Every finding on record at Valley View Care Center

This citation pertains to intake 3064222.Based on observation, interview, and record review the facility failed to ensure a sit-to-stand lift (mechanical mobility device that helps transition a resident from sitting to standing) was used correctly for 1 (Resident #1) of 3 residents reviewed for falls resulting in a fall, right femur (thigh bone) fracture (broken bone), increased pain, and a hospitalization to have a fracture surgically repaired.Findings include:Review of Resident #1 (R#1)'s admission Record, dated 7/14/26, indicated she had a responsible party (a designated individual acting on the resident's behalf)/Power of Attorney (POA; legal document that gives an individual authority to make decisions on behalf of someone else). R#1 had pertinent diagnoses of right femur (thigh bone) fracture, osteoarthritis (occurs when the protective tissue that cushions the ends of your bones gradually wears away), obesity, muscle weakness, and cognitive communication deficit (an impaired ability to speak, listen, read, write, or socialize). Review of R#1's fall investigation summary, undated, stated, Resident: (R#1).Incident Date/Time: 06/20/2026 at approximately 1845 (6:45 PM).Location: Resident Bathroom.Type of Incident: Assisted Lowering/Fall During Sit-to-Stand Lift Transfer.Resident (R#1) was involved in a witnessed assisted lowering to the floor during a transfer utilizing a sit-to-stand lift in the bathroom.the nurse observed the resident partially off the standing platform with the right knee resting on the platform and right foot on the floor while the left leg remained on the lift platform.Resident was alert but unable to explain the circumstances of the incident due to cognitive impairment. Assessment revealed complaints of right knee pain with movement, a superficial (on or near the surface) skin tear, and developing ecchymosis (bruise) to the right knee.Imaging (x-ray) revealed a displaced (bone fracture where the broken pieces are not aligned properly) distal (located away from the center of the body/point of attachment) right femur fracture with posterior (situated at or toward the back of the body) and lateral (away from the center/midline) displacement (bone not in its normal alignment) of the distal fracture.The assigned CNA (CNA J) reported that after assisting the resident to the toilet utilizing the sit-to-stand lift, the resident was cleaned and prepared for transfer back to bed. While exiting the bathroom, the resident began leaning to the left and her right leg started slipping from the platform. The CNA obtained assistance. Upon further review, the CNA stated the safety belt and shin/leg support buckle were not secured during the transfer.A second staff member reported arriving in the bathroom and observing the resident with one knee bent down while both arms remained on the lift.Investigation determined the incident occurred during a sit-to-stand lift transfer when the resident slipped from the lift platform. Review of witness statements identified that required safety devices, including the transfer belt and shin support buckle, were not secured during the transfer process.Resident was transferred to the hospital.Hospital imaging confirmed an oblique (a bone break that occurs diagonally) distal right femur fracture with posterior and lateral displacement.On 06/22/2026, resident (R#1) underwent surgical fixation with insertion of an intramedullary rod (metal device surgically inserted into a bone to stabilize/align a broken bone).Post-operative (after operation/surgery) management included pain control, blood transfusion.The investigation determined the resident's distal right femur fracture was sustained during a sit-to-stand lift transfer when the resident slipped from the lift platform.identified that required safety restraints and support buckles were not secured at the time of transfer.Review of Resident #1's #2996 Fall incident and accident report, dated 6/20/26, stated, .Date: 6/20/2026 18:45 (6:45 PM) .Incident Location: Resident's (R#1's) Bathroom .Witnessed assisted lowering to the floor. Resident slipped from sit-to-stand lift platform during transfer in bathroom. As an immediate intervention to prevent recurrence, staff will utilize all appropriate straps on the sit-to-stand lift while the resident is on the machine .endorsing pain to the right knee with movement. Skin tear and developing ecchymosis noted to right knee .Review of Certified Nurse Aide (CNA) J's witness statement (for R#1's 6/20/26 fall), dated 6/21/26, stated, .Moving out of the bathroom and the right leg was slipping. I ran to get CNA E. Got two nurses (Registered Nurses (RN) N and O). It was determined that it would take all of us to get her up .The belt around her (torso/trunk) was not snapped (utilized/secured). The leg/shin seat buckle was