comfort level with the room arrangement in order to address any individual concerns that may indicate the need for a room change. A Resident's Rights policy/procedure was requested from the facility at 02:16 PM on 09/17/2025 and was not received by the time of survey exit.

This citation relates to Intake #MI00147451. Based on observation, interview, and record review, the facility failed to provide adequate pest control with the potential to affect all 102 facility residents. Findings include: Observations of random rooms adjacent to room [ROOM NUMBER] revealed the following: (In pest glue traps): 115: Two adult cockroaches and several nymphs. (2:22 p.m.) 111: Three adult cockroaches and one nymph. (2:23 p.m.) On 11/06/24 at 2:00 p.m., Licensed Practical Nurse (LPN) B, was asked about the cockroaches in the room. LPN B acknowledged the concern and said they had told facility administration. On 11/06/24 at 2:10 p.m., Housekeeping Staff C was observed cleaning on the 100 hall East unit. Staff C was asked about the cockroaches on the unit and in room [ROOM NUMBER] and responded they had seen dead cockroaches when they cleaned but had not seen any live cockroaches. On 11/06/24 at 2:29 p.m., anoymous resident in room [ROOM NUMBER] was asked if they had any bugs in their room and responded, I have seen five bugs this week. On 11/06/24 at approximately 2:35 p.m., the Nursing Home Administrator NHA), the Director of Nursing (DON), the the Maintenance Director, Staff D, were asked about the cockroaches observed on the 100 hall on the East side of the building. All acknowledged the cockroaches in the building, and the NHA and Staff D reported the pest control company had increased their visits to every two weeks in the past month. The NHA and Staff D were shown the concerns in R113's room, and on the unit, and reported they understood the concerns with the cockroaches, food and clothing/clutter. On 11/06/24 at 3:38 p.m., Observation of the outer doors to the building was completed with the Maintenance Director, Staff D. The [NAME] South door revealed a crack about the size of a half dollar on the right side of the lower door, where the outdoors could be visualized. Staff D reported one of the [NAME] doors had been replaced, and they had received approval for this door to be replaced this week and recognized the concern. On 11/06/24 at 3:45 p.m., Staff D was asked about the cause of the cockroaches found on the 100 hall. Staff D reported the cockroaches were worse on the East side of the building. Staff D explained they believed the cause was residents' personal food (snacks) and some hoarding behaviors (of food/clutter). Review of the facility pest control invoice, dated 10/17/24, obtained from Staff D, reviewed with Staff D and the NHA, revealed an extensive cockroach infestation in the facility in the past month. The logs revealed there were at least 18 resident rooms with cockroaches found in the pest bait traps (zone monitors), primarily on the second floor. The NHA confirmed these rooms were resident occupied. Review of the 10/17/24 pest control invoice revealed room [ROOM NUMBER] had 15 cockroaches, mostly adults, room [ROOM NUMBER] had heavy cockroach activity, and room [ROOM NUMBER] had moderate cockroach activity. The rooms were treated and the zone monitors were replaced. Further review of the invoice revealed several rooms on the second floor were found with many cockroaches. On 11/06/24 at approximately 4:30 p.m., the Regional Environmental Director, Manager E, and Regional Housekeeping Supervisor, Manager G, with the NHA and Staff D present, were asked during a phone interview about the cockroach infestation. Manager E and Manager G shared they would continue their efforts related to increased pest control visits and treatment, increased deep cleaning, onsite visits, weekly audits, and other prevention measures. Manager D reported they understood cockroaches were attracted to food and would address any concerns along with Manager E and the facility staff. Environmental audits were requested and not received by survey exit. On 11/06/24, beginning at approximately 5:50 p.m., observations were completed of three random second floor rooms with heavy or medium pests found, with the NHA. rooms [ROOM NUMBERS] showed the pest glue traps were full of cockroaches, with two live cockroaches on the heat vent in room [ROOM NUMBER]. On 11/06/24 at 6:00 p.m., the residents in both rooms were asked about the cockroaches saying, They [the pesticide company] have been spraying. I do see a roach once in a while. I see the bugs on the wall. I'm afraid to wear my clothes as they lay eggs on them, and pointed to clothing on their dresser. Review of the (Provider) Pest Control Contract, labeled, General Pest Control Proposal, dated 5/29/20, unsigned, revealed, [Vendor] agrees to provide professional pest control service for the control of covered pests listed in Services section below .We will correct pest concerns as quickly and efficiently as possible and implement a successful preventative maintenance program. Essential to the success of your overall program is your cooperation with repair and sanitation recommendations we may make you aware of .Crawling Insects .Interior services [to be provided] twice per month. 24 [times] per year . Review of the policy, Infection Prevention and Control .Pest Control, dated 2017, revealed, .1. Ongoing measures are taken to prevent, contain, and eradicate common household pests, such as roaches .3. Monitor for breaks in screens and doors on a routine basis .5. All food items kept in residents' rooms [will be] stored in covered containers .7. A contract with a pest control company may be elected to assure regular inspection and application of pesticides .12. Environmental services .will maintain records of pest control services and applicable contracts with pest control services.

Based on interview, and record review, the facility failed to obtain and assess the blood pressure (B/P) and administer blood pressure medication based on that assessment for one sampled resident (R104) of one reviewed for monitoring, resulting in a significant low blood pressure and hospitalization . Findings include: A review of R104's closed record revealed they were admitted to the facility on [DATE] with a diagnosis of Hidradenitis suppurativa (chronic skin condition featuring lumps in armpits and groin) and hypertension (high blood pressure). A review of R104's Minimum Data Set assessment revealed R104 had a death within the facility. A review of R104's orders revealed the following orders: -Carvedilol (a medication that lowers B/P) oral tablet 3.125 MG (milligrams) Give 1 tablet by mouth two times a day for hypertension. -Spironolactone (a medication for fluid retention which can also lower the B/P)) oral tablet 25 MG give 1 tablet by mouth one time a day for diuretics. Vital signs every shift. On [DATE] at 1:39 PM, on admission into the facility R104's blood pressure was documented as ,d+[DATE] (normal blood pressure ,d+[DATE]). A review of R104's Medication Administration Record (MAR) revealed on [DATE] at 5:00PM, Carvedilol was administered without the blood pressure being documented as being obtained prior to medication administration. The next blood pressure that was documented was on [DATE] at 6:15 AM which noted B/P - ,d+[DATE]. A review of the MAR revealed on [DATE] at 9:00AM, Spironolactone was administered by Licensed Practical Nurse (LPN) C. Carvedilol was not administered at this time with a notation stating, Vitals outside of parameters for administration. There was no blood pressure documented at that time. The medical record did not reveal a progress note that indicated the physician was contacted. Further record review revealed a physician progress note dated [DATE] at 8:47 PM, Restart B/P meds with hold parameters (a pre-determined parameter to guide the nursing staff when to give and when to hold the medication). MAR revealed on [DATE] at 9:00 AM, Spironolactone and Carvedilol were both administered by LPN C. R104's blood pressure at that time was documented as ,d+[DATE] on the MAR. There were no hold parameters noted on the MAR. The medical did not reveal a progress note that indicated the physician was notified of the low blood pressure. R104's MAR revealed on [DATE] at 5:00 PM, Carvedilol was administered, no B/P was documented. Further record review revealed a progress note dated [DATE] at 11:08 PM, R104 was transferred to the hospital for a Change in condition; B/P reading ,d+[DATE]. On [DATE] at 11:25 AM, during an interview, the Assistant Director Of Nursing (ADON) was asked about the status of R104 and if they expired in the facility or if they were transferred to the hospital. The ADON requested an update from the admissions coordinator. On [DATE] at 12:57 PM the ADON provided a list of discharged residents and explained R104 was transferred to the hospital on [DATE] and is now deceased . The ADON explained the MDS is correct in listing R104 as a death within the facility due to the resident expiring within 24 hours of transfer to the hospital. On [DATE] at 11:55 AM during an interview with Licensed Practical Nurse (LPN) B was asked if orders for blood pressure medications include holding parameters. LPN B explained the majority of the orders for B/P meds do include hold parameters that usually say to hold if the systolic (top number) B/P is less than 130 or if the diastolic (bottom number) B/P is less than 60 but some orders do not. LPN B stated if there were no parameters, I'd use my nursing judgement. If someone's B/P is ,d+[DATE] I'm not gonna give them a pill to drop it lower. I would also call the doctor. On [DATE] at 2:45 PM, during an interview LPN C was asked if orders for blood pressure medications include holding parameters and stated Some do, some don't have hold parameters but if the blood pressure is too low, I would hold it and put in a note why it was held. Most of the blood pressure medications ask you for a blood pressure on the Medication Administration Record (MAR). LPN C was asked to review the blood pressure and medication administration record for R104 on [DATE]. LPN C verified their initials on the MAR for the Spironolactone and Carvedilol indicating they administered the medications. LPN C stated I don't remember. It should not have been given. On [DATE] at 3:04 PM, during an interview the ADON was asked to review R104's record. The ADON confirmed that R104 had a low B/P documented on [DATE] at 9:00 AM and the medications (Spironolactone and Carvedilol) were administered. The ADON was asked to review the administration of blood pressure medications on [DATE] at 5:00PM and confirmed no B/P results were present. The ADON was asked if it was concerning that R104's blood pressure meds were given with a low blood pressure and without it being reevaluated. The ADON stated Yes. They should not have been given and (name of LPN C) should have called the physician. A medication administration policy was requested and not returned by the conclusion of the survey.

This citation pertains to Intake MI00146593. Based on observation, interview, and record review, the facility failed to prevent resident to resident and staff to resident abuse for two residents (R24 and R40) of three reviewed for abuse, resulting in a broken leg and verbal abuse. Findings include: R24 On 8/28/24 at 3:20 PM, during an interview with an anonymous resident they reported they didn't understand why R38 was allowed back to the facility after they assaulted another resident. The anonymous resident explained R24 was pulled out of their wheelchair to the ground a couple of days ago by R38, R38 then was on top of R24 which broke their leg. The anonymous resident stated R24 is a small person and was sent out to the hospital. On 8/28/24 at 8:46 AM, Registered Nurse (RN M) was asked the reason R24 was in the hospital. RN M explained R24 reported pain in their leg that weekend, an x-ray was ordered with the findings of an acute proximal left tibula/fibula fracture. RN M stated, Resident [R38] tripped and fell on [R24]. RN M stated, R38 was being aggressive towards staff when this happened and later R38 was petitioned out to the hospital for a psychological intervention. A review of R24's Minimum Data Set (MDS) assessment noted, Quarterly dated 8/6/24, impaired cognition, Functional Limitation in Range of Motion: Upper extremity (shoulder, elbow, wrist, hand) 0. no impairment. Lower extremity (hip, knee, ankle, foot) No impairment. A review of R24's progress notes revealed, 8/23/2024 13:41 (1:41 PM) Health Status Note: Resident received in back day room. Resident told writer that [R24] is experiencing pain in [their] leg and around [their] ankle. Medications administered as ordered. Supervisor notified about pain in leg. X-rays ordered . Further review of R24's progress notes revealed: 8/23/2024 14:41 (2:41 PM) Health Status Note Late Entry: Resident MD (medical doctor) ordered an X-Ray to left leg. 8/24/2024 01:14 (AM) Health Status Note: [R24] in bed with HOB (head of bed) elevated . no s/s (signs symptoms) of distress some discomfort awaiting for leg x-ray . 8/24/2024 15:17 (3:17 PM) Health Status Note: Resident received alert and verbally responsive. Able to make needs known. Noted resident left leg swelling and resident c/o pain to left leg. Pain meds given as ordered. X-ray done. Awaiting for result . 8/25/2024 07:21 (AM) Health Status Note: Received X-ray results displaced Fx (fracture) Rt. (right) Tibia. [physician] called. Transfer to Hospital. 8/25/2024 07:55 (AM) Health Status Note: Transfer complete to (local) hospital. 8/25/2024 07:41 (AM) Transfer to Hospital or other Facility .Reason for Transfer: Displaced Fracture of the Proximity Rt. Tibia . On 8/28/24 at approximately 9:30 AM, RN M provided an incident and accident report noting, Date: 8/24/24 14:33 (2:33 PM) Incident Description: This writer was informed by [R24] that another resident fell on [their] leg when the resident was being aggressive towards the staff. Was this incident witnessed: Resident [R24] c/o (complained of) pain to left leg this writer asked was it a new onset resident stated another resident fell on [R24] leg when [R38] was trying to throw [R38's] walker. Immediate Action taken. Description: Resident MD (medical doctor) notified that the resident c/o pain to [R24's] left leg a order was given to administered Tylenol 325mg (milligrams) two tabs times one now and PRN (as needed) for pain and a X-ray ordered. Statements: No Statements found . On 8/28/24 at 10:37 AM, the Assistant Director of Nursing (ADON) was asked to review and provide the date the incident and accident report was completed. A review of the ADON's computer revealed the incident and accident report was not signed/completed and had been revised on 8/28/24 at 9:33 AM. The document did not have the statement section completed. The ADON was asked the procedure for completing the incident and accident report and explained the report is to be fully complete with statements and signatures. The ADON was asked for a policy regarding incident and accident report documentation. The policy was not provided by the end of the survey. A review of R24's hospital record documentation revealed, History and Physical: Date of service: 8/25/24. Chief Complaint: Arrive date/time 8/25/24 13:27:00 Nursing Home. Ambulance EMS. Service: trauma: Trauma Code Level: Trauma Evaluation. Chief Complaint: Fall. Site of Injury: residential. History of Present Illness. [R24] . with a hx (history) of a stroke who presented to (local hospital) from nursing home after a fall from a wheelchair. Patient reports that she was at her nursing home when one of the fell ow nursing home residents pushed her out the wheelchair . Left tib/fib (tibla/fibula) xray showed acute proximal left tib/fib fracture . A review of R24's hospital Physical Therapy (PT) eval revealed, PT Initial Evaluation Acute Care Entered On: 8/27/24 . General Info. Reason for Referral to Physical Therapy: Decreased mobility . Past Medical & Surgical History: pt (patient) admit s/p (status post) being pushed out of w/c (wheelchair) at NH (nursing home) by another resident Left tib/fib fx now s/p ORIF (Open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone). PMHx: BLE (bilateral lower extermies) weakness . On 8/29/24 at 11:23 AM, R24 was observed lying in bed and was asked about their leg. R24 stated, [R38] knocked me out of my wheelchair. [R38] has to come downstairs because [R38] starts trouble. R24 stated, [R38] pulled me out of the wheelchair. I can't do anything to fight back, I don't know why [R38] is back (at the facility). R38 On 8/27/24 at 9:35 AM, R38 was observed lying in bed wearing green disposable scrubs. R38 had recently been readmitted from the hospital. A review of R38's medical record noted, R38 was admitted on [DATE] with diagnosis of Dementia. A review of R38's annual MDS dated [DATE] revealed, moderate cognitive impairment and mobility devices walker. A review of R38's care plan did not reveal a care plan to address abusive behavior. A review of R38's progress notes reveled, a pattern of aggressive behavior. 6/1/2024 16:34 (4:34 PM) Behavior Narrative Text: Resident rode the elevator by [R38's self] without assistance. Resident became agitated and verbally aggressive with staff. Redirection unsuccessful . 6/12/2024 20:22 (8:22 PM) Behavior Narrative Note: Resident verbally aggressive and combative with staff unprovoked . 6/13/2024 22:46 (8:46 PM) Behavior Narrative Note: Res (resident) continues with aggressive behavior towards staff. Res lashed out at undersign when trying to redirect res away from female bathroom. Res yelled out obscenities to undersign and was redirected back to [R38's] room by other staff members . 6/14/2024 22:22 (8:22 PM) Behavior Narrative Note: Res continues with aggressive behavior towards staff . 7/17/2024 20:33 (8:33 PM) Behavior Narrative Note: Resident verbally and physically aggressive with other residents unprovoked. Refused afternoon shower. Redirected several times unsuccessfully . 7/27/2024 17:56 (5:56 PM) Health Status Note: Periods of verbal/physical aggression with staff and other residents. Refuses meds and lab draws. No changes in baseline. 8/14/2024 10:17 (AM) Behavior Narrative Note: [R38] is in a bad mood he refused breakfast and was verbally and physically aggressive towards staff and residents . 8/21/2024 15:29 (3:29 PM) Behavior Narrative Note: Resident being disruptive to other residents during activity time. Verbally and physically aggressive unprovoked. Attempts to use [R38's] walker as a defensive tool. Redirected x2. 8/23/2024 11:42 (AM) Transfer to Hospital or other Facility Note: .Key clinical Information: Violent towards staff and other residents, sister notified .doctor informed . 8/23/2024 12:02 (AM) Health Status Note: Resident was picked up by [local] police to go to crises center officer will call back with location of center. On 8/29/24 at 3:37 PM, the Nursing Home Administrator (NHA) was asked about the incident. The NHA administrator explained R38 is shaky on their walker and they bumped R24's wheelchair and R38 fell on top of R24. The NHA could not explain if R38 bummped into R24's wheelchair or if R38 pulled or pushed R24 from the wheelchair. 50223 R40 On 8/27/24 at 2:33 PM, during an interview R40 described an incident with Licensed Practical Nurse (LPN) C and Certified Nurse Assistant (CNA) F. R40 stated LPN C choked them. R40 stated CNA E took a picture of R40's neck after the incident and reported the incident to the Director of Nursing (DON). R40 stated LPN C still worked at the facility and CNA F is on a leave. A review of R40's medical record revealed they were admitted to the facility on [DATE] with the following diagnoses: Chronic obstructive pulmonary disease, senile degeneration of brain, and muscle weakness. A review of R40's Minimum Data Set revealed a brief interview for mental status score of 10 indicating cognitive impairment. On 8/28/24 at 1:20 PM, during an interview, LPN C was asked about the incident involving R40. LPN C explained there was an altercation with another staff member in front of the nursing station and said R40 and the other staff member were getting closer to each other and were both agitated. LPN C explained they tried to diffuse the situation but R40 Got up out of (their) wheelchair and tried to jump at LPN C and the other staff member pushed (R40) back into their chair. LPN C confirmed the incident was reported to Registered Nurse (RN) D and CNA F no longer worked at the facility. On 8/28/24 at 1:49 PM, during an interview, the nursing home administrator (NHA) was asked if they recalled an incident involving R40. The NHA stated CNA 'F' is not here anymore. Yeah (they) probably did get into it with R40. The NHA was asked to provide the incident report. The NHA explained they would have to find it. On 8/28/24 at 3:16 PM a voicemail was left for RN D with a request for a return call. A call was not returned by the completion of the survey. On 8/28/24 at 3:36 PM, during an interview, CNA E was asked if they recalled an incident involving R40. CNA E explained R40 told them CNA F and LPN C choked them. CNA E confirmed (R40's) neck did look red. CNA E explained they took a picture of R40's neck and reported it to RN D. On 8/29/24 at 9:06 AM, LPN C was observed to be working on the unit in which R40 resides. R40 was asked if they felt safe with LPN C working on their unit. R40 stated, I don't know why (they) still work here. On 8/29/24 at 8:19 AM, during an interview, the Assistant Director of Nursing (ADON) was asked to describe what should happen if there is an altercation between two residents or between a resident and a staff member. The ADON stated If it's only a verbal altercation involving residents we separate or redirect, same with staff but we would also reassign the staff member. If its physical, then an incident report is filled out and we notify the administrator, and an investigation is started. The staff member is suspended until the investigation is completed. The ADON was informed of the allegations made by R40 and was asked to provide the documentation of the alleged incident. The ADON was observed looking through R40's medical record and explained they could not find a record of the incident or investigation. On 8/29/24 at 9:31 AM, a review of CNA F's employee file revealed a discipline form that stated: Description of policy, procedure, rules or requirements violated: Verbal altercation with resident. Factual basis for the discipline, including prior counseling: Employees are not allowed to engage into any altercation with a resident this violates company policy. Level of discipline: indefinite suspension pending investigation. A review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property stated the following: The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements immediately .C. PREVENTION ABUSE POLICY REQUIREMENTS: It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The facility will provide feedback regarding complaints and concerns. The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse .

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 08/27/24 at 10:05 A.M., A common area environmental tour was conducted by this surveyor. The following items were noted: Staff Break Room (Basement): The microwave oven was observed (etched, scored, particulate, corroded). The building rear exterior entrance metal door sweep was observed corroded and broken, allowing a significant air gap between the door slab and metal threshold plate. The significant air gap created an increased likelihood for pest entrance into the building. 1st Floor Back Dining Room: The wall mounted [NAME] air conditioner filters and intake grills were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The two window tracks were also observed soiled with accumulated dust and dirt deposits. The window curtains were additionally observed worn, threadbare, and torn. 1st Floor Front Dining Room: The American Standard air conditioning unit intake grills were observed heavily soiled with dust and dirt deposits. The activity storage room was also observed in complete disarray. Holiday decorations and activity items were observed stacked on top of each other, within the storage room. The flooring surface was observed heavily soiled with accumulated and encrusted dirt/grime, and black from accumulated and encrusted dirt/grime deposits. 1st Floor West Soiled Utility Room: The liquid waste hopper interior was observed heavily soiled with accumulated and encrusted soil residue. The return-air-exhaust ventilation was observed non-functional. The ambient air was further observed extremely malodorous. Men's Restroom: Four of four commode base stalls were observed partially or completely plugged with human waste. One of four commode base stalls were also observed with human waste resting directly upon the flooring surface. One of four hand sink faucet assemblies were additionally observed missing both the hot and cold-water control handles. The four-hand sink basin countertop surface was further observed warped and sunken. The countertop front lip was also observed separated from the laminate surface, exposing the porous particle board subsurface. Storage Room: Four of four wooden shelving units were observed (etched, scored, particulate), exposing the porous particle board subsurface. Nurses Station: The restroom hand sink faucet assembly was observed loose-to-mount. The wall mounted radiator cover was also observed loose-to-mount, within the nurse station cubicle. The cubicle flooring surface was further observed soiled with accumulated and encrusted dirt/grime. The nurse station desk laminate surface was also observed (etched, scored, particulate, missing). The wall/floor junctures were further observed heavily soiled with accumulated and encrusted dirt/grime. Two bedside tables were observed (etched, scored, particulate), adjacent to the Nurses Station. Occupational/Physical Therapy: The rolling stool seat cushion was observed (etched, scored, particulate), exposing the inner Styrofoam padding. The Sharp Carousel microwave oven interior was observed (etched, scored, particulate). The black refrigerator exterior and interior was also observed soiled with accumulated and encrusted food residue. Oxygen Storage Room: The flooring surface was observed soiled with accumulated dust and dirt deposits. Paper tags were also observed resting upon the flooring surface. Bathing Room: The body wash and skin protectant dispenser exteriors were observed soiled with accumulated dust and dirt deposits. 1st Floor East Shower Room: Three anti-skid strips were observed (etched, peeling, missing), within the shower stall. The atmospheric vacuum breaker was also observed missing on the shower wand assembly. The shower wand assembly control head chrome plated surface was further observed etched and peeling. Women's Restroom: The commode base grab bar was observed loose-to-mount. Mop Closet: The mop sink basin was observed soiled with accumulated and encrusted dirt/grime. The flooring surface was also observed with two wire hangers, two plastic milk crates, and a severely soiled mop bucket. Staff Restroom: The return-air-exhaust ventilation grill was observed heavily soiled with dust and dirt deposits. The hand sink basin was also observed loose-to-mount. Nurses Station: The laminate countertop surface was observed (etched, scored, particulate, missing). The damaged laminate surface edge measured approximately 2-feet-long and 6-feet-long respectively. The upper laminate countertop surface corner edge was also observed completely missing. The damaged upper laminate countertop surface edge measured approximately 18-inches-long. 2nd Floor East The Sanyo wall mounted air-conditioning unit filters (4) were observed heavily soiled with accumulated dust and dirt deposits. Restroom: 1 of 4 hand sink basin faucet assemblies were observed missing the handle extensions. 2 of 2 overhead light plastic lens covers were also observed soiled with accumulated dust, dirt, and insect carcasses. The overhead light switch cover was further observed soiled with accumulated soil residue. Nurses Station: The desktop laminate surface was observed (etched, scored, missing), creating a non-cleanable and non-sanitizable surface. The medication refrigerator was also observed unsecured. One Healthy Choice Pineapple Chicken meal and a bottle of drinking water was further observed stored within the medication refrigerator. The medication refrigerator ambient temperature was also observed to read 55.8 degrees Fahrenheit. The medication refrigerator was further observed with accumulated ice [NAME] resting upon the refrigeration coil plate. The restroom hand sink basin faucet assembly was additionally observed leaking water, was loose-to-mount and separated from the wall surface. The return-air-exhaust ventilation grill was also observed heavily soiled with accumulated dust and dirt deposits. 2nd Floor Back Dining Room: The [NAME] Electronic Air Cleaner intake grill was observed heavily soiled with accumulated dust and dirt deposits. The Blueridge wall mounted air-conditioning unit was also observed soiled with accumulated dust and dirt deposits. Previous moisture discoloration was further observed on the wall surface, adjacent to the Blueridge air-conditioning unit. 2nd Floor Front Dining Room: 8 of 8 return-air-exhaust ventilation grills were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The Activity Storage Room was also observed in disarray. Activity items were further observed stacked upon each other. The drywall surface was also observed unfinished on the central column pillar. The unfinished drywall surface measured approximately 5-feet-wide by 6-feet-long times two. The wall/floor vinyl coving strip was further observed missing around the column pillar perimeter. 2nd Floor West Bathing Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The commode base grab bar was also observed loose-to-mount. The oxygen storage room was further observed in disarray. Two wire hangers and paper tags were also observed resting upon the flooring surface. Nurses Station: The oscillating desk fan was observed heavily soiled with accumulated dust and dirt deposits. The desktop laminate surface was observed loose-to-mount in various locations. One small cockroach nymph was observed moving across the upper desktop laminate surface. One adult cockroach was also observed above the restroom entrance door. On 08/28/24 at 10:50 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services K. The following items were noted: Clean Laundry Room: The large floor fan (36-inches-wide) was observed soiled with accumulated dust and dirt deposits. The wall surface, adjacent to the waste receptacle, was also observed soiled with dust, dirt, and debris. The flooring surface was further observed soiled with accumulated dust and dirt deposits, directly behind the three commercial driers. Soiled Laundry Room: The flooring surface was observed soiled with accumulated dust and dirt deposits. The corners and wall/floor junctures were also observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation grill plate and interior plenum were additionally observed soiled with accumulated and encrusted dust/dirt deposits. The mop sink basin interior and backsplash faucet countertop were further observed heavily soiled with accumulated and encrusted soil residue. Washing Machine Room: The flooring surface, located between and directly behind the two commercial washers, was observed heavily soiled with accumulated and encrusted dust/dirt deposits. On 08/28/24 at 11:05 A.M., An interview was conducted with Regional Director of Maintenance L regarding the facility maintenance work order system. Regional Director of Maintenance L stated: We have the TELS system. On 08/29/24 at 09:20 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance J and Director of Housekeeping and Laundry Services K. The following items were noted: 102: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. One pest control monitoring glue board was also observed with numerous dead adult cockroaches, adjacent to the room entrance door. 104: The hand sink basin was observed loose-to-mount. One pest control monitoring glue board was also observed with numerous dead adult and nymph cockroaches resting upon the surface. The glue board was additionally observed resting on the flooring surface, directly behind the wooden wardrobe. The window tracks were further observed soiled with accumulated and encrusted dust/dirt deposits. The wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter. 106: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The radiator metal cover upper ledge was also observed soiled with accumulated and encrusted dust/dirt deposits. 108: The hand sink faucet assembly was observed loose-to-mount. The wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter. 110: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The radiator metal cover was also observed loose-to-mount, adjacent to the corner surface. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits. 111: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The window tracks were also observed with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor edge was additionally observed heavily soiled with accumulated and encrusted dust/dirt deposits. 113: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The window tracks were also observed soiled with accumulated and encrusted dust/dirt deposits. 115: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The radiator metal cover upper ledge was also observed soiled with accumulated dust, dirt, and debris. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits. The window shade was further observed soiled with dust, dirt, and food residue. 202: The electrical cover plate was observed loose-to-mount, adjacent to the wooden wardrobe next to the room entrance door. 203: The oscillating wall fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits. 207: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The radiator metal cover plate upper ledge was also observed soiled with accumulated and encrusted dust/dirt deposits. 208: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter. 210: The hand sink basin was observed loose-to-mount. The window tracks were also observed soiled with accumulated and encrusted dust/dirt deposits. 211: The wall/floor vinyl coving strip was observed missing throughout the entire room perimeter. The radiator metal cover plate upper ledge was also observed soiled with accumulated and encrusted dust/dirt deposits. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits. 212: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. The wall/floor vinyl coving strip was also observed missing throughout the entire room perimeter. 215: The box fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor edge was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. The window tracks were additionally observed soiled with accumulated and encrusted dust/dirt deposits. 218: The window tracks were observed soiled with accumulated and encrusted dust/dirt deposits. On 08/29/24 at 02:15 P.M., Record review of the Policy/Procedure entitled: Daily Cleaning Procedures dated (no date) revealed under Procedures: (4) High Dust. Work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces. This includes, but is not limited to: pictures/prints, televisions, over-the-bed lights, blinds, vents, and all corners. (5) Disinfect. Work your way clockwise around the room (starting at the door and finishing at the door) and disinfect flat surfaces and high-touch items. 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, windowsills, chairs, heating unit, and any flat surfaces. If the resident has a fan in his/her room, check and clean routinely to avoid buildup of dust. (7) Clean Restroom. Complete the following steps in the restroom: (a) Restock all supplies - paper towel, toilet paper, soap, etc. (b) Empty trash (follow step 2 above). (c) High dust - lights, vents. (d) Disinfect sink area. (e) Disinfect toilet area - including handrails, call lights, and tub/shower. On 08/29/24 at 02:25 P.M., Record review of the Policy/Procedure entitled: Preventative Maintenance (TELS) and Inspections dated (no date) revealed under I. Policy Guidelines: It is the policy of (facility name) that in order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program (TELS) has been implemented to promote the maintenance of equipment in a state of good repair and condition. Record review of the Policy/Procedure entitled: Preventative Maintenance (TELS) and Inspections dated (no date) further revealed under III Procedural Components: (D) Work Orders and Service Requests: (1) A system for electronic work orders is established in TELS among all staff, and maintenance personnel that provides rapid communication regarding equipment problems. (2) The system includes documentation of: (a) The problem, (b) Date the problem was identified, (c) Who was assigned, and (d) Location of the problem. On 08/29/24 at 02:35 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the outdoor waste and cardboard recycling receptacles effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 08/28/24 at 09:00 A.M., An environmental tour of the outdoor waste receptacle cement pad area was conducted with Regional Director of Dietary Services I. The following items were noted: The cardboard waste receptacle was observed missing 1 of 2 plastic lids. The metal mounting rod was also observed bent and convoluted. The drain plug was further observed missing from the cardboard waste receptacle port. The solid waste receptacle was observed with offset plastic lids. The metal mounting rod was also observed bent and convoluted. The rear metal brace bars were further observed bent, unattached, and convoluted. Regional Director of Dietary Services I indicated she would contact the waste removal contractual service for necessary repairs as soon as possible. The cement pad surface was observed heavily soiled with accumulated and encrusted dirt and debris. One large plastic container with wheel castors was also observed full of water. Two wooden containers were further observed resting on the cement pad near the rear fence line. The waste grease container was additionally observed with rancid and malodorous used grease product. One large wooden skid was further observed resting against the waste grease container. On 08/29/24 at 02:00 P.M., Record review of the Policy/Procedure entitled: Dispose of Garbage and Refuse dated 09/01/2021 revealed under Standard: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Record review of the Policy/Procedure entitled: Dispose of Garbage and Refuse dated 09/01/2021 further revealed under Guideline: (1) The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. (3) Appropriate lids are provided for all containers.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 104 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 08/27/24 at 08:53 A.M., An initial tour of the food service was conducted with Dietary Manager H and Dietary Support G. The following items were noted: The [NAME] 2-door reach-in cooler door gaskets and upper door ledge were observed soiled with accumulated and encrusted food residue. 12 of 12 overhead plastic light lens covers were observed soiled with accumulated and encrusted dust, dirt, and food residue. Dietary Manager H indicated she would have staff thoroughly clean and sanitize the door gaskets and light lens covers as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The [NAME] 2-door reach-in cooler door gaskets were observed worn and torn. The damaged gasket surfaces measured approximately 12-inches-long and 8-inches-long respectively. Dietary Manager H indicated she would have maintenance replace the worn and torn door gaskets as soon as possible. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 08/29/24 at 01:50 P.M., Record review of the Policy/Procedure entitled: Kitchen Equipment dated 9-1-21 revealed under Standard: All food service equipment will be clean, sanitary, and in proper working order. Record review of the Policy/Procedure entitled: Kitchen Equipment dated 9-1-21 further revealed under Guidelines: (1) All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.

Based on observations, interviews, and record reviews, the facility failed to effectively provide pest control services effecting 104 residents, resulting in the increased likelihood for pest attraction and harborage. Findings include: On 08/27/24 at 10:05 A.M., The rear building exterior entrance door sweep was observed (corroded, loose, broken), creating a significant air gap between the door slab and metal threshold plate. The significant air gap created an increased likelihood for pest entrance into the building. On 08/27/24 at 10:20 A.M., One lone cockroach was observed on the flooring surface, near the 1st floor Back Dining Room entrance door. On 08/27/24 at 11:15 A.M., One small cockroach nymph was observed moving across the upper desktop laminate surface of the 2nd Floor [NAME] Nurses Station. One adult cockroach was also observed above the 2nd Floor [NAME] Nurses Station restroom entrance door. On 08/28/24 at 10:17 A.M., The facility Pest Control Program was reviewed with Director of Maintenance J and Regional Director of Maintenance L. On 08/28/24 at 10:30 A.M., Record review of the facility Pest Control Contract revealed the following treatment categories and frequencies: Crawling Insects & Mice - Interior serviced twice per month. (24/year) Exterior Treatment - May thru October treat for crawling insects and spiders. (6/year) Fall Invader Treatment - Fall time treat exterior for fall invaders. (1/year) ILT (Insect Light Traps) Service - Install 2 units service April thru October. (8/year) Rodent Control - 10 exterior bait stations serviced and cleaned monthly. (12/year) Supplemental Fly Control - Fly control large and small April thru November. (8/year) On 08/28/24 at 10:35 A.M., Record review of the Pest Control Technician Treatment Invoices for the last 12 months revealed no specific treatment for targeted pests only general treatment for pests. On 08/28/24 at 04:10 P.M., One housefly was observed flying throughout the facility Administrator's Office, during our day 2 team meeting. On 08/29/24 at 09:20 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance J and Director of Housekeeping and Laundry Services K. The following items were noted: 102: One pest control monitoring glue board was observed with numerous dead adult cockroaches resting upon the surface. The glue board was also observed resting on the flooring surface, adjacent to the room entrance door. 104: One pest control monitoring glue board was observed with numerous dead adult and small nymph cockroaches resting upon the surface. The glue board was also observed resting on the flooring surface, directly behind the wooden wardrobe. On 08/29/24 at 09:40 A.M., An interview was conducted with Resident #51 regarding cockroach activity. Resident #51 was asked: Have you seen any cockroaches in your room? Resident #51 stated: Yes. I have seen them around.

Based on observation, interview, and record review, the facility failed to date and store oxygen tubing for one (R64) of five residents reviewed and failed to complete proper hand hygiene for four of four staff members (Staff member's #1, #2, #3, and CNA O) . Findings include: Review of the facility record for R64 revealed an admitted [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. R64's record included active physician orders for supplemental oxygen use. On 08/27/24 at 11:00 AM, R64 was using oxygen that was connected to the room condenser and the tubing was not dated. Extra oxygen tubing was laying on the floor and was not in a bag or dated. The oxygen tubing connected to R64's portable condenser on the wheelchair was not dated or bagged. Two flies were observed on and around R64 during the interview. On 08/28/24 at 10:30 AM, R64's oxygen tubing attached to the large condenser was not dated or bagged. Additional tubing was laying on the bed and was not dated or bagged and the tubing on the portable condenser the resident was using at the time was not dated. On 08/29/24 at 09:33 AM, R64's oxygen tubing being used from the room condenser was not dated. The tubing connected to the portable condenser was not dated or bagged. On 08/29/24 at 10:20 AM, the facility Assistant Director of Nursing (ADON) reported the expectation is oxygen tubing should be dated. The ADON reported that oxygen tubing not in use should be stored in a bag and should not be on the floor. A facility policy addressing maintenance of oxygen tubing was requested however the policy provided only addressed storage and safety as it related to oxygen cylinders or tanks. 50223 On 8/27/24 at approximately 9:00 AM, a hand sanitizer dispenser mounted in the hallway on the 2nd floor west wing was noted to be empty. The other hand sanitizer dispensers on the 2nd floor west wing were all tested and were all found to be empty. On 8/27/24 at 10:46 AM, an unidentified staff member #1 was observed to enter room [ROOM NUMBER] and to pick up dirty laundry from the floor next to the bed. The staff member carried the laundry without bagging it, across the hall into the soiled utility room. The staff member immediately walked out of the soiled utility room and into another resident's room without performing hand hygiene. On 8/27/24 at 10:44 AM, an unidentified staff member #2 was observed performing a blood draw on a resident in room [ROOM NUMBER]. On 8/27/24 at 10:48 AM, the staff member finished the blood draw and removed their gloves, threw them away and walked out of room [ROOM NUMBER] while placing the specimens into the bag hanging over their shoulder. The staff member then walked directly into another residents room without performing hand hygiene. The staff member then applied gloves and performed a lab draw without performing hand hygiene. On 8/27/24 at 10:53 AM, the staff member then removed their gloves and left the room carrying the specimen without performing hand hygiene. On 8/27/24 at 10:55 AM, an unidentified staff member #3 was observed removing the linen from room [ROOM NUMBER] bed, linens was observed to have a brown substance on it. The staff member was observed to not be wearing gloves and carried the bed linens without being bagged across the hall to the soiled utility room and immediately left the soiled utility room and walked down the hall past the nurse's station without washing their hands. On 8/27/24 at 11:16 AM, Certified Nurse Assistant (CNA) O was observed putting a sock on a residents foot that had an uncovered wound on it. CNA O was observed to not perform hand hygiene before or after putting the sock on. On 8/28/24 at approximately 11:00 AM during an interview the Assistant Director of Nursing (ADON) was asked to describe the facility's hand hygiene practices. The ADON explained they use hand sanitizer which is maintained by housekeeping and does hand washing audits and education. The ADON provided hand hygiene education and a check off skills hand wash observation form instead of audits. The skills check off provided were not completed and lacked signatures. The ADON explained the hand sanitizer in the hallways is sometimes removed because the residents will eat it. The ADON explained there should be sanitizer at the nurse's station and all staff should use the sanitizer before and after coming out of resident rooms or providing care to the residents. A facility policy on hand hygiene and copies of the hand hygiene education was requested but not returned by the completion of the survey.

This citation pertains to Intake MI00146593. Based on Interview and record review the facility failed to investigate a physical altercation between staff to resident and between resident to resident for two residents (R24 and R40) out of three residents reviewed for abuse. Findings include: R24 On 8/28/24 at 3:20 PM, during an interview with an anonymous resident they reported they didn't understand why R38 was allowed back to the facility after they assaulted another resident. The anonymous resident explained R24 was pulled out of their wheelchair to the ground a couple of days ago by R38, R38 then was on top of R24 which broke their leg. The anonymous resident stated R24 is a small person and was sent out to the hospital. On 8/28/24 at 8:46 AM, Registered Nurse (RN M) was asked the reason R24 was in the hospital. RN M explained R24 reported pain in their leg that weekend, an x-ray was ordered with the findings of an acute proximal left tibula/fibula fracture. RN M stated, Resident [R38] tripped and fell on [R24]. RN M stated, R38 was being aggressive towards staff when this happened and later R38 was petitioned out to the hospital for a psychological intervention. A review of R24's Minimum Data Set (MDS) assessment noted, Quarterly dated 8/6/24, impaired cognition, Functional Limitation in Range of Motion: Lower extremity (hip, knee, ankle, foot) No impairment. On 8/28/24 at approximately 9:30 AM, RN M provided an incident and accident report noting, Date: 8/24/24 14:33 (2:33 PM) Incident Description: This writer was informed by [R24] that another resident fell on [their] leg when the resident was being aggressive towards the staff. Was this incident witnessed: Resident [R24] c/o (complained of) pain to left leg this writer asked was it a new onset resident stated another resident fell on [R24] leg when [R38] was trying to throw [R38's] walker. Immediate Action taken. Description: Resident MD (medical doctor) notified that the resident c/o pain to [R24's] left leg a order was given to administered Tylenol 325mg (milligrams) two tabs times one now and PRN (as needed) for pain and a X-ray ordered. Statements: No Statements found . A review of R24's hospital record documentation revealed, History and Physical: Date of service: 8/25/24. Chief Complaint: Arrive date/time 8/25/24 13:27:00 Nursing Home. Ambulance EMS. Service: trauma: Trauma Code Level: Trauma Evaluation. Chief Complaint: Fall. Site of Injury: residential. History of Present Illness. [R24] . with a hx (history) of a stroke who presented to (local hospital) from nursing home after a fall from a wheelchair. Patient reports that she was at her nursing home when one of the fell ow nursing home residents pushed her out the wheelchair . Left tib/fib (tibla/fibula) xray showed acute proximal left tib/fib fracture . R38 A review of R38's medical record noted, R38 was admitted on [DATE] with diagnosis of Dementia. A review of R38's annual MDS dated [DATE] revealed, moderate cognitive impairment and mobility devices walker. 8/21/2024 15:29 (3:29 PM) Behavior Narrative Note: Resident being disruptive to other residents during activity time. Verbally and physically aggressive unprovoked. Attempts to use [R38's] walker as a defensive tool. Redirected x2. 8/23/2024 11:42 (AM) Transfer to Hospital or other Facility Note: .Key clinical Information: Violent towards staff and other residents, sister notified .doctor informed . 8/23/2024 12:02 (AM) Health Status Note: Resident was picked up by [local] police to go to crises center officer will call back with location of center. On 8/29/24 at 3:37 PM, the Nursing Home Administrator (NHA) was asked about the incident. The NHA administrator explained R38 is shaky on their walker and they bumped R24's wheelchair and R38 fell on top of R24. The NHA could not explain if R38 bumped into R24's wheelchair or if R38 pulled or pushed R24 from the wheelchair because an investigation was not done. R40 On 8/27/24 at 2:33 PM, during an interview R40 described an incident with Licensed Practical Nurse (LPN) C and Certified Nurse Assistant (CNA) F. R40 stated LPN C choked them. R40 stated CNA E took a picture of R40's neck after the incident and reported the incident to the Director of Nursing (DON). R40 stated LPN C still worked at the facility and CNA F is on a leave. A review of R40's medical record revealed they were admitted to the facility on [DATE] with the following diagnoses: Chronic obstructive pulmonary disease, senile degeneration of brain, and muscle weakness. A review of R40's Minimum Data Set revealed a brief interview for mental status score of 10 indicating cognitive impairment. On 8/28/24 at 1:20 PM, during an interview, LPN C was asked about the incident involving R40. LPN C explained there was an altercation with another staff member in front of the nursing station and said R40 and the other staff member were getting closer to each other and were both agitated. LPN C explained they tried to diffuse the situation but R40 Got up out of (their) wheelchair and tried to jump at LPN C and the other staff member pushed (R40) back into their chair. LPN C confirmed the incident was reported to Registered Nurse (RN) D and CNA F no longer worked at the facility. On 8/28/24 at 1:49 PM, during an interview, the nursing home administrator (NHA) was asked if they recalled an incident involving R40. The NHA stated CNA 'F' is not here anymore. Yeah (they) probably did get into it with R40. On 8/28/24 at 3:36 PM, during an interview, CNA E was asked if they recalled an incident involving R40. CNA E explained R40 told them CNA F and LPN C choked them. CNA E confirmed (R40's) neck did look red. CNA E explained they took a picture of R40's neck and reported it to RN D. On 8/29/24 at 9:31 AM, a review of CNA F's employee file revealed a discipline form that stated: Description of policy, procedure, rules or requirements violated: Verbal altercation with resident. Factual basis for the discipline, including prior counseling: Employees are not allowed to engage into any altercation with a resident this violates company policy. Level of discipline: indefinite suspension pending investigation. On 8/29/24 at 10:02 AM, during an interview with the Nursing Home Administrator (NHA) they stated I have been looking for the incident report and I can't find anything. The NHA was asked to provide the reference number for the facility reported incident. The NHA stated We didn't call it in. I've been looking for the investigation and can't find it. The CNA was suspended. The NHA was asked if CNA F was suspended in response to the incident. The NHA stated yes. The NHA was asked if the incident should be documented in R40s medical record. The AD responded, Yeah, there should be something. They usually put it in the chart. The NHA was asked if they reported the incidents to the State of Michigan and complete a 5-day investigative follow-up. The NHA stated, I didn't think we had to. A review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property stated the following: The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements immediately . E. INVESTIGATION ABUSE POLICY REQUIREMENTS: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. PROCEDURE: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include:i. Who was involved ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. iii. Resident's roommate statements (if applicable) iv. Involved staff and witness statements of events v. A description of the resident's behavior and environment at the time of the incident vi. Injuries present including a resident assessment vii. Observation of resident and staff behaviors during the investigation

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to address aggressive behaviors, for one sampled resident (R38) of a total sample of 21 residents reviewed for care plans. Findings include: On 8/29/24 at 11:23 AM, R24 was observed lying in bed and was asked about their leg. R24 stated, [R38] knocked me out of my wheelchair. [R38] has to come downstairs because [R38] starts trouble. R24 was asked how did R38 knock them out of their wheelchair. R24 was observed to motion with their arms in a pulling motion. R24 stated, [R38] pulled me out of the wheelchair. I can't do anything to fight back, I don't know why he's back. A review of R38's progress notes revealed, the following patterns of aggressive behavior. 6/1/2024 16:34 (4:34 PM) Behavior Narrative Text: Resident rode the elevator by [R38's self] without assistance. Reorientated resident of facility policy and safety concerns. Resident became agitated and verbally aggressive with staff. Redirection unsuccessful. Safety maintained. 6/12/2024 20:22 (8:22 PM) Behavior Narrative Note: Resident verbally aggressive and combative with staff unprovoked. Repeatedly gives roommate drinks despite being asked not to r/t (related to) roommates fluid restriction. Requires constant redirection. Safety maintained. 6/13/2024 22:46 (8:46 PM) Behavior Narrative Note: Res (resident) continues with aggressive behavior towards staff. Res lashed out at undersign when trying to redirect res away from female bathroom. Res yelled out obscenities to undersign and was redirected back to [R38's] room by other staff members. Will monitor. 6/14/2024 22:22 (8:22 PM) Behavior Narrative Note: Res continues with aggressive behavior towards staff. Res also continues to give [R38's] roommate items after staff has told [R38] on several occasions not to do this. Res yells obscenities when staff reminds him. Will continue to monitor behaviors. 7/17/2024 20:33 (8:33 PM) Behavior Narrative Note: Resident verbally and physically aggressive with other residents unprovoked. Refused afternoon shower. Redirected several times unsuccessfully. Removed from area. Safety maintained. 7/27/2024 17:56 (5:56 PM) Health Status Note: MONTHLY SUMMARY Resident remains alert. Able to make needs known . Remains a safe smoker with staff supervision. Periods of verbal/physical aggression with staff and other residents. Refuses meds and lab draws. No changes in baseline. 8/14/2024 10:17 (AM) Behavior Narrative Note: [R38] is in a bad mood he refused breakfast and was verbally and physically aggressive towards staff and residents. Redirected several times with success. 8/21/2024 15:29 (3:29 PM) Behavior Narrative Note: Resident being disruptive to other residents during activity time. Verbally and physically aggressive unprovoked. Attempts to use [R38's] walker as a defensive tool. Redirected x2. Safety maintained. 8/23/2024 11:42 (AM) Transfer to Hospital or other Facility Note Text: Most Recent Admission: 07/25/2022 11:48. Key clinical Information: VIOLENT TOWARDS STAFF AND OTHER RESIDENTS SISTER NOTIFIED . Dr . informed. Reason for Transfer: VIOLENT TOWARDS RESIDENTS AND STAFF . 8/23/2024 12:02 (AM) Health Status Note: Resident was picked up by [local] Police to go to crises center officer will call back with location of center. A review of R38's medical record noted, R38 was admitted on [DATE] with diagnosis of Dementia. A review of R38's annual Minimum Data Set Assessment (MDS) dated [DATE] revealed, moderate cognitive impairment and mobility devices walker. A review of R38's care plan did not reveal resident does not have a care plan regarding abusive behavior. On 8/29/24 at 3:26 PM, the Assistant Director of Nursing (ADON) was asked about R38's care plan for interventions regarding R38's aggressive behavior. The ADON was observed to look at the medical chart and explained that R38 should have one because R38 has a history of aggressive behavior but was unable to locate a care plan that addressed R38's aggressive behavior.

This citation pertains to Intake MI00146498. Based on observation, interview, and record review, the facility failed to provide an appropriate sized bed for one (R255) of five residents reviewed for accommodation of needs. Findings include: On 08/27/24 at 10:21 AM, R255 was observed laying in bed. Their left heel was resting on top of the footboard of the bed and the right leg was bent at the knee and resting over the left leg. Review of the facility record for R255 revealed an admitted [DATE] with diagnoses that included Parkinson's Disease and Dementia. The resident's height was documented to be six feet, four inches. On 08/28/24 at 10:23 AM, R255 was observed laying in bed. Their head was near the top of the mattress and their feet were resting on top of the footboard of the bed. R255 was asked if their feet resting on the footboard was uncomfortable and they stated yes. When asked if they would prefer a bed that accommodates their height R255 stated That would be nice. R255 expressed they were only able to fit on the matress by bending their legs. On 08/28/24 at 02:19 PM, R255 was observed laying in bed. The head of the bed was raised to approximately 70 degrees and the resident had slid down far enough in the bed that their legs were hanging over the end of the bed from the knees down. R255 was asked about their positioning and they stated I need some help. It was observed the bed adjustments were manual and did not have a remote control. R255 was not able to adjust themselves up in the bed independently. On 08/29/24 at 09:24 AM, R255 was observed laying in bed. The resident was positioned with their head near the head of the bed and their feet were resting on the footboard. On 08/29/24 at 10:26 AM, the facility Assistant Director of Nursing (ADON) reported their expectation is that residents should have a bed that fits their body and residents feet/legs should not be resting on the footboard. The ADON reported a bed extension can be added or a larger bed can be ordered and direct care staff would have identified that the bed was too small and addressed the issue. Review of the facility policy Accommodation of Needs and Preferences and Homelike Environment Guideline dated 11/28/17 included the following entries: Purpose: It is the practice of this facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. Reasonable accommodation of resident needs and preferences means the facility's efforts to individualize the resident's physical environment.

This citation pertains to Intakes MI00140574 and MI00140631. This citation has two deficient practice statements. Deficient practice statement #1. Based on interview and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement for one resident (R901) from a total sample of two who were reviewed for elopement, when resident R901, who had a severe cognitive impairment and was assessed, and care planned as an elopement risk. R901 also had a recent history of exit seeking behavior. R901 eloped from the facility during a smoke break on 10/15/2023 at approximately 11:00 AM, without the staff being aware of R901's whereabouts. The facility was notified by R901's guardian at approximately 12:30 PM that they were picking R901 up from a hospital associated building in a city ([NAME] Arbor) that was located 39 miles away from the facility. This resulted in an Immediate Jeopardy (IJ) to the safety and health to the residents in the facility and the likelihood for serious harm, injury, or death. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 11/6/2023 at 3:56 p.m. and was asked for a plan to remove the immediacy. The IJ was removed on 11/6/2023 based on the facility's implementation of the removal plan as verified onsite on 11/7/2023. Findings Include: A review of Intake MI00140574 documented the following, .[R901] left the facility and was found in [NAME] Arbor. The guardian called the [facility] and had no knowledge that [R901] was gone. They made multiple excuses as to how [R901] left. They first reported that [R901] left walking after smoking a cigarette and then they reported that [R901] called someone for a ride and left. [R901] is elderly with dementia, and [R901] has no family or support. [R901] only knows their guardian and [they] don't know their guardian's phone number due to the dementia. APS (Adult Protective Services) is concerned that [R901] was not being monitored properly at this facility. A review of Intake MI00140631 documented the following, [R901] escaped and they didn't follow proper protocol. They created a fake AMA (Against Medical Advice). A review of the medical record revealed that R901 admitted into the facility on [DATE] with the following diagnoses, Schizophrenia, Heart Failure, Chronic Kidney Disease, and Psychoactive Substance Abuse. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental score of 7/15 indicating severe cognitive impairment. R901 also required supervision set up for bed mobility and transfers. Further review of R901's care plan revealed the following, Focus: The resident is an elopement risk/wanderer) r/t (related to) speaks often of going back to [NAME] Arbor and staring at the exit signs on the unit. Date initiated: 10/6/2023. A review of the progress notes revealed the following: Date:10/9/2023 14:18 (2:18 PM). Note Text: Resident received awoke walking the hall with coat on .Resident continued to seek an exit. Resident moved upstairs to [room number] to prevent elopement and maintain safety. Notified guardian through voicemail. Date:10/15/2023 12:56 PM. Note Text: Resident went out on smoke break this am, staff unable to locate resident when smoke break was over. Building alert sounded (Code White). Staff went out looking for resident, police called, along with police report, guardian/DON (Director of Nursing) notified. Date: 10/15/2023 15:49 (3:49 PM) Note Text: Facility wide search, all locked doors opened by security noted in resident beauty shop. Resident assisted to unit, stating I'm leaving, unable to contact guardian writer continuing to tell resident that attempts were being made to contact Guardian, resident becoming combative with staff stating I'm getting the hell out of here. Resident stated [they] had called a ride, attempted to obtain ride information, refused, finally resident agreed to sign AMA paper, resident walked out of building and got into car before staff was able to get license plate number. Still unable to contact Guardian. On 11/6/2023 at 9:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A stated that they were the assigned nurse for R901 on 10/15/2023. LPN A stated that R901 went downstairs to smoke at 10:00 AM and that they were told that R901 put a chair up to the back fence and hopped over it. LPN A stated that the Certified Nursing Assistant (CNA) noticed that R901 was not back on the unit, around 11:00 AM and that is when they called the code, and the weekend supervisor called the police. LPN A stated that R901 was not found prior to them leaving the facility for the day at approximately 4:00 PM. On 11/6/2023 at 11:00 AM, an interview was conducted with Guardian I. Guardian I stated that they had called the facility around 10:00 AM to speak with R901 and was put on hold for approximately 30 minutes until they were told that by the facility that they would contact them back as they could not locate R901. Guardian I stated that they were called by the hospital related facility in [NAME] Arbor at approximately 11:00 AM stating that R901 was at their location. Guardian I stated that they contacted the facility at approximately 12:00 PM and informed them that R901 was in [NAME] Arbor, and that they would be bringing them back to the facility. Guardian I stated that they do not believe the facility realized that R901 was gone until they called and told them. Guardian I stated that R901 told them that they jumped over a fence located around the perimeter of the facility, and walked to the bus stop. On 11/6/2023 at 11:10 AM, an interview was conducted with APS Worker (AW) J. AW J stated that they had been working with R901 for about ten months prior to R901 being admitted into the facility, so they were very familiar with them. AW J stated that the guardian called them and informed them that R901 had ran away from the facility and that the facility did not know where R901 was located. AW J stated that they called the facility and were told multiple stories from the facility. AW J stated that they were first told that R901 walked away from the facility during smoke break. Then AW J stated they were told that R901 walked away, and then finally R901 allegedly called a ride. AW J stated that R901 had Dementia, as well as mental health issues. AW J confirmed that R901 could not call anyone for a ride because they did not have any support in Michigan to call besides their guardian and R901 did not know their number. On 11/6/2023 at 12:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B stated that they worked a double shift the day of the elopement on the first floor. LPN B stated that from their understanding when the residents went outside to smoke, R901 ended up getting outside the gate. LPN B stated that one of the CNA's stated that R901 was missing, and they began to do a count. LPN B stated that they did not see R901 again in the facility and they heard that R901 had got away and was found in [NAME] Arbor. On 11/6/2023 at 1:24 PM, an interview was conducted with the Director of Nursing (DON) regarding the incident. The DON stated that they were called by the facility nurses indicating that R901 had gotten out of the facility. The DON stated that when they arrived to the facility, staff were still looking for them, but no one had checked the basement. The DON stated that they went down to the basement and noticed that the beauty shop door was closed. The DON stated that they had maintenance open the door and R901 was found in the beauty shop, sitting behind the door, with the lights off. The DON was queried as to if this should have been checked prior to them arriving to the facility to which they replied, Yes, it should have. The DON stated that R901 was very belligerent and agitated, stating how they were getting out of the facility. The DON stated that they were still able to get R901 up to the second-floor unit. The DON stated that when they made it to the unit, R901 was calm and sat at the dining room table. The DON was queried on how R901 was able to get to the basement as the elevator and stairwells require codes to enter and and exit, and she stated You know these residents know the codes. The DON was asked if they told anyone that R901 was found, including their assigned nurse or CNA. The DON stated that they think they told the CNA's that they (R901) was back and then they proceeded to walk downstairs. The DON stated that when they made it back down to the first floor, R901 was on the first floor as well. The DON stated that R901 stated that they were leaving the facility and that they had called a ride. The DON stated that R901 was yelling and cursing and refused to calm down, so they had R901 sign an AMA form. The DON was asked why the facility would allow a resident who was mentally ill, severely cognitively impaired, a known elopement risk, had a guardian and exhibiting a mental health crisis leave the facility AMA. The DON explain that they are unsure how they got out the locked front door, and that they also were unable to get the vehicle information that R901 left in. On 11/6/2023 a tour of the beauty shop was completed with the Nursing Home Administrator. Upon going down to the beauty shop, two different codes had to be entered to get in the corridor for the steps, as well as to get in the basement. It was noted that a code is also needed to use the elevator (a total of 3 different codes). In the basement the beauty shop was unlocked and there was a camera noted right above the door. The NHA was queried if the video could be seen of R901 going into the beauty shop. The NHA stated that they did not have any video of that. The NHA stated that maintenance mostly uses the beauty shop for storage. On 11/6/2023 at 2:08 PM, an interview was conducted with Certified Nursing Assistant (CNA) F. CNA F stated that they were working with the other CNA on the floor taking care of all the residents so there really wasn't an assignment. CNA F stated that they saw R901 that morning before they went to smoke. CNA F stated that a CNA that was working on the first floor came and told them that they believed they saw R901 at a bus stop but needed to see a picture because R901 was a newer resident. After seeing the picture of R901 they confirmed it was R901 and then they went and got in a car to look for them, but R901 was long gone by then. CNA F stated that they did not see R901 in the facility after that and had not heard anything about R901 being found in the basement. On 11/6/2023 at 2:10 PM, an interview was conducted with CNA G. CNA G stated that they were on their way to break from working on the first floor and saw R901 at the bus stop located about two miles away from the facility. CNA G stated that they were unsure, so they didn't want to approach R901 until, they were sure. CNA G stated that they then went back to the facility and told R901's CNA's and Nurse and confirmed that R901 was missing and then everyone went out looking for R901. CNA G stated that it was about 11:00 AM when they confirmed that R901 was not in the facility. CNA G stated that R901 was not back in the facility prior to them leaving for their shift. CNA G stated that they never heard about R901 being found in the basement. A review of a facility policy titled, Wandering and Elopement Guideline revealed the following, .Missing Resident .The person in charge will assign each staff member an area to search to include: All residents rooms, Offices ,Storage Rooms, Beauty Shop, Bathrooms, Therapy Rooms, Linen Rooms, Basement, Closets, Kitchen, Dining Rooms, Breakroom, Bathing Rooms, Freezers, Housekeeping and Maintenance Storage, and Ancillary .Notify the search team that the resident has been located( e.g., police, hospitals, friends, staff, etc). Facility Abatement Plan The facility is providing the following information to demonstrate that the immediacy of the cited deficiencies has been removed. RESIDENT AT RISK Resident #901 no longer resides in the facility IDENTIFYING OTHER RESIDENTS AT RISK Residents who are assessed as an elopement risk and smoke have the potential to be affected. Residents deemed at risk for elopement had a care-plan review to ensure appropriate interventions were in place. Residents who smoke care-plans are being reviewed to ensure appropriate interventions were in place. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE On 11.6.2023 the facility measures to implement and endure a second employee to supervise outdoor smoking sessions. An employee will assist residents in and out of the facility, while another employee will remain in the smoking corridor at all times. On 11.6.2023, in-servicing for all staff was initiated by the DON/Designee on the required supervision during smoking sessions and on immediately notifying someone in management if a resident is seen off the premises. At this point, 90% of required staff have been in-serviced. Smoking times will be posted at the main entrance and nursing stations to enhance awareness of when residents are out of the facility. Head counts of residents going out to smoke will be performed upon exiting the facility and re-entering the facility. Elopement Guidelines was reviewed with staff during in-servicing. The facility alleges the immediacy of these discrepancies have been removed on 11.6.2023. Deficient practice #2. Based on observation, interview, and record review, the facility failed to safely store medications for one resident (R902) out of one reviewed for medication storage, resulting in the potential for mistakes in medication administration. Findings Include: On 11/6/2023 at 9:40 AM, a medication cart on the second floor was observed with the computer screen (revealing resident information) and cart unlocked, and six pills in a medication cup sitting on top of the cart. No staff were visible in the hallway and the assigned nurse was observed in another resident's room. Residents were observed walking around in the hallway where the medicaiton cart was located. On 11/6/2023 at 9:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) L. LPN L stated that they were the assigned nurse for the medication cart. LPN L was queried as to if the pills should have been left on the cart, and the computer screen and cart unlocked. LPN L stated that everything should have been secured and locked. On 11/7/2023 at 12:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they have completed in-services with LPN L. The DON stated that their expectation is that the computer screen and cart is to be locked when not in use, and pills are not placed into cup until the time of administration. A review of a facility policy titled, Medication Storage in the Facility noted the following, Policy: Medications and biologicals are stored safely, securely and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

This citation pertains to Intake MI00135866. Based on observation, interview, and record review, the facility failed to perform adequate and timely assessment for two of two residents (R42 and R71), resulting in a delay in treatment and evaluation of a fractured arm (R42) and delay in diagnostic evaluation of a resident who complained of abdominal pain (R71). Findings include: R42 A review of multiple Intakes submitted to the State Agency revealed allegations surrounding R42 sustaining a broken arm at the facility. A review of R42's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Cardiovascular Disease, Dementia, Anxiety, Depression, Psychotic Disorder, and Malnutrition. Further review revealed that the resident was severely cognitively impaired and required limited to extensive assistance from staff for activities of daily living (ADLs). On 7/17/23 at 9:41 AM, R42 was observed sitting at a table in the dining room. R42 was unable to accurately answer interview questions and was pleasantly confused. R42 was observed to be wearing plain white socks and had no shoes on. R42 had a yellow Fall Risk band on their wrist. R42 was observed to not be using their right arm. A review of R42's progress notes revealed the following: -6/5/2023 19:02 (7:02 PM) Skin Observation Note Text: Resident has NO NEW skin issue(s) observed . -6/15/2023 19:14 (7:14 PM) Received resident awake and alert in bed. Unable to move .right arm and observed to be bruised. Resident unable to describe what happened due to confusion. (Doctor) was notified and ordered STAT (right away) X-Ray of right arm and requested. Written by Registered Nurse (RN) I (who works the 3 PM to 11 PM afternoon shift). No progress notes were found entered into the record between the above dated 6/5/23 through 6/15/23. Additionally, a review of R42's Evaluations revealed no entries (skin assessments, nursing assessments, etc.) from 6/6/23 through 6/15/23. Subsequent progress notes included the following: -6/15/2023 21:07 (9:07 PM) .Waiting for x-ray. -6/15/2023 22:57 (10:57 PM) .(Staff) from x-ray called at 11:00 pm stated x-ray machine was not working but will do x-ray in AM. -6/16/2023 10:24 (AM) .X-ray completed, waiting on results. -6/16/2023 16:22 (4:22 PM) .Writer talked to resident and asked (them) did (they) fall .shook (their) head yes, MD (physician) notified and said to send resident out, resident is now (on the way to the hospital) . -6/17/2023 11:52 (AM) .Resident return (sic) from hospital alert and orientated to self. Has sling on right arm. Has taken sling off .needs to be seen by orthopedic evaulateing (sic) . -6/17/2023 13:17 (1:17 PM) .Late Entry: .Resident has NEW skin issue(s) observed .Right shoulder (rear) - Bruising . -6/17/2023 19:29 (7:29 PM) .Received resident in bed awake and verbally responsive. Has a displaced fracture of right humerus (bone between shoulder and elbow). Refused to wear a sling provided .will require orthopedic consult and need to bring the papers from (hospital) .Right arm remained bruised . A review of R42's radiology results for the x-ray performed in the facility revealed: Reported Date: 06/16/2023 09:56 .PROCEDURE: Shoulder, Complete, 2+ Views .IMPRESSION: Proximal right humeral fracture as discussed above . A review of R42's June 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that pain medication was not ordered for R42 until the resident re-entered the facility from the hospital on 6/17/23. No administrations of any pain medication prior to 6/17/23 were found. The MAR/TAR indicated that on day shift on 6/16/23, R42's pain was rated as a 5/10 (moderate pain). Continued review of R42's June 2023 MAR/TAR revealed the following: Weekly Skin Check on first Bath/Shower Day of each week every evening shift every Tuesday for Routine Skin Monitoring -Start Date- 09/05/2017. Documentation for the skin check scheduled on 6/13/23 was not present in the record. No documentation was found elsewhere in the record to indicate it was completed. On 7/18/23 at 8:49 AM, Certified Nursing Assistant (CNA) C was interviewed. CNA C revealed that she had been the aide caring for R42 when the resident sustained their broken arm. CNA C explained that on the day of the injury, she had been working midnight shift, but was unable to recall the exact date. CNA C stated that it had been early in the morning and she was helping R42 get up out of bed for the day. CNA C claimed that there was a puddle of urine on the floor and that she told the resident to wait while she grabbed something to clean it up with. CNA C explained that R42 got up and she grabbed the resident's arm as the resident slipped and fell . CNA C claimed she reported it to the nurse on duty, Licensed Practical Nurse (LPN) J. CNA C stated she was suspended partially due to the fact that the resident was unable to say how their injury occurred. CNA C stated that LPN J assessed the resident, however, review of R42's record did not reveal documentation to support that claim. On 7/18/23 at 9:09 AM, R42 was observed sitting at a table in the dining room. R42 was observed to be using their left arm, but not their right arm. R42 remained confused and unable to be interviewed. R42 was observed to now have on yellow non-slip socks. On 7/18/23 at 1:09 PM, LPN B was interviewed. LPN B indicated she had cared for R42 on 6/16/23 and initiated the resident's transfer to the hospital. When queried regarding how the injury occurred, LPN B indicated that she was not directly involved at the time of the injury and as far as she knew, R42 had fallen the previous day while a staff member was getting them up out of bed at 4-5 AM. LPN B confirmed that CNA C had been suspended and the situation had been investigated because initially, they could not determine exactly what happened. LPN B claimed the resident indicated to her that they fell when she asked. LPN B was unable to speak to the lack of documentation from when the resident was reported to have fallen at 4-5 AM (on midnight shift) to when RN I entered an assessment at 7:14 PM (afternoon shift). On 7/19/23 at 8:46 AM, R42 was observed sitting at a table in the dining room. R42 was observed to not be using their right arm. On 7/19/23 at 8:50 AM, RN I was called for an interview and a voicemail was left for call-back. No return call was received prior to survey exit. On 7/19/23 at 9:57 AM, LPN J was called for an interview and a voicemail was left for call-back. No return call was received prior to survey exit. On 7/19/23 at 12:31 PM, the Director of Nursing (DON) was interviewed. The DON confirmed that CNA C had been suspended after R42 sustained their broken arm. The DON indicated that the facility wanted to ensure that the CNA had not been too rough during the incident. The DON added that CNA C should have been calling out for someone to help her. When queried if CNA C reported the incident and possible injury to the nurse on duty, the DON stated, My understanding is she did, however, the DON also confirmed there was no documentation in the record to support that claim. While discussing lack of documentation to support that skin assessments have been completed, the DON indicated that is an area that needs improvement. On 7/19/23 at 2:11 PM, the Nursing Home Administrator (NHA) was interviewed. When queried regarding the circumstances surrounding R42's fractured humerus, the NHA indicated that the situation was brought to her attention to rule out any abuse concerns. The NHA also acknowledged the lack of documentation in R42's record related to the fall and injury. The NHA indicated she would have expected the nurse to have documented an assessment after being made aware of the incident involving R42. R71 A review of R71's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was most recently readmitted into the facility on [DATE] with medical diagnoses of Dementia, Arthritis, and Malnutrition. Further review revealed that the resident is moderately cognitively impaired and requires limited assistance from staff for activities of daily living (ADLs). On 7/17/23 at 9:27 AM, R71 was observed sitting in the dining room. R71 was noted to have a healing bruise around their eye (black eye). When queried, R71 indicated they do not know how it happened. On 7/17/23 at 9:33 AM, LPN K was interviewed regarding R71. LPN K indicated that she did not know how R71 obtained a black eye but would check the resident's record. LPN K stated that the resident has dementia and is confused. A review of R71's progress notes revealed the following: -7/11/2023 07:25 (AM) .resident was calling out around 0100 (AM) on 7/11/2023, CNA went into the room saw resident and (resident) seemed to have had a incident was back in .bed. Noticed a small mark on face not really looking like a bruise until 0630 (AM) then the right eye was totally red and bruise and (resident) was c/o (complaining of) right side pain in the abdomen and notice a bruise (black eye) present at that time also. Contacted MD (physician)/family/caregiver assessed vitals and ordered labs. Will continue to monitor for pain and communicate any additional findings to MD. No additional progress notes were entered into R71's record prior to survey exit on 7/19/23. A review of R71's orders revealed the following: -X-Ray of the right side and abdomen for c/o (complaints of) abdominal pain .7/15/23. -X-Ray of the right side and abdomen for c/o (complaints of) abdominal pain .Ordered 7/11/23 .Revised 7/17/23. No radiology results were found in R71's record and no documented reason for the delay in obtaining the x-ray per order was found during further review. On 7/19/23 at 12:31 PM, the Director of Nursing (DON) was interviewed. When queried regarding the status of R71's abdominal x-ray, the DON confirmed that the test had been ordered multiple times due to an alleged fall. The DON was unable to say why the order had not yet been carried out and was unable to provide results of the x-ray when asked. A review of the facility's policy/procedure titled, Fall Evaluation Safety Guideline, dated 11/28/17, revealed, .Post Fall Action: .Determine causal factors of fall, evaluate resident and re-evaluate risk, evaluate effectiveness of interventions . A review of the facility's policy/procedure titled, Laboratory, Radiology, and Other Diagnostic Services Guideline, dated 6/1/2020, revealed, Purpose: To ensure laboratory, radiology and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis and treatment .Our facility is responsible for the quality and timeliness of the services .

This citation pertains to intake # MI 014. Based on observation, interview and record review, the facility failed to supervise and provide intervention for one resident (Resident #701) of three residents reviewed for accidents, resulting in Resident #701 being hit on the head with a cane by another resident, causing a laceration, pain headaches, and dizziness. Findings include: On 4/19/2021 at 1:00 PM, Resident #701 was observed up in their wheelchair in the activity area. Resident #701 was dressed and groomed, calm, alert, oriented, and had clear speech. At this time, Resident #701 was interviewed and asked if they recalled a physical incident that occurred with another resident. Resident #701 stated, Yes, I was hit on my head with a cane! Resident #701 was asked if it had hurt when they were struck and stated, Yes, it hurt! It was with a cane! I still have headaches from it! Resident #701, then lifted their knitted hat up to expose an L shaped healing wound on their right temple. Resident #701 was asked if they needed stitches or sutures as a result of the altercation and stated, No, they (the facility) didn't think I needed the clinic. On 4/20/2021 at 9:30 AM, Resident #701 was sitting up in bed eating breakfast. Resident #701 was asked about the incident with the cane again and stated, I don't remember when it happened, I think seven months ago. I get dizzy and headaches from it still. When asked what sparked the altercation, Resident #701 stated, I was up in my chair in the doorway and she (Unsampled Resident) told me I wasn't going anywhere, and wouldn't move. It was just her way of being mean. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 was readmitted to the facility on [DATE] with the diagnoses of Hypertension, Weakness and Dementia. Resident #701 needed limited assist with dressing and transfers, and had a Brief Interview for Mental Status (BIMS) score of 06, indicating an impaired cognition. The MDS also noted no behaviors exhibited by the Resident during the time of the assessment. A record review of the Progress Notes for Resident #701 revealed the following: 4/12/2021 12:43 (PM) Incident Note .Writer alerted by nursing staff that resident was hit by another resident during outside activities. Writer immediately removed resident from environment. Full physical assessment complete, Open area to right side of fore head, area cleanse with wound cleanser, TX (treatment) in place. Resident alert with confusion within normal limits of residents baseline, PRN (as needed) PO (by mouth) pain medication administered, Pain level 6 (out of 10). MD (Medical Doctor) notified, new orders skull/orbital x-ray, neuro checks, steri-strips .Guardian notified. Will continue to monitor. 4/13/2021 06:45 (AM) Skin/Wound Note .Assessment performed at bedside. 1 cm (centimeter) L (length) x 1 cm W (width) minor laceration noted on right frontal scalp .Triple antibiotic ointment applied, dressing attempted resident refused. States 'I don't want nothing on my head' . On 4/19/2021 at 2:40 PM, an interview was completed with Confidential Witness C. Confidential Witness C explained that she had received a call from the facility stating that Resident #701 was hit by another resident with a cane while outside. Confidential Witness C stated, I am sorry, but there is no way they were supervising the residents. It should not have gotten to that point (of getting hit on the head with a cane). A record review of the Report of Resident Allegation Of Abuse Of Another Resident report dated 4/12/2021 revealed the following for Resident #701: .Describe objectively what was observed-Resident states 'I threw water on her ass, because she wouldn't move out of my way, and then she hit me in the head with her cane', both residents immediately separated full physical assessment noted to open area R (right) side of the head, area immediately cleansed. .Summarize the investigation-Resident was outside both residents became upset with each other, because they wouldn't get out each other way, [Resident #701] became agitated and threw water on [Unsampled Resident], [Unsampled Resident] became agitated and hit [Resident #701] in the head with a cane, [Resident #701] immediately rendered First Aide, [Unsampled Resident] immediately transferred to Hospital for immediate Psych eval and Treatment. A record review of a hand written statement dated 4/12/2021 from Nurse A revealed the following: On Monday, April 12th @ approx (approximately) 10:30 AM I witnessed Resident [#701] throw water into resident [Unsampled Resident] face as they were having a verbal altercation. [Unsampled Resident] then raised a walking cane up in the air, and proceeded to hit [Resident #701] on top of .forehead. I stepped in and removed the cane from the resident. [Resident #701] was then accompanied to .unit for follow up care. The incident occurred outside as the resident were preparing for a smoke break. On 4/20/2021 at 11:59 AM, Nurse A was interviewed on what she had seen on 4/12/2021 involving Resident #701. Nurse A stated, I was walking in the building towards the gate, the residents (Resident #701 and Unsampled Resident) were within feet away. They were arguing about something and just as I started to say, 'Hey, ladies!', I seen [other Resident] pick up a cane and hit [Resident #701] right in the head. It all happened so fast. Nurse A was asked of the force of the impact on the cane with Resident #701's head and stated, It was quite a hit, I mean she hit (Resident #701) pretty hard. Nurse A was asked if there were any staff members outside supervising the residents and recalled that there was a male activities staff member outside supervising, but his back was turned because he was wheeling another resident. On 4/20/2021 at 2:34 PM, an interview was completed with Activity Aide B in regard to the incident that had occurred with Resident #701 on 4/12/2021. Activity Aide B explained that he had been there on that day but was upstairs with other residents. Activity Aide B also explained that the other male Activity Aide had not worked at the facility anymore. On 4/21/2021 at 8:55 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed in regard to the physical altercation that had occurred with Resident #701 on 4/12/2021. The DON stated, My nurse came to me and said [Unsampled Resident] hit [Resident #701]. The DON was asked if she knew why the incident had occurred and stated, Because, (Resident #701) took a cup of ice and threw it in [Unsampled Resident]'s face. I interviewed [Resident #701] and (Resident #701) said they didn't do anything to her (Unsampled Resident). So, we sent [Unsampled Resident] to the crisis center. Then, I found out what [Resident #701] had done (with the water). When I interviewed the other residents, they said they didn't feel safe with her (Unsampled Resident) here, so we sent her to another facility. Neither of them had any physical behavior history. Later, I heard [Resident #701] bragging that they would get people kicked out if they messed with (Resident #701). The DON was asked why the a staff member did not intervene while the residents were arguing to avoid escalation and stated, There was another staff member out there that was wheeling another resident, when he heard the commotion he turned around and [Nurse A] was there. He didn't think it would escalate the way it did. He doesn't work here anymore .I did clean up the wound and applied ice. It wasn't deep, but there was a lot of blood because it was a scalp wound. I put steri strips on it. The NHA added, I guess the verbal argument happened because one of the residents would not move out of the way. We called the family (of Resident #701) and they told us that '(Resident #701) could be a pistol'. R701's care plan dated 4/13/2021 reflected they had verbal aggression with staff and physical aggression with other residents related to anger and depression.

Based on observation, interview and record review the facility failed to ensure residents were free from physical abuse for one sampled (R27) and care plan aggressive behaviors for one sampled resident (R75) of three reviewed for abuse resulting in R27 being hit about the head and arms by R75 and the likelihood of psychosocial harm. Findings include: On 02/22/21 at 10:35 AM, R75 was redirected by staff after shutting off the overhead lights in the hallway. R75 mumbled some words in a defiant tone and walked down the hall toward their room. On 02/22/21 at 10:37 AM, R75 went to enter into their room. The door to the room was partially closed and R75 pushed the door open and it banged against the wall. R75 entered the room and walked past R27 who was seated in their wheelchair. As R75 passed R27, R75 pushed a loose wheel chair into a night stand to the right of R75. R 75 then sat down on their bed. An activity staff walked in and asked R75 about attending an activity and R75 declined. The activity staff exited the room. On 02/22/21 at 10:41 AM, R75 was observed to be standing over R27, batting R27 about the head and arms with open hands. R27 was seated in their wheelchair head down slightly and hands held up at the level of their ears. R75 made back and forth motions with open hands striking R27 on the head and arms. Staff was called to the room and R75 was escorted out of the room. R75 verbalized about kicking someone's (-ss). R75 was redirected by staff. R27 was removed from the room by staff. On 02/22/21 at 10:50 AM, R75 had returned to their room and sat down in their wheelchair and appeared calm. R75 was asked about the incident, but did not report what happened. R75 was asked about the confrontation with R27 and mumbled a few different words and something about root beer. R75 did not provide further comment to questions. On 02/22/21 at 10:52 AM, Nurse C was asked about the incident and knowledge of R75's behaviors. Nurse C reported R75 had a history of [REDACTED]. Nurse C also reported one can redirect R75 and get them to calm down and R75 will then sit somewhere alone. On 02/22/21 at 11:32 AM, R27 was observed in their new room. R 27 was asked about the incident and reported that they were hit on the head, but did not recall how many times. On 02/23/21 at 1:07 PM, Nurse G reported they had known R75 about as long as they had been at the facility. Nurse G reported a history of good days and bad days for R75 and R75 likes to throw paper in the toilet and pushed a wheelchair into and broke a toilet one time. Nurse G also reported R75 had been verbally aggressive to staff with a history of yelling and throwing their hands around. A review of the progress notes for R75 confirmed documentation of the incident. On 02/23/21 at 2:19 PM, the Administrator was asked about the incident between R27 and R75 and reported they had sent R75 out to the crisis center who sent them right back. The Administrator further reported they had not known R75 to have fought with anybody in the past and no other abuse incidents with R75 were known. On 02/23/21 at 2:26 PM and 02/24/21 at 12:14 PM, the Director of Nursing (DON) was asked about the incident between R75 and R27 and reported usually you can kid with R75 and R75 may refuse things sometimes , but had not known R75 to be physical with other residents. The DON did report R75 may break things like TVs and pull sinks off the wall. The DON reported R75 had been transferred in hopes a different environment would help. On 02/24/21 at 4:14 PM, the Social Worker (SW) was asked if they had spoken with R75 about the incident and reported an attempt was made, but R75 did not talk to them. It was noted that the care plan did not reflect the aggressive and vandalizing behaviors. The SW reported they were not aware of R75's vandalizing behaviors and that a team approach was used to manage R75's behaviors. The SW further noted that they speak more often with the sister than R75. The SW was asked for psych notes from any visits since August of 2020. No additional psych notes for R75 were received prior to survey exit. A review of the record for R27 revealed, R27 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE] indicated moderately impaired cognition, and the need for extensive assistance of one person for locomotion. A review of the record for R75 revealed, R75 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated severely impaired cognition and the need for supervision of one for transfer, and locomotion. A review of the progress notes revealed, 12/3/2020 10:44 Behavior Narrative Note, Note Text: resident is yelling 'Air Raid' at staff and residents. When being redirected by staff, resident refuse(s) and opens the door to the restroom and aggressively push(es) (their) wheelchair into the toilet and breaks the toilet. safety precautions maintained. 10/14/2020 04:39 AM Health Status Note, (nurses note), Note Text: The resident is alert, no observable s/s of pain. The resident has been up all night. (R75) has been wandering and tampering with whatever (they) can get (their) hands on. (R75) stopped up the toilet and filed it with bags. Activating call lights throughout (unit). The resident has been turning lights on and off. Disturbing the other residents during the shift. A review of the care plan revealed no care plan for the aggressive or vandalizing behaviors. A review of the Behavior Management Program policy (revised 11/28/17) revealed, This facility will maintain a strong commitment to the safety and welfare of all residents under our care. We will assess residents for risk factors for the development of mood and behavior symptoms according to established guidelines. Ongoing evaluation of potential risks and care plan effectiveness is part of the overall treatment plan for all residents. A review of the Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property policy revised 07/19/17 revealed, iii. Physical abuse includes hitting, slapping, pinching and kicking .It is the policy of the Facility that each resident will be free from abuse .residents will be protected from abuse, neglect and harm while residing at the facility.

Based on observation, interview and record review the facility failed to consistently monitor and address [MEDICAL CONDITION] and pain for one sampled resident (R88) of two reviewed for Quality of Care resulting in unmet care needs and pain. Findings include: On 2/22/21 at 9:15 AM, R88 was sitting on the side of their bed with their feet uncovered, and observed as swollen. R88 was asked about the swelling of their feet, and they explained that their feet were in pain due to the swelling. A review of R88's medical record revealed that R88 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of R88's medical record revealed that the resident was Cognitively Impaired and required extensive assistance for Activities of Daily Living for toileting, transfers and bathing. Further review of R88's medical record revealed the following care plan: Focus: (R88) has DX (diagnosis) of [MEDICAL CONDITION]. Date Initiated 1/21/2021 .Interventions: Monitor/Document/Report PRN (as needed) s/s (signs and symptoms) of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and perioribital [MEDICAL CONDITION] .date initiated 1/22/2021. On 2/23/21 at 1:54 PM, R88 was observed laying down in bed, and asked how they were feeling. R88 grimaced in pain and stated, My feet hurt, they are so tight. R88 was asked if they had told anyone about the pain, and stated, Yeah, I guess this is just how it's going to be. R88 was asked how long their feet had been swollen and in pain, and stated, They've been like this since I got here. On 2/23/21 at 2:00 PM, Nurse E was asked if they were aware that R88 had been complaining of [MEDICAL CONDITION] and pain in the feet. Nurse E explained, that she did not know, and entered into R88's room to assess and speak with R88. Nurse E was observed to ask an unidentified Certified Nursing Assistant (CNA) to obtain pillows in order to elevate R88's feet. As the CNA was walking away to obtain the pillows, she stated, (R88's) feet have been like that since (they) got here. A review of R88's medical record revealed that they had not been seen by the physician since admission, and the daily skilled nursing notes dating from 2/5/2021 to 2/22/2021 noted that R88 had [MEDICAL CONDITION] that was documented as, Type of [MEDICAL CONDITION]: Non-Pitting . R88's progress notes were reviewed and revealed the following: 1/24/2021 12:48 (12:48 PM) Health Status Note (nurses note) Note Text: resident assist with adl's and am (AM) care very friendly meds as ordered complaint of leg pain appetite good no gi (Gastointestinal) distress v.s.s. (vital signs stable) able to make needs known will continue to monitor. On 2/24/21 at 8:51 AM, R88 was asked about their feet, and stated, They still hurt. They gave me some pills that are supposed to help. On 2/24/21 at 3:37 PM, an interview was completed with the Director of Nursing (DON) about R88 and their expectation for assessing and monitoring for pain and [MEDICAL CONDITION]. The DON explained that any resident complaining of pain should be assessed by nursing, and this is apart of their daily skilled charting. A review of the facility's Pain Management policy dated 11/28/17 states the following, Purpose: It is the facility practices to observe residents for pain upon admission, quarterly, with a significant change in condition that may cause an onset or increase pain and any time it is suspected a resident is in pain. Residents are observed for pain regularly during daily care and interactions. Based on observation, interview and record review the facility failed to provide timely wound care for two residents (R13) of one reviewed for wound care, resulting in saturated and loose dressings, the potential for infection and the likelihood of decreased wound healing. Findings include: On 02/22/21 at 9:59 AM, R13 was observed to be laying in bed. R13 had visible wounds with open areas to both legs and feet. The dressings to both legs were saturated top to bottom, (base of the toes to the knees) with yellow drainage, had gaps between the wrappings and hung loosely off the lower legs and feet. R13 reported they did not know when the dressing were last changed. A date on the dressings was not found. On 02/22/21 at 10:13 AM, Nurse C was asked about the the condition of the dressings and reported the wound nurse took care of the wounds during the week and would be in later and may want to take pictures so a dressing change was not completed. Nurse C was asked to notify the wound nurse of the need to observe the dressing change. On 02/22/21 at 11:32 AM, wound care for R13 was observed already in process with the wound nurse Staff O. Dressings were observed to be placed on the both the left and right lower legs and feet. The dressings were covered with heavy drainage pads and wrapped snugly with rolled gauze. No gaps appeared from the top to the bottom of the dressings. On 02/22/21 at 11:35 AM, R27 was observed to be seated in a wheelchair wearing a gown. R27 had an undated dressing which ran vertically down the center of the torso from just above the nipple line to the upper abdomen. Dried yellow drainage appeared at the left side of the dressing at the level of the breast. R27 could not recall when the dressing was last changed. On 02/22/21 at 4:23 PM, R27 was observed to be in bed the dressing to the chest/breast area had been changed and dated. R13 was hunched over asleep in their wheelchair. Both feet with the dressings, rested on the floor. On 02/24/21 at 7:44 AM, A dried dark colored spill was on the floor in front of the night stand next to the bed of R13. R13 indicated it to be urine. A feces soiled brief also lay in front. R13's bilateral dressings were observed with yellow drainage on both feet. The dressings and feet rested on the floor. On 02/24/21 at 12:14 PM. the Director of Nursing (DON) was asked about the care of soiled dressings and reported they should be changed when needed. A review of the record for R27 revealed, R27 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE] indicated moderately impaired cognition, and the need for extensive assistance of one person for locomotion. A review of the care plan revealed, (R27) has Alteration in self care: requires assist with dressing, bathing, grooming and oral care. Assess residents skin daily every shift and assess for any abnormal findings such as redness, rash, open areas and irritation. A review of the record for R13 revealed R13 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The care plan revealed, has actual impairment to skin integrity r/t chronic BLE venous ulcers. circumference left leg. venous stasis ulcers on right leg. Heavy drainage. admitted with excoriation to coccyx + groin area .At risk for further breakdown r/t fragile skin & [MEDICAL CONDITION]. Non-compliant with diabetic diet. Refuses to elevate lower extremities to assist with swelling., refuses to elevate heels to prevent breakdown. Apprehensive and refuses care of the periarea at times. Circumference measurement 16.00 (centimeters) cm (W)ide x 11.80 cm (L)ong x0.5 cm Depth. [MEDICATION NAME] 3.4. Healed Sebaceous cyst back of left thigh. Resident picks at skin. Education provided on infection control. Venous ulcer on right heel 3.5 cm L x 3.00 cm W . Resident refuses treatments at times. The resident's will have no complications (related to) r/t documented skin impairment through the review date. A review of the Skin Management Guideline effective 11/28/17 revealed, It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. A review of the treatment record for February 2021 revealed wound care to the right heel and bilateral lower legs was not dcoumented as completed on 02/20/21.

Based on observation, interview and record review, the facility failed to ensure one (#3) of three sampled residents reviewed for physical restraints was free from an unauthorized physical restraint, used for the purpose of convenience, resulting in an Immediate Jeopardy (IJ) which began on 10/29/19, when Resident #3 was restrained with a gait belt to a chair and with the likelihood for serious injury, harm, or death. The Immediate Jeopardy (IJ) started on 10/29/19 and was identified on 10/30/19. The Administrator was notified of the Immediate Jeopardy on 11/4/19 and was asked for a plan to remove the immediacy. The IJ was removed on 10/29/19, based on the facility's implementation of the removal plan as verified onsite on 11/4/19. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: On 10/29/19 at 9:15 AM, Resident #3 was observed in their room sitting in a Geri Chair (a reclined chair). Resident #3 was moving forward and backwards in a jerking motion in the chair. On the floor was a grey floor mat that was folded in half. Resident #3 was observed with a contracted left arm (no movement) and right arm was reaching towards the floor mat. Resident #3 was observed to have a gait belt (safety device used to help someone move) around their waist and buckled behind the geri chair out of reach of the resident. Resident #3 continued to rock their upper body back and forward hitting the back of the chair forcefully. Resident #3 was asked if they were ok and the resident stated, Help me. Help me. Resident #3 was asked what was wrong. Resident #3's reply was not understood, but Resident #3 was observed pulling the belt and reaching for the floor mat. On 10/29/19 at 9:18 AM, Unit Clerk B was asked if Resident #3 was being restrained with a gait belt. Unit Clerk B stated, I'm not sure. I don't want to tell you the wrong thing. Let me find out. Unit Clerk B was observed to walk to the medication cart and asked Nurse C, Is (Resident #3) being restrained with a gait belt? Nurse C was observed talking to Certified Nursing Assistant A (CNA A) and a Restorative aide (RA), they were observed to walked to Resident #3's room. The RA was observed removing the gait belt from around Resident #3's waist and from around the back of the chair. The RA was asked if he placed the restraint around Resident #3. RA stated, No. CNA A was asked if Resident #3 was their assigned resident. CNA A stated, Yes. CNA A was asked if he placed the restraint around Resident #3. CNA A stated, No. CNA A was asked if he got Resident #3 up this morning out of bed. CNA A stated, No. CNA A was asked if they saw the restraint on Resident #3 this morning. CNA A stated, No. On 10/29/19 at 9:20 AM, Nurse C was observed to do a skin check on Resident #3. Nurse C stated, No redness. Skin is ok. Nurse C was asked if she placed the restraint around Resident #3. Nurse C stated, No. Nurse C was asked if she knew who did. Nurse C stated, No. On 10/29/19 at 9:45 AM, the assignment for midnight shift was reviewed and a request was made for the contact information for the staff. On 10/29/19 at 10:40 AM, midnight Nurse F were called, a voice mail was left for all and no return call was received. On 10/29/19 at 10:59 AM, the public Guardian was called and asked when was the last visit to the facility and were there any reports of behaviors. The Guardian stated, I was there last in August 2019, no behaviors reported. (Resident #3) was stable, no we don't have anything documented for behaviors. On 10/29/19 at 11:00 AM, the Administrator was asked the facility's policy on the use of restraints. The Administrator stated, I will find out who did it. That is immediate termination. Record review revealed that Resident #3 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment revealed, a severely impaired cognition and extensive assistance required for activities of daily living. The MDS revealed no impairments in mood, behavior, and noted physical restraints as not used. Resident #3's medical record did not reveal any documented evidence of a restraint assessment, consent, order, and or care plan for use. A review of Resident #3's care plan revealed, the following: Focus: (Resident #3) has a behavior problem aggression and combative r/t (related to) inability to control impulses. Date Initiated: 01/27/2019. Goal: Resident will show a decrease in negative behaviors by next review date. Date Initiated: 01/27/2019. Interventions: Provide a calm and safe environment to allow resident to express feelings as needed. Provide resident with area for decreased stimulation as needed for negative behaviors. Date Initiated: 11/16/2018. Focus: (Resident #3) has impaired cognitive function and thought processes AEB (as exhibited by) short and long term memory impairment R/T (related to) [MEDICAL CONDITION] and cerebral infract. Goal: The resident will be safe while on the secured unit. Intervention: Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions - turn off TV, radio, close door etc. The resident understands consistent simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Date initiated: 09/10/2018. Focus: (Resident #3) has a communication problem r/t speech unclear, difficulty expressing (themselves). Goal: The resident will be able to make basic needs known on a daily basis through the review date. Intervention: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, avoid isolation. Date initiated: 10/08/2019. Focus: (Resident #3) has limited physical mobility .: contractures on Lt. (left) side Date Initiated 10/08/2019. Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 10/08/2019. Interventions: Resident has a weight bearing restriction (specify). Uses Wheelchair (ensure foot pedals are in place). Date initiated: 08/29/19. Ambulation: x (times) 1 staff Physical Assist (use gait belt). Date initiated: 9/29/19. Ambulation: x2 Physical Assist (use gait belt). Date initiated:10/08/19. The resident is NON-WEIGHT BEARING. Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date initiated 9/10/2018 . Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date initiated:10/08/19. Further review of Resident #3's medical record revealed the following progress notes: 10/17/2019 15:35 (3:35 PM) Behavior Narrative Note Text: (Resident #3) acting out most of day yelling for help!! knocking over furniture hitting at staff and others. Refused medication and through (threw) food on the floor. Placed in room and allowed to vent feeling. Given med after one hour. 10/17/2019 11:11 (AM) Medication Administration Note Text: Resident acting out throwing food and medication on floor. A review of Resident #3's Medication Administration Record [REDACTED]. On 10/29/19 at 12:34 PM, Nurse C was asked if she saw the restraint on Resident #3 during med pass at 9:00 AM. Nurse C stated, I did not do my normal rounds this morning because I was running late. I normally come in at 7:00 AM. I got here around 8:30 AM and started passing meds. I started with the residents that were in the dining room first. I gave (Resident #3's) meds after 9:00 AM. Nurse C was asked if that was Resident #3's floor mat that they were reaching for. Nurse C stated, Yes. It was (Resident #3's) floor mat (Resident #3) is a fall risk and has [MEDICAL CONDITION]. Nurse C was asked to explain how a gait belt had been used as a restraint. Nurse C stated, I don't know. This is a Restraint free facility, there should not be any restraints. On 11/4/19 at 7:37 AM, CNA E was asked about the restraint found on Resident #3. CNA E stated, I thought we could use it if they were in danger. CNA E was asked if they placed the restraint on Resident #3. CNA E stated, I worked the west unit. I am not sure who did it. I thought that they said we could restrain them with a gait belt if they were in danger, but that was a while ago. On 11/4/19 at 7:55 AM, CNA D was interviewed via phone and was asked about the restraint found on Resident #3. CNA D stated, At first I didn't put it around (Resident #3). I was trying to calm (them) down to get (Resident #3) back in bed. (Resident #3) kept saying 'This is my house get out of my house.' (Resident #3) was trying to get to the floor. I didn't want (them) to get on the floor. I put it around (Resident #3) to stop (them) from getting on the floor. I didn't want (Resident #3) to hurt themselves. I got (Resident #3) cleaned up and forgot to take it (restraint) off of (them). Afternoon shift said (Resident #3) was agitated. This day I wasn't able to get (Resident #3) calm. CNA D was asked why they used the gait belt. CNA D stated, I used it to keep (Resident #3) in the chair. CNA D was asked how long Resident #3 was restrained in the chair. CNA D stated, About 20 min. CNA D did not indicated what time the restraint was applied on Resident #3. On 11/4/19 at 11:18 AM, a review of CNA D's time punch revealed, Date: Monday 10/28/19 Scheduled 11:00 PM - 7:30 AM, IN: 11:08 PM, OUT: 3:00 AM, IN: 10/29/19, 3:31 AM, OUT 7:31 AM. Resident #3 was first observed with the restraint on at 9:15 AM on 10/29/19 and off at 9:18 AM, indicating the restraint was on the resident for at least one hour and 45 minutes, after CNA D left. On 11/4/19 at 11:30 AM, the Administrator was asked about Resident #3 being restrained. The Administrator stated, Restraints are not to be used. It should not have been used. The Administrator was asked if there was any other residents that had been restrained by CNA D. The Administrator stated, No. On 11/4/19 at 1:28 PM, the Medical Director and attending Physician were called, a voice mail was left for all and no return call was received by the end of this survey. A review of the facility's policy titled Restraint Policy, dated 3/8/2008, noted, HCFA (Centers for Medicaid and Medicare) has defined physical restraint, in the context of the nursing facility regulations, as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the individual's body that the individual cannot remove easily, which restricts freedom of movement or access to his her body. Source-Surveyor Guidebook on Dementia . It is the philosophy of the facility . to not use physical and chemical restraints until all other interventions have failed. If a restraint is to be used the IDCP team and physician will begin using restraints that are the least restrictive. The staff will care plan and document the restraint. A review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Properly dated 11/28/17, noted, Abuse Policy: It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual. or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical and chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms . Abatement Plan Element 1 Resident #3 restraint (gait belt) was removed immediately. Head to toe assessment completed and no injury was noted. Guardian and physician notified. Resident #3 care plan reviewed and deem appropriate. Psych services provided to resident for evaluation regarding potential for psychosocial harm and none noted. Element 2 All residents have the potential to be affected. All current residents were assessed, and medical record was reviewed related to restraints; order, consent and care plan and no other restraints were noted in use at the facility. All residents that were interview appropriate, all denied having the same experiences as Resident #3. They verbalized not being affected by the event. All staff were queried on 10/29 thru 11/4/19, all denied that there is an inappropriate use of gait as restraint. An employee involved in the inappropriate use of gait belt as a restraint was removed from the facility immediately and placed on administrative suspension. Element 3 The Administrator and Asst (Assistant) Director of Nursing (DON) reviewed the restraint policy considering the incident and deem appropriate. 100% of all staff were educated on 10/29/19 thru 10/30/19 regarding gait belts and restraint policy. ADHOC QAPI with the medical director was completed on November 4, 2019. All residents will be audited for restraint use; ensuring that physicians order, consent, and care plan are in place daily x 4 weeks, then weekly x 4 weeks, then monthly x 3 months. Findings will be discussed at QAPI monthly. Identified trends will be addressed immediately. Element 4 Administrator and Asst. Director of Nursing will be responsible for sustained compliance. Element 5 Date of Abatement - October 29, 2019

Based on observation, interview and record review, the facility failed to ensure one (#3) of three sampled residents reviewed for physical restraints was free from an unauthorized physical restraint, used for the purpose of convenience, resulting in an Immediate Jeopardy (IJ) which began on 10/29/19, when Resident #3 was restrained with a gait belt to a chair and with the likelihood for serious injury, harm, or death. The Immediate Jeopardy (IJ) started on 10/29/19 and was identified on 10/30/19. The Administrator was notified of the Immediate Jeopardy on 11/4/19 and was asked for a plan to remove the immediacy. The IJ was removed on 10/29/19, based on the facility's implementation of the removal plan as verified onsite on 11/4/19. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: On 10/29/19 at 9:15 AM, Resident #3 was observed in their room sitting in a Geri Chair (a reclined chair). Resident #3 was moving forward and backwards in a jerking motion in the chair. On the floor was a grey floor mat that was folded in half. Resident #3 was observed with a contracted left arm (no movement) and right arm was reaching towards the floor mat. Resident #3 was observed to have a gait belt (safety device used to help someone move) around their waist and buckled behind the geri chair out of reach of the resident. Resident #3 continued to rock their upper body back and forward hitting the back of the chair forcefully. Resident #3 was asked if they were ok and the resident stated, Help me. Help me. Resident #3 was asked what was wrong. Resident #3's reply was not understood, but Resident #3 was observed pulling the belt and reaching for the floor mat. On 10/29/19 at 9:18 AM, Unit Clerk B was asked if Resident #3 was being restrained with a gait belt. Unit Clerk B stated, I'm not sure. I don't want to tell you the wrong thing. Let me find out. Unit Clerk B was observed to walk to the medication cart and asked Nurse C, Is (Resident #3) being restrained with a gait belt? Nurse C was observed talking to Certified Nursing Assistant A (CNA A) and a Restorative aide (RA), they were observed to walked to Resident #3's room. The RA was observed removing the gait belt from around Resident #3's waist and from around the back of the chair. The RA was asked if he placed the restraint around Resident #3. RA stated, No. CNA A was asked if Resident #3 was their assigned resident. CNA A stated, Yes. CNA A was asked if he placed the restraint around Resident #3. CNA A stated, No. CNA A was asked if he got Resident #3 up this morning out of bed. CNA A stated, No. CNA A was asked if they saw the restraint on Resident #3 this morning. CNA A stated, No. On 10/29/19 at 9:20 AM, Nurse C was observed to do a skin check on Resident #3. Nurse C stated, No redness. Skin is ok. Nurse C was asked if she placed the restraint around Resident #3. Nurse C stated, No. Nurse C was asked if she knew who did. Nurse C stated, No. On 10/29/19 at 9:45 AM, the assignment for midnight shift was reviewed and a request was made for the contact information for the staff. On 10/29/19 at 10:40 AM, midnight Nurse F were called, a voice mail was left for all and no return call was received. On 10/29/19 at 10:59 AM, the public Guardian was called and asked when was the last visit to the facility and were there any reports of behaviors. The Guardian stated, I was there last in (MONTH) 2019, no behaviors reported. (Resident #3) was stable, no we don't have anything documented for behaviors. On 10/29/19 at 11:00 AM, the Administrator was asked the facility's policy on the use of restraints. The Administrator stated, I will find out who did it. That is immediate termination. Record review revealed that Resident #3 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment revealed, a severely impaired cognition and extensive assistance required for activities of daily living. The MDS revealed no impairments in mood, behavior, and noted physical restraints as not used. Resident #3's medical record did not reveal any documented evidence of a restraint assessment, consent, order, and or care plan for use. A review of Resident #3's care plan revealed, the following: Focus: (Resident #3) has a behavior problem aggression and combative r/t (related to) inability to control impulses. Date Initiated: 01/27/2019. Goal: Resident will show a decrease in negative behaviors by next review date. Date Initiated: 01/27/2019. Interventions: Provide a calm and safe environment to allow resident to express feelings as needed. Provide resident with area for decreased stimulation as needed for negative behaviors. Date Initiated: 11/16/2018. Focus: (Resident #3) has impaired cognitive function and thought processes AEB (as exhibited by) short and long term memory impairment R/T (related to) [MEDICAL CONDITION] and cerebral infract. Goal: The resident will be safe while on the secured unit. Intervention: Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions - turn off TV, radio, close door etc. The resident understands consistent simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Date initiated: 09/10/2018. Focus: (Resident #3) has a communication problem r/t speech unclear, difficulty expressing (themselves). Goal: The resident will be able to make basic needs known on a daily basis through the review date. Intervention: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, avoid isolation. Date initiated: 10/08/2019. Focus: (Resident #3) has limited physical mobility .: contractures on Lt. (left) side Date Initiated 10/08/2019. Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 10/08/2019. Interventions: Resident has a weight bearing restriction (specify). Uses Wheelchair (ensure foot pedals are in place). Date initiated: 08/29/19. Ambulation: x (times) 1 staff Physical Assist (use gait belt). Date initiated: 9/29/19. Ambulation: x2 Physical Assist (use gait belt). Date initiated:10/08/19. The resident is NON-WEIGHT BEARIN[NAME] Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Date initiated 9/10/2018 . Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date initiated:10/08/19. Further review of Resident #3's medical record revealed the following progress notes: 10/17/2019 15:35 (3:35 PM) Behavior Narrative Note Text: (Resident #3) acting out most of day yelling for help!! knocking over furniture hitting at staff and others. Refused medication and through (threw) food on the floor. Placed in room and allowed to vent feeling. Given med after one hour. 10/17/2019 11:11 (AM) Medication Administration Note Text: Resident acting out throwing food and medication on floor. A review of Resident #3's Medication Administration Record [REDACTED]. On 10/29/19 at 12:34 PM, Nurse C was asked if she saw the restraint on Resident #3 during med pass at 9:00 AM. Nurse C stated, I did not do my normal rounds this morning because I was running late. I normally come in at 7:00 AM. I got here around 8:30 AM and started passing meds. I started with the residents that were in the dining room first. I gave (Resident #3's) meds after 9:00 AM. Nurse C was asked if that was Resident #3's floor mat that they were reaching for. Nurse C stated, Yes. It was (Resident #3's) floor mat (Resident #3) is a fall risk and has [MEDICAL CONDITION]. Nurse C was asked to explain how a gait belt had been used as a restraint. Nurse C stated, I don't know. This is a Restraint free facility, there should not be any restraints. On 11/4/19 at 7:37 AM, CNA [NAME] was asked about the restraint found on Resident #3. CNA [NAME] stated, I thought we could use it if they were in danger. CNA [NAME] was asked if they placed the restraint on Resident #3. CNA [NAME] stated, I worked the west unit. I am not sure who did it. I thought that they said we could restrain them with a gait belt if they were in danger, but that was a while ago. On 11/4/19 at 7:55 AM, CNA D was interviewed via phone and was asked about the restraint found on Resident #3. CNA D stated, At first I didn't put it around (Resident #3). I was trying to calm (them) down to get (Resident #3) back in bed. (Resident #3) kept saying 'This is my house get out of my house.' (Resident #3) was trying to get to the floor. I didn't want (them) to get on the floor. I put it around (Resident #3) to stop (them) from getting on the floor. I didn't want (Resident #3) to hurt themselves. I got (Resident #3) cleaned up and forgot to take it (restraint) off of (them). Afternoon shift said (Resident #3) was agitated. This day I wasn't able to get (Resident #3) calm. CNA D was asked why they used the gait belt. CNA D stated, I used it to keep (Resident #3) in the chair. CNA D was asked how long Resident #3 was restrained in the chair. CNA D stated, About 20 min. CNA D did not indicated what time the restraint was applied on Resident #3. On 11/4/19 at 11:18 AM, a review of CNA D's time punch revealed, Date: Monday 10/28/19 Scheduled 11:00 PM - 7:30 AM, IN: 11:08 PM, OUT: 3:00 AM, IN: 10/29/19, 3:31 AM, OUT 7:31 AM. Resident #3 was first observed with the restraint on at 9:15 AM on 10/29/19 and off at 9:18 AM, indicating the restraint was on the resident for at least one hour and 45 minutes, after CNA D left. On 11/4/19 at 11:30 AM, the Administrator was asked about Resident #3 being restrained. The Administrator stated, Restraints are not to be used. It should not have been used. The Administrator was asked if there was any other residents that had been restrained by CNA D. The Administrator stated, No. On 11/4/19 at 1:28 PM, the Medical Director and attending Physician were called, a voice mail was left for all and no return call was received by the end of this survey. A review of the facility's policy titled Restraint Policy, dated 3/8/2008, noted, HCFA (Centers for Medicaid and Medicare) has defined physical restraint, in the context of the nursing facility regulations, as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the individual's body that the individual cannot remove easily, which restricts freedom of movement or access to his her body. Source-Surveyor Guidebook on Dementia . It is the philosophy of the facility . to not use physical and chemical restraints until all other interventions have failed. If a restraint is to be used the IDCP team and physician will begin using restraints that are the least restrictive. The staff will care plan and document the restraint. A review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Properly dated 11/28/17, noted, Abuse Policy: It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual. or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical and chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms . Abatement Plan Element 1 Resident #3 restraint (gait belt) was removed immediately. Head to toe assessment completed and no injury was noted. Guardian and physician notified. Resident #3 care plan reviewed and deem appropriate. Psych services provided to resident for evaluation regarding potential for psychosocial harm and none noted. Element 2 All residents have the potential to be affected. All current residents were assessed, and medical record was reviewed related to restraints; order, consent and care plan and no other restraints were noted in use at the facility. All residents that were interview appropriate, all denied having the same experiences as Resident #3. They verbalized not being affected by the event. All staff were queried on 10/29 thru 11/4/19, all denied that there is an inappropriate use of gait as restraint. An employee involved in the inappropriate use of gait belt as a restraint was removed from the facility immediately and placed on administrative suspension. Element 3 The Administrator and Asst (Assistant) Director of Nursing (DON) reviewed the restraint policy considering the incident and deem appropriate. 100% of all staff were educated on 10/29/19 thru 10/30/19 regarding gait belts and restraint policy. ADH[NAME] QAPI with the medical director was completed on (MONTH) 4, 2019. All residents will be audited for restraint use; ensuring that physicians order, consent, and care plan are in place daily x 4 weeks, then weekly x 4 weeks, then monthly x 3 months. Findings will be discussed at QAPI monthly. Identified trends will be addressed immediately. Element 4 Administrator and Asst. Director of Nursing will be responsible for sustained compliance. Element 5 Date of Abatement - (MONTH) 29, 2019

This citation pertains to Intake MI 359. Based on interview and record review, the facility failed to accurately assess and document the development and worsening of a pressure ulcer for one sampled resident (R200) of three reviewed for pressure ulcers, resulting in the development and worsening of a pressure wound. Findings include: On 9/23/19 at 8:55 AM, family member A was interviewed regarding R200 wound that developed in the facility. Family member A said, I had a meeting in (MONTH) with the care team about the status of my (family member). They said (R200) had a small bed sore and they were putting some type of cream on it. On about (MONTH) 25th, they called me and said that my (family member) fell and went to the hospital .They (hospital) also said that (R200) had a stage four (full thickness tissue loss extending to muscle, tendon and/or bone) bed sore that they debrided (surgically cleaned) three times. On 9/23/19 at 9:45 AM, the electronic medical record showed R200 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The care plan dated 6/20/19 was reviewed and noted resident had, Potential for skin impairment related to incontinence and limited mobility, monitor skin when providing care, assist with turning and repositioning every 2-3 hours. The resident required extensive assistance with activities of daily living and bed mobility. A review of R200's, The McGreers Infection Symptom Tracking, tool dated 7/22/19 at 12:58 PM noted no soft tissue injury or wounds. However, the Wound Summary dated 7/22/19 at 8:52 AM, identified by Nurse B noted a coccyx wound with moderate serosanguineous (clear, pink-tinged) exudate (drainage) measuring 2.80 cm (centimeters) by 3.40 cm by 0.20 cm. No treatment plan was initiated. A review of R200's, Wound Assessment Details Report dated 7/29/19 at 10:24 AM noted a coccyx wound measuring 2.80 cm by 3.40 cm by 0.20 cm. A review of R200's, Wound Assessment Details Report dated 8/9/19 at 11:36 AM noted a coccyx wound with moderate serosanguineous exudate measuring 2.80 cm by 3.40 cm by 0.20 cm. A review of R200's, Wound Assessment Details Report dated 8/14/19 at 2:35 PM by Nurse B noted a coccyx wound with moderate serosanguineous exudate measuring 2.80 cm by 3.40 cm by 0.20 cm. Although the measurements for dates 7/22/19, 7/29/19, 8/9/19, and 8/14/19 were the same, an observation of the pictures presented by the facility did not correlate visibly. Each picture of the above wound showed an obvious progression of each wound. In addition, 7/22/19, 7/29/19, 8/9/19, 8/14/19 and 8/19/19 all noted the wound type as skin tear, type two: partial flap loss, clinical stage-denuded, and facility-acquired. A Braden Scale dated 8/21/19 noted a score of 12, indicating R200 was a high risk for pressure ulcers. A review of R200's, Wound Assessment Details Report dated 8/19/19 at 12:23 PM by Nurse B noted a coccyx wound with moderate serosanguineous exudate measuring 8.00 cm by 6.50 cm by 6 cm. Current Plan and Comments noted the following: 8/19/2019 12:35 PM (by the ADON): Wound eval noted with non-improvement to Coccyx MASD (moisture-associated skin damage) wound noted with scattered yellow necrotic base, heavy s.s (serosanguineous) drainage, irregular & indistinct wound edges, order conts (continue) with [MEDICATION NAME] Gel QD (every day) & prn (and as needed) Coccyx. No documentation was found in the medical record indicating any of the following interventions were completed: The skin and body check section should be completed within the first 2 hours .Modify the interventions as appropriate, completed weekly for the first 4 weeks post admission .Inspection of skin daily with cares and weekly by a licensed nurse .Specified turning and repositioning. On 9/23/19 at 12:18 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed about the development and the progression of R200's wound. The ADON said, I'm also the wound care nurse. I just took on the ADON role. (R200) was not eating well and was also incontinent. No additional information was provided. A review of the facility's document titled, Skin Management Guideline effective 11/28/17 noted the following: 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 .The skin and body check section should be completed within the first 2 hours .Modify the interventions as appropriate, Completed weekly for the first 4 weeks post admission .Inspection of skin daily with cares and weekly by a licensed nurse .Specified turning and repositioning.

This citation pertains to intake #'s MI 716, , . Based on observation, interview, and record review, the facility failed to prevent the elopement of one (#901) of six residents reviewed for elopement when resident #901, who had a recent history of exit seeking behavior and was known to have knowledge of the elevator access code, eloped from the facility without staff knowledge on 6/17/18 at an unknown time. The facility was notified by the local Police on 6/19/18 at 7:45 a.m., to indicate that the resident was admitted into a local hospital emergency room . This resulted in an Immediate Jeopardy (IJ) to the safety and health to the residents in the facility and the likelihood for serious harm, injury, or death. The Administrator was notified of the Immediate Jeopardy on (MONTH) 21, (YEAR) at 1:00 p.m. and was asked for a plan to remove the immediacy. The IJ was removed on 6/19/18, based on the facility's implementation of the removal plan as verified onsite on 6/21/18. Findings include: On 6/21/18 at 8:48 a.m., Resident #901 was observed in the dining room eating breakfast and was dressed appropriately. On 6/21/18 at 10:50 a.m., Resident #901 was observed laying in bed, fully clothed with shoes on, and a walker was next to the bed with bags on it. Resident #901 was interviewed regarding leaving the building on 6/17/18 and stated, I left a couple of days ago. I needed to get out of here. I left walking and used transportation for the rest of the way. I left from the second floor by myself, alone. Resident #901 was asked if they were aware of the elevator code and stated, Yes I know it . The resident was asked if there was a reason for leaving the facility and stated, I didn't want to be here. On 6/21/18 at 9:30 a.m., the clinical record for Resident #901 was reviewed and revealed that the resident was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated a moderate impairment of cognition and the resident required limited assistance of staff for activities of daily living (ADL). On 6/21/18 at 9:39 a.m. Nurse A was interviewed via telephone regarding Resident #901's elopement. Nurse A stated, On the 3:00 p.m. - 11:00 p.m. shift, Resident (#901) took meds (medication) and had dinner. I gave her meds in the coffee. I helped with passing the trays and fed a resident. Close to 7:00 p.m., I helped with putting the trays on the cart. I remember seeing Resident (901) during that time. I then went to the nurses station to do some charting. The shift went on and the 11:00 p.m. staff came in. I gave report to the on-coming nurse and continued to work. At 2:00 a.m., I was preparing to leave when Certified Nursing Assistant B (CNA B) asked if resident (901) was on a leave of absence. I said no. We started looking around in the building, outside, and in the neighborhood . Review of the Medication Administration Record [REDACTED]. Nurse A stated, I gave them and documented on them. Not sure why it's not showing documented. On 6/21/18 at 10:13 a.m., during a phone interview, CNA B was questioned regarding resident (901's) elopement. CNA B stated, I punched in at 11:03 p.m., made my rounds on 2 West to make sure that my residents are ok and I gave care if they need it. A few of them needed care so I did that. When I got to resident (901's) room the door was closed so I went to the next room, because I figured she was in there and was ok. I got distracted when another co-worker came in looking for a cell phone. Around 12:30 a.m. or 1:00 a.m., I sat down to look at my assignment, then a call light on 2 East came on. We were sharing the units because it was just three of us on the floor. I came back to 2 West and went to resident (901's) room, the door was still closed. I knocked on it, no answer, knocked again, no answer, I called the resident's name, no answer. I opened the door and did not see the resident. I went to Nurse A and asked if resident (901) was out on a leave of absence. Nurse A said no. That's when we started looking around the building . CNA B was asked if resident (901) had tried to leave before. CNA B stated, Yes. She sits in the day room by the window. When it's time for bed she gives us a hard time. We found out that she knows the code to the elevator, because there was a CNA in the basement waiting for the elevator and when the door opened resident (901) was in the elevator alone . CNA B was asked when did this incident occur. CNA B stated, On the midnight shift. I don't remember the day. On 6/21/18 at 2:31 p.m., during a phone interview, CNA C was questioned regarding Resident #901's elopement. CNA C stated, I have only been working there for two months on the afternoon shift. I use to be on the first floor, so I don't know these residents that well. That Sunday I had 27 residents and there was a lot of stuff going on. I saw her during dinner because resident (901) asked for some sugar for the coffee. Around 7:45 p.m., I saw someone sitting on resident (901's) bed. I was trying to handle two other resident situations, fed a resident, pick up trays, so I didn't see who it was on the bed. I left at 11:45 p.m . CNA C was asked if Resident #901 was assigned to them. CNA C stated, Yes. resident (901) was mine, but it was just one of those days. I had 27 residents on my assignment. On 6/21/18 at 2:58 p.m., during a phone interview, CNA D was questioned regarding Resident 901's elopement. CNA D stated, I worked 11:00 p.m. - 7:30 a.m. I remember the (CNA B) that had resident (901), later that night discovered she wasn't in her room. I went downstairs and outside to look for resident (901) and could not find resident (901) . CNA D continued and stated, resident (901) wasn't there when we got there. Usually we would've seen her in the dining room at the window or watching us get off the elevator. Resident (901) would sit there with her coat and boots on ready to go. Resident (901) had been trying to get out all week. Resident (901) knows the elevator code. An employee escorted Resident (901) back up from the basement. Resident (901) had made it down to the basement alone. It must not have stopped on the first floor. That's when another CNA brought Resident (901) back to the second floor. When questioned if the staff reported Resident #901 knowing the code and making it to the basement to the Administrator or Director Nursing. CNA D stated, I'm not sure. On 6/21/18 at 3:37 p.m., during a phone interview, Nurse E was asked to explain the incident with Resident #901. Nurse E stated, I worked 2 East that Sunday. I had passed my meds, and was helping with picking up trays. I sat down around 7:00 p.m., to chart so I could get out the red (Per the nurse: explained that meds had been passed and not documented). While I was doing that residents were at the desk begging me to take them out to smoke . Around 7:30 p.m., I told them to go to the elevator and I would meet them there. I had all male residents a couple were in wheelchairs, a couple walking. There was one female resident on the elevator, but she was with her boyfriend. I don't know resident (901) and not sure if they smokes and resident (901) was not on the elevator with the group. We went to the back of the building and smoked two cigarettes and came back in the building. Resident 901 was not in the back smoking area with us . I left for the day at 11:10 p.m. On 6/21/18 at 4:43 p.m., during a observation of the facility's video surveillance the following observations were noted: 19:07 (7:07 p.m.) Resident #901 observed standing at door inside facility. Nurse E put the code in on the key pad and then opened the door. One unknown resident was pushed out by another person. Resident #901 came out of the door and held the outside door opened for the person pushing the wheelchair, then Resident #901 let the door go. 19:09 (7:09 p.m.) Resident #901 appeared in the video walking to the side courtyard and sitting in a chair. Nurse E and other residents walked by Resident #901 towards the back of building. 19:35 (7:35 p.m.) Nurse E and group of residents walked passed Resident #901 toward the front door of the building. 19:55 (7:55 p.m.) Resident #901 got up from chair and walked away out of view of the facility's camera. On 6/21/18 at 5:06 p.m., during an interview with the Administrator and Director of Nursing (DON). They were asked if there were any reports to them regarding Resident #901 knowing the elevator code and making it off the second floor to the basement. They both stated, Not before yesterday (6/20/18). The Administrator stated, We were told that she made it to the basement, but not told that she knew the code. They did not report when it happened. The Administrator was asked when should the facility be notified of a high risk elopement resident getting to the basement and knowing the elevator code. The DON and Administrator stated, When it happens. The Administrator was asked if the elevator code had been changed. The Administrator stated, No. We tried and couldn't do it. We had to call the company and they are coming out to change it. The DON was asked what are the expectations for Nursing staff when there are residents sitting outside without staff. The DON stated, We in-serviced all staff if you see someone sitting in the yard you check to make sure they are not a resident. On 6/21/18 at 4:45 p.m., a review of the following facility's policies was completed: Policy titled Wandering and Elopement Guideline, dated (MONTH) 16, (YEAR), noted, This facility will provide the least restrictive and safe environment for wandering residents at risk for elopement . Process: . At any time during a resident stay there may present indication of elopement risk . It is the responsibility of our staff to remain with the resident until a licensed nurse is able to conduct an evaluation . Documentation of this process will be included within the medical record .Resident identified at risk will have an elopement risk bracelet application placed in designated facilities with this feature . Facility Procedures: Door security codes will be shared with staff members only. Security codes will not be shared with resident representatives or residents. It is the responsibility of staff to enter security codes to support visitors with exiting the facility and / or units as indicated . Observation of a Resident exiting the Facility: Attempt to prevent the departure . Policy titled Routine Resident Checks, dated (MONTH) 2013, noted, Policy Statement: Staff shall make routine resident check to help maintain resident safety and well-being. Policy Interpretation and Implementation: 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine check on each unit at least once per each 8 hours shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify weather the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc . Policy titled Midnight Census, dated 6/1/15, noted Policy: It is mandated by law that every night at Midnight a physical count of resident must be taken. Procedure: 1. Each month the business office prints a census report (Referred to as the midnight census) for each wing off the AR system. The report is brought to the nurse's station to be completed nightly by the charge nurse. 2. At midnight the charge nurse takes the report and verifies that each patient on the report is still in the facility, by making a physical round of the unit and reporting any existing changes. The 3rd shift charge nurse should make notations directly on the report The facility plan to remove immediacy: Element #1 On 6.17.2018: 1908: Licensed Nurse took a group of residents out for activity but did not recall seeing Resident # 901. 1936: nurse returned into facility with group of residents. 1955: Resident remained in the courtyard and walked away from facility, unbeknownst to facility staff On 6.18.18: 0230: Resident # 901 was not in the facility, unbeknownst to facility staff, during rounds. Staff immediately implemented the facility elopement policy, notified Director of Nursing and ground search also initiated. Local law enforcement was immediately notified to assist with search. Head count of all residents present in facility. 0330: Police present and neighborhood and community search initiated, with staff included 0700: Initiation of staff education on elopement, abuse and neglect, and monitoring of all residents who attend outdoor activities. Staff will not work or provide care for any residents until education has been complete. Any staff on leave of absence, vacation, etc. will receive the education prior to working or providing care for residents. Education conducted by Director of Nursing/Designee. Family, guardian, state of Michigan, Medical Director notified of event On 6.19.18 0700: law enforcement notified facility that resident was in local hospital, in good condition. 1330: Resident returned to the facility at baseline condition, after being assessed by physician and staff at the hospital emergency department. Reassessment completed for Resident #901 for elopement, physical, BIMs, transfer, falls, hydration, PHQ-9, neurological, pain, and skin. No negative findings noted. Immediate intervention, upon resident return to the facility, included close monitoring of resident with a minimum of every two hours visual check and with shift change to ensure resident location; resident room move to across nurses station for additional visualization; and medication review. Element #2 On 6.18.18 The Elopement/Wandering Guideline was reviewed by the Administrator and Director of Nursing and deemed appropriate. Implementation of staff re-education on elopement policy and procedure. No staff worked or cared for residents until they received education including those on FMLA or on vacation. Included in the education was review of the policy and visualization of residents during outside activities and all residents return into the facility upon conclusion of activity. All residents residing in facility were reassessed for elopement risk with plan of care updated as necessary by Director of Nursing/Designee. The Director of Nursing/Designee reviewed all Elopement books and updated with any changes identified from the reassessment of residents. On 6.19.18 Elopement drills conducted at various times during the 24 hour period. Elopement drills have been conducted on a quarterly basis at various times. Element #3 On 6.19.18 Continued education of staff regarding elopement, abuse and neglect, visual awareness during activities outdoors, and rounds between shift changes. No staff worked or cared for residents until they received the education. Continuous monitoring implemented for Resident #901 upon return to the facility, including room change to across nurse's station. Review of facility policy and procedure for elopements and routine checks completed by Administrator and Director of Nursing. All residents at risk for elopement are monitored by staff, by completing a visual check of each resident at a minimum of every two hours. Element # 4 On 6.19.18 Review of all residents for elopement risk was conducted by Director of Nursing/Designee. Review of binders for elopement risk residents to ensure accuracy by Director of Nursing/Designee. Visual proximity for all residents during outdoor activities, including all residents return into facility upon conclusion of outdoor activity Visual checks to verify all residents, who are at risk for elopement, are accounted for at minimum every two hours. Director of Nursing/Designee to monitor. On 6.20.18 Review of plan and policy/procedure completed by Quality Assurance and Process Improvement Committee was completed by QAPI team members. On 6.21.18 Visual checks to verify all residents, who are at risk for elopement, are accounted for at a minimum of every 2 hours and at shift change. The DON will be responsible to maintain compliance. All reviews and findings will be reviewed monthly at the facility quality assurance and process improvement meetings. The Administrator is responsible for maintaining compliance. Element #5 The Administrator is responsible for maintaining compliance.

This citation has two deficient practices Deficient practice #1: Based on observation, interview and record review, the facility failed to ensure staff adequately supervised one (#613) resident with a history of falls of five residents reviewed for falls from a total of 22 sampled residents, while he was in the back dining room resulting in two unwitnessed falls that resulted in a laceration above the left eye, a posterior fifth rib fracture, and pain. Findings include: On 11/12/14 at 2:30 A.M., Resident #613 was observed sitting in the first floor back dayroom in a high-back wheelchair with self-release seatbelt. Bruising (fading/dark) was observed on the left side of the face. Resident # 613 was asked about the bruising on his face; however, was unable to say what caused the bruising. On 11/13/14 at 9:00 A.M. Resident #613's clinical record was reviewed and indicated the resident was admitted on [DATE] and [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) resident assessments, dated 7/08/14 and 10/18/14 described Resident #613 had "moderately impaired" cognitive skills for daily decision making and required total physical assistance of two staff members for transfers and total physical assistance from one staff member for bed mobility, dressing, eating, hygiene and bathing. Two "Fall Assessment" reports, dated 7/04/14 and 9/12/14 were reviewed and Resident #613 scored 26 and 29 respectively. (According to the Fall Assessment document, a score of 16 or more indicated risk of falling). A plan of care for falls (dated 10/23/13) identified that the resident was "at risk" for falls and injury due to decreased mobility and history of seizures. The care plan goal: "Resident will not sustain and serious injury". Interventions included: To provide close supervision, appropriate footwear and use of bed and wheelchair alarm. During review of the Nursing Notes on 11/13/14 at 9:00 a.m., it was revealed Resident #613 had a fall incident on 9/11/14 at 3:00 P.M. and the nurse documented: "Called to back of dining room by certified nurse aide (CNA) observed resident lying on the floor on left side, head on floor. Upon exam noted small amount of blood on the left side of head above left eye, VS (vital signs) 129/80 (blood pressure), 93 (pulse), 20 (respiration), pupils reactive to light and resident verbally responsive. States he had slight pain to left side of head above eye. Obtained physician order [REDACTED]." The radiology report dated 9/11/14 at 2:30 p.m. was reviewed and revealed there was no acute fracture. The Incident Report for the fall event that occurred on 9/11/14 was requested from the Director of Nursing (DON) on 11/13/14 at 10:00 A.M. On 11/14/14 at 10:00 A.M., Employee 'O' (the In-service Educator) stated, "I cannot find anymore incident reports for the resident. I know I had one dated 9-11-14, but I cannot find it." On 11/13/14 at 3:00 P.M., Licensed Practice Nurse, employee 'C' (who was identified as an employee who worked with the resident) was interviewed about the fall incident that occurred on 9/11/14 and stated, "I remember, it was on a Thursday and a lot of staff was standing in the back day room. I had just come in to work afternoon shift. He (resident #613) was on the floor. I ran to see. The resident had a habit of attempting to stand without assistance. He has paralysis to one side and has to be watched and monitored at all times. He leans and slides out the wheelchair. He has a personal monitor alarms that goes off if he moves, Nurse (employee 'B') was the day shift nurse" (on 9/11/14--the day of the fall). On 11/13/14 at 3:15 P.M., Licensed Practice Nurse, employee 'B' (who was identified as the nurse responsible for the resident's care that day) was interviewed. He stated, "I completed the nurse notes (dated 9/11/14 at 3:00 P.M.) and an incident report . It was during shift change and people were moving around. I was called to the back day room by a CNA (not sure who). The resident (Resident #613) was observed on the floor with a small amount of blood noted to left side of head/eye, vital signs were checked with complaint of pain, verbally responsive, doctor called and ordered skull x-rays with neurological checks initiated. When questioned about corrective measures put in place he stated, "It's our procedure that someone should be in the day room to monitor residents at all times due to falls and safety issues." On 11/14/14 at 1:20 P.M. the In-service Director, employee 'O' was interviewed about the fall event that occurred on 9/11/14. She stated, "It was found that the alarm had not been on the resident (Resident #613). I educated the CNA on following the appropriate procedures. She claims she did not know the resident had an alarm. The aide was educated on ensuring that the resident had appropriate assistive devices in place. A review of the personnel record for the CNA revealed that she was hired 7/22/14 and terminated 10/30/14 due to attendance issues. A review of the in-service training dated 9/12/14 noted that "resident safety and safety devices for resident #613, who sustained a fall when the ordered wheelchair alarm wasn't in place. The CNA was re-educated on assuring that residents have proper safety devices in place as ordered. If unfamiliar with a resident/unit, assess ADL (activity of daily living) sheet and/or consult with the charge nurse." On 11/13/14 at 9:00 A.M. Resident #613's clinical record was reviewed. According to a nursing note dated 10/5/14 at 7:00 P.M., Resident #613's fall was not witnessed by facility staff, as the nurse documented, "Called to the back dining room by resident (supplemental resident #33), observed resident (#613) lying on his left side with alarm attached to the resident no signs or symptoms (s/s) of acute distress noted, left side of resident's face was red, no bleeding, abdomen bruised, vital signs (vs) obtained 156/71 blood pressure, 100 pulse , 20 respiration, 98 temperature. No s/s of seizure noted. The resident denies pain no changes in loc (level of consciousness), resident verbally responsive. The physician and resident's responsible party was informed of incident." The physician ordered x-rays (radiology report). The radiology report dated 10/06/14 was reviewed. Reason: shoulder contusion/bruise, chest contusion and hip contusion/bruise. Conclusion: Left posterior fifth rib fracture. The Incident Report for the fall that occurred on 10/05/14 was requested from the Director of Nursing (DON) on 11/13/14 at 10:00 A.M. On 11/13/14 at 2:00 P.M., the DON provided the incident report for the fall that occurred on 10/05/14 at 7:00 P.M. The Incident report was reviewed and noted to be consistent with the Nursing Progress note of 10/05/14. The resident slid from wheelchair, bruising noted to left ear and left abdomen area. Corrective measures taken: placed in bed with alarm in place, to be evaluated by Occupational the physical therapy (OT/PT). On 11/13/14 at 2:40 P.M., certified nurse aide, employee 'P', who was identified as Resident #613's care-giver on 10/5/14, was interviewed by phone about the fall incident. She stated, "I was assigned (10/5/14), but I was not in the back day room (staff were putting residents to bed) when a resident ( resident #33) came to me and the nurse (at nurse desk) and said that a resident (#613) had slid out his chair. We went to the day room. The nurse assessed and we got the resident up with (mechanical lift) and put him into bed." When asked if the resident had injuries or had been left alone in the back day room, employee 'P' stated, "I did not see injuries. It's normal for residents not to be left alone in the back dayroom." On 11/14/14 at 10:30 A.M., Licensed Practice Nurse, employee 'Q' (who was on duty 10/5/14 on the afternoon shift on the day of the 10/5/14 fall incident) was interviewed. She stated, "I was at the nursing desk when resident (resident #33) called my name. He was exiting the first floor dining room area. He said, 'I need you.' I responded and observed that resident (#613) was on the floor and had slid out his wheelchair. I called for an aide to assist. I assessed the resident and noticed his ear and left side of face was red. He was lifted off the floor with a (mechanical lift) and placed in bed. I completed the incident report and monitored." When asked if the nursing staff had been monitoring residents left in the back dining room, the nurse stated, "We normally have one aide monitoring the dining room, but no one was there. The resident was in the dining room at table with alarm. I heard it sounding as the resident (resident #33) exited the dining room to inform me." Resident #33 (witness to the fall event on 10/5/14) was interviewed, on 11/14/14 at 12 noon. He stated, "He (resident #613) was sitting in his chair and went to sleep. He leaned over in chair-- falling forward--head first...I went to the nursing station for help." Resident #33's clinical record was reviewed on 11/14/14 at 1:00 P.M. and the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE], noted cognitive skills that were moderately impaired. The resident was oriented and able to recall the incident (dated 10/5/14). On 11/14/14 at 1:30 P.M., the Director of Nursing was interviewed about the two unwitnessed fall events for Resident #613 (9/11/14 and 10/5/14) and stated, "Someone should be in the dayrooms at all times to monitor residents at risk for falls and safety concern." When further queried about who was responsible to ensure residents at high risk for falls were monitored, there was no reply. The facility was asked (11/13/14 at 9:00 A.M.) for a policy on fall prevention. On 11/14/14 a policy titled "Incident Reports" dated 4/96, was received and reviewed. "Any resident who sustains a fall must have an incident report completed by nurse...etc. No additional information policy related to fall prevention was provided prior to exiting the facility. ( ) Deficient practice #2 Based on observation, interview and record review, the facility failed to ensure cigarette lighters were stored safely, and failed to provide adequate supervision for two sampled Residents (#'s 614 and 619) of four residents reviewed for smoking from a total of 21 residents who currently smoked and residing at the facility, resulting in the risk of unsupervised smoking, accidental fire in the facility and potential for residents to burn themselves. Findings include: On 11/12/14 at 4:15 p.m., Resident #614 was observed sitting in the dining room holding a pack of cigarettes and a lighter. Resident #614 then stood and proceeded to exit the facility's front door unaccompanied by staff. Resident #614 had the cigarettes and lighter in his hand as he exited the facility. On 11/12/14 at 4:20 p.m., Licensed Practical Nurse (LPN "C") was questioned about Resident #614's smoking habits. When asked who provides the residents with cigarettes and lighters, LPN "C" reported, "Usually the Activity department gives them their cigarettes." When asked if Resident #614 was to be outside unattended and unsupervised while smoking, LPN "C" reported, "He does go outside to smoke." LPN "C" then walked away and towards her medication cart. When asked if she was going to assess Resident #614's whereabouts as he was observed with cigarettes and a lighter, LPN "C" reported, "They (Resident #614) usually just go out front down a ways from the building." LPN "C" initially just stood at her medication cart and then walked outside to look for Resident #614. LPN "C" walked back into the facility moments later, followed by Resident #614. LPN "C" replied, "He (Resident #614) wasn't even smoking." When asked if the cigarettes and lighter had been retrieved from Resident #614, LPN "C" offered no response and returned to her medication cart. On 11/12/14 at 4:32 p.m., the Director of Nursing (DON) was interviewed and reported, "Residents are not to have cigarettes and lighters on their person. Regarding Resident #614, you can't make that man do nothing. We're still trying to figure out where he gets cigarettes from and he is not his own responsible party. He has a guardian but he signs his own self out LOA (leave of absence) to go out and smoke." The DON approached Resident #614 to inquire if he had cigarettes and lighter on his person. Resident #614 stated that he had cigarettes and a lighter, but did not give them to the DON. Resident #614 then looked at another resident sitting across from him and stated, "Kiss my ass!" The DON stated, "I asked Resident #614 for the cigarettes and lighter but he claimed he didn't have them on him. He claimed he put them in his room." The DON instructed LPN "C" to approach Resident #614 to see if he would relinquish the cigarettes and lighter to her. LPN "C" replied, "I already asked him when he was outside. You want me to ask him again? I thought we weren't suppose to keep asking them (Residents). LPN "C" then adjusted items on top of her medication cart and walked over to Resident #614. Resident #614 then stood to walk to his room followed by LPN "C". On 11/12/14 at 4:50 p.m., the DON reported, LPN "C" got the cigarettes and a lighter from him. The Administrator has them." On 11/13/14 at 1:30 p.m., during a follow up interview, the DON reported, "We do sweeps and if residents are seen with cigarettes, they would be given to the nurse." When asked to provide a schedule or documented evidence that sweeps were regularly performed, the DON stated, "We don't document anything." On 11/13/14 at 2:50 p.m., Resident #614 was observed sitting in the dining room during an activity session. When greeted, Resident #614 was cordial and smiled. When asked about the incident where smoking paraphernalia was taken from him, Resident #614 reported, "Oh, yea, they took my cigarettes for now. They (facility staff) said not to go outside to smoke by myself today and tomorrow because they said The State is here. They said somebody has to go outside with me when I smoke and then when y'all leave, I can go back outside by myself to smoke." On 11/13/14 at 3:00 p.m., a review of the clinical record revealed the following: Resident #614 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed that Resident #614 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of "13" and was independent with ambulation. The "Admission Record" dated 11/12/14 revealed that Resident #614 had an appointed guardian. A "Smoking Risk Assessment" dated 9/26/14 documented, "Safe smoker. Monitor on facility safe smoking program." "Nursing Notes" reviewed documented: 10/11/14 "Resident was limping as he went out to smoke." 10/18/14 "Resident out at 5:00 a.m. to smoke." 10/21/14 5:25 a.m., "Resident signed out LOA." 10/26/14 6:00 a.m., "Signed out LOA." 10/27/14 6:00 a.m., "Signed out LOA." 11/11/14 and 11/12/14 "Signed out LOA." There was no documented evidence in the clinical record that Resident #614 had been supervised by staff during LOA. A Nursing Note dated 11/12/14 written by LPN "C" documented, "This writer was asked to ask Resident if he has any cigarettes to give them to this writer which the Resident did give up 2 half packs of cigarettes and a lighter." A "Resident non-compliant with care" care plan dated 9/26/14 documented, "Resident leaves the building unauthorized and refused to give up cigarettes at times. Goal: Resident will not smoke in unauthorized rea and will not leave the building at least one time weekly." The care plan made no mention of any interventions which required staff supervision and monitoring of unauthorized paraphernalia in light of Resident #614's history of non-compliance in order to ensure the safety of Resident #614 and other residents who resided at the facility. On 11/13/14 at 1:50 p.m., Resident #619 was observed in his room at the facility clean dressed and well groomed lying on top of his made bed. Resident # 619 was queried as to whether he smoked and replied, "Yes, I can go out and smoke myself." When asked where he gets his cigarettes he states "I keep them in my coat pocket. I have cigarettes in my drawer." Resident #619 opened the top drawer of his bedside table and three unopened packs of cigarettes were observed in the drawer. When asked what items he had in his coat he stated "my cigarettes and a lighter. I ask the Nurses' if I can go out and smoke and I go myself, or sometimes with the group. If the Nurse says it is ok I take the elevator and go outside to smoke." When asked if he was allowed to have cigarettes and lighters in his room Resident #619 stated, "Don't you go and get my cigarettes taken away now." During the conversation with Resident #619, Certified Nursing Assistant (CNA) Staff "H" was observed in the room assisting another resident. CNA "H" was observed a few minutes later leaving Resident #619's room with an open pack of cigarettes, a lighter and three unopened packs of cigarettes. The items were given to Nurse "G". On 11/13/14 at 1:55 p.m., CNA "H" stated Resident #619 signs out and goes outside to smoke or he will go out with the group. He knows he is not suppose to have them (cigarettes and lighter) in his room. I took them. They (Staff) are suppose to do that (remove smoking paraphernalia) on midnights." On 11/13/14 at 2:00 p.m., Resident #619's clinical record was reviewed and the revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum data set assessment dated [DATE], Resident # 619 was cognitively intact, independent for transfer and bed mobility, and supervision of zero staff for ambulation. The admission nursing assessment dated [DATE], documented Resident #619 was a smoker. A review of the assessment and care plan section of the clinical record revealed no assessments or care plans related to smoking. On 11/13/14 at 2:45 p.m., Nurse "G" stated, "He (Resident #619) is a smoker, I take him out myself sometimes. He knows he is not suppose to have cigarettes in his room. He doesn't go out to smoke on his own. He goes down the elevator himself, then out with staff. I have never told him he could go out unassisted or seen him out by himself smoking. All Resident's who smoke are supervised." Nurse "G" was informed that no smoking assessment or care plan could be found in the clinical record. Nurse "G" reviewed the clinical record for Resident #619 and stated, "No, they aren't here. They should have been done on admission." On 11/13/14 at 2:55 p.m., The facility Director of Nursing (DON) was queried regarding Resident #619's smoking paraphernalia in his room and lack of assessment and care plan related to smoking. The DON stated, "He (Resident #619) is a smoker and he is very non-compliant. We did a sweep last night about 7:00 p.m., and he said he didn't have any, I looked in his drawers, he wouldn't allow us to look in his cabinet. He doesn't go out to smoke by himself. Activity staff takes him out to smoke. He hasn't been a problem since he was readmitted . We do weekly sweeps every Wednesday and ask residents if they have and cigarettes or lighters. They are not allowed to have them. The smoking assessment and care plan should be in the chart." When queried about documentation of sweeps for smoking paraphernalia the DON denied the sweeps were documented. On 11/13/14 at 2:35 staff nurse "K" who cared for Resident #619 stated "I never saw him (Resident #619) out smoking himself without supervision." On 11/14/14 at 11:30 a.m., the facility Activity Director Staff "I" stated, " I take him out when he asks. I never saw him smoking without staff or unsupervised. We do not have scheduled smoking times. Residents ask staff and then are taken out to smoke with staff." Observations during the onsite survey from 11/12/14 to 11/14/14 did not reveal any Residents requesting to go outside to smoke or seen outside smoking. On 11/14/14 at 2:30 p.m., the facility protocol titled "Resident Smoking" dated 2003, was reviewed and documented the following: "This is a smoke free facility. However, residents may smoke outside with supervision during designated times." The Policy titled "Smoking Policy" undated, documented "Attention smoking Residents, family members and Guardians: (Facility name) does allow residents to smoke but due to the smoking law that was passed in May of 2010, Residents that wish to smoke must do so outside of the building abiding within the guidelines stated in the smoking law. Please be advised that with this new policy any outdoor smoking will be allowed only when the weather permits, and if, the resident is dressed appropriately and must be supervised by staff. Residents are not allowed to possess any fire accelerants such as lighters, matches, mini-torches, or any other device or substance that produces heat and/or flame. All smoking material, including lighters and matches must be given to the Charge Nurse."

This citation has two deficient practices. Deficient practice #1: Based on observation, interview, and record review the facility failed to adequately supervise one resident (#310) while he was dressing, of eight residents reviewed for falls from a total sample of 21 residents resulting in an avoidable fall and hip fracture. Findings include: On 10/23/13 at 8:25 a.m. resident #310 was observed being transferred from wheelchair to bed with assistance of two nursing aides. Resident #310 was then observed lying in bed with a scarred and scabbed wound on his outer right hip. A review of the clinical record on 10/23/13 at 10:27 a.m. revealed that resident #310 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His original admission minimum (MDS) data set [DATE] revealed that resident #310 was totally dependent and required extensive physical assistance from staff for dressing and ambulation, and limited assistance of one person for transferring from wheelchair to bed. The minimum data set also revealed resident #310 was moderately cognitively impaired. On 10/23/13 at 11:00 a.m. a review of the incident report dated 8/27/13 at "approximately 6:30 a.m." indicated that resident #310 fell while "getting dressed--attempting to put on pants--lost balance and fell to the floor. CENA (certified nursing assistant) assisted resident from floor, resident at first denied pain, upon returning to room, CENA noticed resident in bed wincing in bed, not responding in usual manner." On 10/24/13 at 10:30 a.m. a review of the fall assessment completed on 7/24/13 indicated that resident #310 was at risk for falls having scored points for incontinence of bowel and bladder, and "unable to independently come to a standing position, loses balance while standing, requires hands-on assistance for ambulation." Per interview with the Therapy Facility Manager and record review on 10/24/13 at 11:00 a.m. review of the "Physical Therapy Progress Report" with service dates from 8/6/13 to 8/26/13 indicated that resident #310 progressed to needing minimal physical assistance with transferring, meaning someone needed to be present during transfers giving safety cues. On 10/24/13 at 11:00 a.m. a review of the "Occupational Therapy Progress Report" dated 7/29/13 to 8/14/13 with the Physical Therapy Facility Manager and Certified Occupational Therapy Assistant indicated that resident #310 needed minimal assistance with lower body dressing interpreted by the Physical therapy Manager and COTA meaning someone needed to be present to hand clothes to resident, give directions, and provide safety cues. On 10/25/13 at 12:55 p.m. a review of the nursing note dated 8/27/13 at 2:00 p.m. indicated that xray results from the fall on 8/27/13 revealed the resident sustained [REDACTED]. During an interview on 10/25/13 at 9:25 a.m. Certified Nursing Assistant (K) (CNA) said that resident #310 was trying to put his pants on and that's why he fell , he was sitting on the edge of the bed and fell . "I wasn't in the room at the time, I was making my rounds. Clothes may have been on his bed or chair." "Roommate came out and said he was on the floor...I helped him off the floor, took his pants off and I reported to the nurse." Certified Nursing Assistant (K) said she did not tell the night shift nurse that resident fell because the night shift nurse already knew by the roommate coming out of the room and yelling for help and that the day shift nurse was informed of the fall. During an interview on 10/24/13 at 11:40 a.m. Licensed Practical Nurse (LPN) (F) indicated that CNA (K) told her the resident fell on her way out the door, about 7:00 a.m. LPN (F) stated that when she went to see the resident to assess him, he was already in bed. LPN (F) said she assessed the resident at approximately 7:04 a.m., after the CNA working days shift with her told her resident was in pain. During an interview on 10/24/13 at 9:50 a.m. LPN (L) stated that she did not know resident #310 had a fall, that she thought the roommate was yelling at resident #310. LPN (L) also stated that CNA (K) got resident #310 dressed and took him to the dining room after the incident of the yelling roommate. On 10/25/13 at 10:00 a.m. a review of typed document dated 8/27/13 provided by the adminstrator indicated that the Certified Nursing Assistant reported that she left he room to get resident #310 a pair of socks and the roommate was yelling...observed the resident on the floor...and assisted resident back to bed and went to locate the nurse," instead of letting the nurse assess the resident before moving. On 10/25/13 at 10:15 a.m. a review of the document titled: "Protocol: Falls Prevention," dated 2012, indicated that care planning for fall risk residents is individualized. On 10/25/13 at 10:15 a.m. a review of the care plans for resident #310 before the fall did not indicate any interventions regarding dressing and assistance needed for resident #310. A review of the policy titled "Incident Reports" dated 4/96 provided when a post falls policy/procedure was requested did not indicate that a nurse should assess a resident before moving a resident after a fall. During an interview on 10/25/13 at 9:45 a.m. Nurse Supervisor (B) indicated that the expectation is to get a nurse to assess the resident before moving the resident after a resident falls. ( ) Deficient Practice #2: The facility failed to secure oxygen tanks in safe manner in one of two oxygen tank storage areas resulting in the potential for tank to fall and act as a projectile. Findings include: During a tour of the environment with the Maintenance and Housekeeping Supervisors on 10/23/13 at 11:50 a.m. an empty oxygen cylinder was found standing behind the nurses station without the support of a oxygen cylinder holding rack. ( ) Deficient practice #2

THIS CITATION PERTAINS TO INTAKE # MI 678 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MAINTAIN ACCEPTABLE PARAMETERS OF NUTRITION IN 2 OF 4 RESIDENTS (RESIDENT #102 AND RESIDENT #105) SAMPLED FOR NUTRITION, FROM A TOTAL OF 6 SAMPLED RESIDENTS, RESULTING IN SIGNIFICANT WEIGHT LOSS FOR BOTH RESIDENT #102 AND RESIDENT #105 AND THE POTENTIAL FOR ONGOING NUTRITIONAL COMPROMISE, AND DECLINING MEDICAL CONDITIONS ASSOCIATED WITH [MEDICAL CONDITION]. FINDINGS INCLUDE: RESIDENT #102 REVIEW OF THE FACE SHEET DATED 1/16/2013, REVEALED RESIDENT #102 WAS AN [AGE] year OLD MALE admitted TO THE FACILITY 1/11/2012, REadmitted [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #102 HAD COGNITIVE IMPAIRMENTS, A PRESSURE ULCER, RECENT SIGNIFICANT WEIGHT LOSS, AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE EXTENSIVE ASSISTANCE WITH EATING. REVIEW OF THE "MENTAL ILLNESS/MENTAL [MEDICAL CONDITION]/RELATED CONDITION" FORM DATED 10/18/2012 REVEALED RESIDENT #102 HAD DEMENTIA. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE HISTORY AND PHYSICAL DATED 10/01/2012 REVEALED RESIDENT #102 WAS AT RISK FOR SKIN BREAKDOWN AND HISTORICALLY CONSUMED LITTLE FOOD, RESULTING IN FAILURE TO THRIVE. REVIEW OF THE NUTRITIONAL assessment dated [DATE], REVEALED THE IDEAL BODY WEIGHT RANGE FOR RESIDENT #102 WAS 166 TO 202 LBS (POUNDS), THOUGH HE ONLY WEIGHT 91 LBS. ADDITIONALLY, DIETARY DOCUMENTED RESIDENT #102 WAS EMACIATED, WITH NO OPEN SKIN, HE ATE INDEPENDENTLY, REQUIRED SET UP ASSISTANCE WITH HIS TRAY, MAGACE AND CONTINUED DIETARY MONITORING. REVIEW OF THE CARE PLANS DATED 10/2012, 11/2012, 12/2012, 1/2013, 2/2013, AND 3/2013 FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST A NUTRITIONAL CARE PLAN HAD EVER BEEN DEVELOPED FOR RESIDENT #102. REVIEW OF A COMMUNICATION FORM BETWEEN THE CONSULTING DIETITIAN AND ATTENDING PHYSICIAN DATED 10/01/2012, REVEALED DIETARY SUGGESTED RESIDENT #102 BE PLACED ON A "REGULAR" DIET "WITH 8 OZ (OUNCES) MEDICATION PASS AND ONE SCOOP OF PROTEIN PLUS THREE TIMES DAILY " WITH THE PHYSICIAN SIGNING IN AGREEMENT 10/11/2012. HOWEVER, DESPITE THE AGREEMENT BETWEEN THE TWO SPECIALISTS, THE ORDER WAS NOT IMPLEMENTED FOR 13 DAYS. REVIEW OF NURSING NOTES BETWEEN 10/01/2012 AND 10/14/2012 REVEALED RESIDENT #102 ROUTINELY CONSUMED AT LEAST 75% (PERCENT) OF HIS MEALS BEFORE BEING SENT TO THE HOSPITAL 10/14/2012 WITH SHORTNESS OF BREATH. REVIEW OF REadmission orders [REDACTED]. REVIEW OF NURSING ADMISSION NOTES DATED 10/18/2012 REVEALED RESIDENT #102 WEIGHED 103 LBS, AND HAD A SIGNIFICANT WEIGHT GAIN OF 12 LBS IN LAST 18 DAYS. DESPITE THE INFECTION, DISCONTINUED APPETITE STIMULANT, DIET CHANGE AND SIGNIFICANT WEIGHT GAIN, REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST, DIETARY EVER REASSESSED RESIDENT #102. REVIEW OF ORDERS DATED 10/24/2012 REVEALED RESIDENT #102 WAS ORDERED 8 OZ (OUNCES) OF MEDICATION PASS 2.0 (A NUTRITIONAL SUPPLEMENT) THREE TIMES DAILY. REVIEW OF THE MEDICATION ADMINISTRATION RECORDS BETWEEN 10/24/2012 AND 3/20/2013 FAILED TO DOCUMENT THE ADMINISTRATION OF THIS ORDERED NUTRITIONAL SUPPLEMENT. REVIEW OF WEIGHTS DATED 11/13/2012 REVEALED RESIDENT #102 WEIGHED 109 LBS, WITH A DOCUMENTED GAIN OF 18 LBS IN THE PAST 43 DAYS. DESPITE THE SIGNIFICANT WEIGHT GAIN, REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST, DIETARY EVER REASSESSED RESIDENT #102. REVIEW OF WEIGHTS DATED 12/03/2013 REVEALED RESIDENT #102 WEIGHED 100 LBS, WITH A DOCUMENTED LOSS OF 9 LBS IN THE LAST 20 DAYS. REVIEW OF THE MEDICAL RECORD FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST, DIETARY EVER REASSESSED RESIDENT #102. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE MEDICAL RECORD REVEALED NO DOCUMENTED EVIDENCE TO SUGGEST, DIETARY EVER REASSESSED RESIDENT #102. REVIEW OF NURSING NOTES DATED 2/25/2013 REVEALED RESIDENT #102 HAD DEVELOPED A PRESSURE ULCER ON HIS COCCYX. REVIEW OF ORDERS DATED 2/25/2013 REVEALED RESIDENT #102 HAD BEEN admitted TO HOSPICE AND REQUIRED A REGULAR DIET WITH 1:1 FEEDING ASSISTANCE. REVIEW OF WEIGHTS DATED 3/03/2013 REVEALED RESIDENT #102 ONLY WEIGHED 94 POUNDS, A 15 POUND WEIGHT LOSS IN LESS THAN FIVE MONTHS. DURING OBSERVATIONS 3/20/2013 BETWEEN 12:30 P.M. AND 1:30 P.M., RESIDENT #102 WAS OBSERVED SITTING IN THE FIRST FLOOR DINING ROOM NEAR THE FRONT DOOR, WITH HIS EYES CLOSE. WHEN THE SURVEYOR SPOKE WITH RESIDENT #102 HE AROUSED EASILY, SPOKE A FEW WORDS AND WENT RIGHT BACK TO SLEEP. WHEN MEAL TRAYS CAME AT APPROXIMATELY 1:00 P.M., STAFF PASSED RESIDENT #102 HIS TRAY, OPENED THE LIDS, AND WALKED AWAY WITHOUT AROUSING HIM FROM SLEEP, OR PROVIDING ANY ADDITIONAL FEEDING ASSISTANCE. AT 1:30 P.M., CERTIFIED NURSING ASSISTANT (CENA) #1 APPROACHED RESIDENT #102 ASKED IF HE WAS DONE WITH HIS FOOD TRAY, AND RECEIVED NO RESPONSE FROM THE SLEEPING RESIDENT BEFORE SHE WITHDREW THE TRAY FROM THE TABLE FOR DISPOSAL. WHILE CENA #1 REMOVED THE TRAY, AN UNIDENTIFIED MALE SITTING AT THE SAME TABLE SAID "HE HASN'T TOUCHED IT". CENA #1 LOOKED AT THE CONCERNED CITIZEN, SAID NOTHING AND DISPOSE OF THE FOOD. DURING AN INTERVIEW 3/20/2013 AT 1:40 P.M., CENA #1 SAID 100% OF THE FOOD AND FLUIDS PROVIDED ON RESIDENT #102'S LUNCH TRAY REMAINED PRESENT WHEN SHE REMOVED IT FROM THE TABLE. WHEN ASKED WHY SHE REMOVED THE TRAY BEFORE WAKING HIM AND/OR ASSISTING HIM TO EAT, CENA #1 SAID, "HE EATS ON HIS OWN." DURING AN INTERVIEW 3/22/2013 AT 2:15 P.M., DON #1 (DIRECTOR OF NURSING #1) FAILED TO EXPLAIN HOW NURSING STAFF ENSURED RESIDENT #102 MET HIS NUTRITIONAL REQUIREMENTS WITHOUT A CARE PLAN. DON #1 COULD NOT EXPLAIN WHY CENA #1 HAD NOT FOLLOWED THE PHYSICIANS ORDER FOR ONE TO ONE FEEDING ASSISTANCE. DURING AN INTERVIEW 3/22/2013 AT 2:35 P.M., DM #1 (DIETARY MANAGER #1) SAID ALL RESIDENTS WITH FAILURE TO THRIVE AS A [DIAGNOSES REDACTED]. DM #1 THEN REVIEWED THE MEDICAL RECORD FOR RESIDENT #102 AND SAID "IT WAS AN OVER SITE" BY DIETARY THAT RESIDENT #102 WAS NEVER REASSESSED AFTER 10/01/2012. DM #1 THEN EXPLAINED THE NUTRITIONAL SUPPLEMENT ORDERED THREE TIMES DAILY FOR RESIDENT #102 WAS POURED BY DIETARY IN THE KITCHEN, AND SENT ON ASSIGNED MEAL TRAYS FOR CONSUMPTION. DM #1 COULD NOT EXPLAIN HOW THE FACILITY ENSURED THE ORDERED NUTRITIONAL SUPPLEMENT HAD BEEN CONSUMED BY THE APPROPRIATE RESIDENT. RESIDENT #105 REVIEW OF THE FACE SHEET DATED 3/14/2013 REVEALED RESIDENT #105 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 1/04/2013, REadmitted [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MDS dated [DATE] REVEALED RESIDENT #105 HAD IMPAIRED COGNITION, RECEIVED A THERAPEUTIC DIET, ATE INDEPENDENTLY, AND DEMONSTRATED NO EVIDENCE OF RECENT WEIGHT LOSS. REVIEW OF WEIGHTS FOR 1/06/2013 REVEALED RESIDENT #105 WEIGHED 108 LBS. REVIEW OF REadmission orders [REDACTED]. REVIEW OF WEIGHTS FOR 3/04/2013 REVEALED RESIDENT #105 WEIGHED 99 LBS, A LOSS OF 9 LBS IN LESS THAN 2 MONTHS. REVIEW OF THE MEDICAL RECORD BETWEEN 3/04/2013 AND 3/20/2013 FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST THE FACILITY COMPLETED A DIETARY ASSESSMENT. REVIEW OF CARE PLANS DATED 3/2013 FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE TO SUGGEST STAFF EVER DEVELOPED A NUTRITIONAL CARE PLAN FOR RESIDENT #105. DURING AN INTERVIEW 3/22/2013 AT 2:15 P.M., DON #1 (DIRECTOR OF NURSING #1) FAILED TO EXPLAIN HOW NURSING STAFF ENSURED RESIDENT #105 MET HER NUTRITIONAL REQUIREMENTS WITHOUT A CARE PLAN. DURING AN INTERVIEW 3/22/2013 AT 2:35 P.M., DM #1 (DIETARY MANAGER #1) SAID ALL RESIDENTS WITH DIABETES REQUIRED ROUTINE, ONGOING DIETARY ASSESSMENTS TO MANAGE THEIR NUTRITIONAL STATUS. DM #1 REVIEWED THE MEDICAL RECORD FOR RESIDENT #105 AND SAID "IT WAS AN OVER SITE" THIS RESIDENT WAS NEVER SEEN BY DIETARY AFTER HER ADMISSION 3/04/2013. DM #1 COULD NOT EXPLAIN THE FACILITY'S PRACTICE TO ENSURE DIETARY CONSULTS FOR RESIDENTS admitted AND/OR readmitted .

THIS CITATION PERTAINS TO INTAKES: MI 691 AND MI 702 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PREVENT THE PHYSICAL ABUSE OF 1 (RESIDENT #103) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR ABUSE FROM A TOTAL SAMPLE OF 4 BY ANOTHER RESIDENT (#104), RESULTING IN INJURY WHEN RESIDENT #104 ASSAULTED RESIDENT #103, RESULTING IN INJURY TO RESIDENT #103. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 10/22/12 AT 1:05 A.M., RESIDENT #104 GRABBED RESIDENT #103 AROUND THE NECK AND PUNCHED HIM IN THE FACE AFTER RESIDENT #103 ACCUSED HIM (RESIDENT #104) OF STEALING HIS CLOTHES. THE RESIDENTS WERE SEPARATED AND RESIDENT #103 WAS SENT OUT TO THE HOSPITAL FOR EVALUATION AND TREATMENT. ACCORDING TO THE HOSPITAL RECORDS DATED 10/22/12 AT 3:00 A.M., RESIDENT #103 WAS diagnosed with [REDACTED]. NO SURGICAL OR PHARMACEUTICAL INTERVENTION WAS PRESCRIBED. A MEDICAL RECORD REVIEW FOR RESIDENT #103 REVEALED THAT HE WAS A [AGE] year OLD MALE WHO HAD RESIDED AT THE FACILITY SINCE 6/27/12 WITH [DIAGNOSES REDACTED]. A REVIEW OF THE NURSING NOTES REVEALED THAT ON 9/26/12, ON 10/9/12 AND AGAIN ON 10/20/12, RESIDENT #103 WAS DESCRIBED AS HAVING AGGRESSIVE AND COMBATIVE BEHAVIORS WITH STAFF AND OTHER RESIDENTS THAT DID NOT RESULT IN ACTUAL PHYSICAL INJURY. ON 10/20/12, DURING THE AFTERNOON SHIFT, RESIDENT #103 ACCUSED HIS ROOMMATE (RESIDENT #104) OF STEALING HIS CLOTHING. THE ENSUING ARGUMENT RESULTED IN RESIDENT #104 BEING TEMPORARILY LOCATED TO ANOTHER ROOM. HOWEVER, ON 10/22/12 AT 1:00 A.M., RESIDENT #103 AND RESIDENT #104 WERE AGAIN IN THE SAME ROOM AND ANOTHER ARGUMENT BROKE OUT. THIS ARGUMENT RESULTED IN INJURY TO RESIDENT #103 WHEN HE WAS ASSAULTED BY RESIDENT #104 AND SUSTAINED A FRACTURED NOSE AND BRUISED EYE. DURING AN INTERVIEW ON 10/25/12 AT 2:55 P.M., LICENSED PRACTICAL NURSE (LPN) #9 SAID THAT ON 10/20/12, SOMETIME DURING THE AFTERNOON SHIFT, SHE BROKE UP AN ARGUMENT BETWEEN RESIDENT #103 AND HIS ROOMMATE, RESIDENT#104. RESIDENT #104 WAS MOVED INTO ANOTHER ROOM IN THE FACILITY. THERE WAS NO INJURY TO REPORT AND NO INCIDENT REPORT WAS COMPLETED. LPN #9 SAID SHE DID NOT COMPLETE THE PROCEDURE TO PERMANENTLY MOVE RESIDENT #104 TO THE OTHER ROOM BECAUSE 10/20/12 WAS A SATURDAY. LPN #9 SAID THAT ON 10/22/12 AT 1:00 A.M., RESIDENT #104 ENDED UP BACK IN HIS ORIGINAL ROOM WITH RESIDENT #103 AND A FIGHT BROKE OUT BETWEEN THE TWO RESIDENTS. LPN #9 SAID SHE BROKE UP THE FIGHT WITH THE ASSISTANCE OF THE LOCAL POLICE AND SENT RESIDENT #103 OUT TO THE HOSPITAL BECAUSE HE HAD A BLOODY NOSE AND SWOLLEN EYE. RESIDENT #104 DID NOT SUSTAIN ANY INJURY. LPN #9 COULD NOT EXPLAIN WHY RESIDENT #104 WAS BACK IN HIS ORIGINAL ROOM WITH RESIDENT #103, BUT SPECULATED THAT RESIDENT #104 MAY HAVE AUTOMATICALLY WENT BACK INTO HIS ORIGINAL ROOM AFTER HE WENT TO THE BATHROOM DURING THE NIGHT. DURING AN OBSERVATION AND INTERVIEW ON 10/23/12 AT 2:00 P.M., RESIDENT #103 WAS RESTING QUIETLY ON THE 2ND FLOOR OF THE FACILITY IN A PRIVATE ROOM. RESIDENT #103 DENIED ANY PAIN AND COULD NOT RECALL ANY INCIDENT OR ARGUMENT WITH ANOTHER RESIDENT. RESIDENT #103'S RIGHT EYE WAS SLIGHTLY SWOLLEN AND REDDENED. A MEDICAL RECORD REVIEW FOR RESIDENT#104 REVEALED THAT HE WAS A [AGE] year OLD MALE WHO HAD RESIDED AT THE FACILITY SINCE 12/29/09 WITH [DIAGNOSES REDACTED]. A REVIEW OF THE NURSING NOTES REVEALED THAT ON 9/25/12, ON 10/13/12, AND AGAIN ON 10/20/12, RESIDENT #104 HAD DISPLAYED AGGRESSIVE BEHAVIORS WITH STAFF AND OTHER RESIDENTS. ON 10/20/12, RESIDENT #104 WAS INVOLVED IN A VERBAL ARGUMENT WITH HIS ROOMMATE (RESIDENT#103), AND AS A RESULT OF THIS ARGUMENT, WAS RELOCATED TO ANOTHER ROOM. ON 10/22/12 AT 1:00 A.M., RESIDENT #104 WAS BACK IN HIS ORIGINAL ROOM WITH RESIDENT #103. DURING AN ARGUMENT WITH RESIDENT #103, RESIDENT #104 WAS OBSERVED TO GRAB RESIDENT#103 BY THE NECK AND PUNCH HIM IN THE FACE. RESIDENT #104 DID NOT SUSTAIN ANY INJURY. DURING AN OBSERVATION AND INTERVIEW ON 10/23/12 AT 3:00 P.M., RESIDENT #104 WAS RESTING QUIETLY IN HIS ROOM, WITHOUT ANY SIGNS OF INJURY. HE DID NOT COMPLAIN OF ANY PAIN AND DID NOT RECALL ANY INCIDENT OR ARGUMENT WITH ANOTHER RESIDENT. ON 10/24/12 AT 1:00 P.M., AND AGAIN ON 10/25/12 AT NOON, RESIDENT #104 WAS OBSERVED SEATED IN THE LUNCH ROOM WITH OTHER RESIDENTS EATING WITHOUT INCIDENT OR AGGRESSIVE BEHAVIORS. DURING AN INTERVIEW ON 10/23/12 AT 3:00 P.M., THE SOCIAL SERVICE TECHNICIAN (STAFF #4) SAID THAT BOTH RESIDENT #103 AND RESIDENT #104 HAD DISPLAYED AN INCREASE IN [MEDICAL CONDITION] ACTIVITY AND AGGRESSIVE BEHAVIORS IN THE PREVIOUS MONTH. STAFF #4 COULD NOT EXPLAIN WHY RESIDENT #103 AND RESIDENT #104 WERE NOT PERMANENTLY SEPARATED, OR EVALUATED FOR DISCHARGE PLANNING AFTER PATTERNS OF THEIR AGGRESSIVE BEHAVIORS WAS IDENTIFIED. DURING AN INTERVIEW ON 10/25/12 AT NOON, THE DIRECTOR OF NURSING (STAFF #2) REVIEWED THE REPEATED INCIDENTS OF AGGRESSIVE AND COMBATIVE BEHAVIORS BETWEEN RESIDENT #103 AND RESIDENT #104. STAFF #2 COULD NOT PROVIDE AN EXPLANATION AS TO WHY RESIDENT #104 WAS NOT PERMANENTLY MOVED FROM RESIDENT #103'S ROOM AFTER THE INCIDENT ON 10/20/12. ( )