not snapped or buckled . Review of R#1's 6/20/26 Falls Assessment, dated 6/21/26, stated, Contributing factors .difficulty maintaining sitting balance .Difficulty maintaining standing position .Does the resident have any of the following internal risk factors? .Pain .Summarize the impact of this problem/need on the resident .This RN completed a post-incident analysis regarding Resident's slip from the sit-to-stand lift. The impact of this event includes impaired skin integrity and acute pain with right knee ROM (range of motion), which currently limits the resident's baseline mobility and safe transfer ability .Potential complications involve a right knee fracture pending X-ray results .and further functional decline secondary to pain. A root-cause-analysis (process to uncover underlying reasons behind a problem) indicates the fall occurred d/t (due to) a situational and procedural failure; specifically, the resident slipped from the platform because all appropriate safety straps were not utilized on the sit-to-stand machine. Review of R#1's progress note, dated 6/20/26 7:00 PM, stated, During shift report, a CNA requested assistance stating Resident was falling out of the sit-to-stand lift. Upon entering the bathroom, this RN observed the resident's right knee on the standing platform with the right foot on the floor, while the left leg remained on the lift platform. BUE (bilateral upper extremities; both arms) were elevated with the right hand gripping the wall grab bar. This nurse, along with CNAs, gently lowered the resident the remaining way to the floor with observation of the day shift RN. The nurse performed PROM (passive range of motion; movement of a joint performed by qualified staff without any effort from the resident's own muscles) on all extremities (arms and legs); resident endorsed pain to the right knee during flexion (bending a joint) and extension (straightening of a joint). Pt (Patient/R#1) was unable to state what occurred prior to the incident. Pt was transferred to bed via [Brand Name Omitted] lift by the nurse and two CNAs.The nurse notified the on-call provider (doctor) of the incident, and an order for a STAT (medical abbreviation for urgent) right knee X-ray was obtained. Assessment of the right knee revealed developing ecchymosis to the inferior (lower portion) aspect and a superficial skin tear.Review of R#1's nurse's (RN N) progress note, dated 6/21/2026 at 4:00 PM, stated, Patient (R#1) in bed all shift, states pain right leg with movement. Remained still with leg supported by pillows. X-ray in to do film (x-ray), nurse observed x-ray screen. Observed possible fx (fracture) of right femur.Send to ER (emergency room) for eval (evaluation) and treat (treatment) .Review of R#1's Pain Level Summary, dated 4/22-6/28/26, showed R#1 had increased pain level scores (0-10 scale; 0 reflected no pain and 10 reflected severe pain) after the 6/202/26 fall compared to pain levels from before. From 4/22-6/19/26 R#1's pain values never reached a 9 or a 10. R#1's pain level summary indicated: - 6/20/26 at 7:17 AM (before the fall), R#1's pain score was 4.- 6/20/26 at 7:37 PM (after the fall), R#1's pain score was 10.- 6/21/26 at 7:15 AM, R#1's pain score was 10.- 6/27/26 at 10:13 PM, R#1's pain score was 7.Review of R#1's Radiology (medical imaging; x-ray) Results Report (The x-ray obtained at the facility), dated 6/21/26, stated, .X-Ray .Knee 1 or 2 Views, Right .Findings: There is a displaced fracture of the distal femoral diaphysis (shaft or central part of the femur) .Conclusion: Fracture of the distal femur .Review of R#1's Transfer Form, dated 6 21 26, stated, .Sent To: [Hospital Name Omitted] .Date: 6/21/2026 (at) 15 30 (3:30 PM) .Reason(s) for Transfer: Abnormal X-ray .Pain .Pain Level: 9 (9 out of 10, 10 being most high level pain) .Date: 6/21/2026 11:53 (11:53 AM) .Pain Location .Right leg .Most Recent Pain Mediation .Orders: Tramadol (pain medication/opioid) HCl (hydrochloride) Oral Tablet 50 MG (milligrams) .Last Administration: 06/21/2026 11:50 (11:50 AM) Usual Mental Status .Alert, oriented, follows instructions .Usual Functional Status .Not ambulatory .ADLs (activities of daily living) .Transfers .Need Assistance .Toileting .Need Assistance .Assistive device .Yes .[Lift Company's Name Omitted] transfer at baseline (sit-to-stand device) .Review of R#1's hospital notes, dated 6/21-6/25/2026, stated, .Reason for Visit.Chief Complaint.Leg Pain (Per EMS.she (R#1) had a fall yesterday.Visit Diagnoses Closed (broken bone didn't puncture the skin) displaced fracture of distal epiphysis (rounded end of the bone) of right femur .Procedure performed: insertion, intramedullary rod, femur . The hospital notes indicated R#1's pain at rest to the right hip/leg was a 9 out of 10 (10 being the highest level of pain) at 4:57 PM on 6/21/26. During an interview on 7/14/2026 at 9:56 AM, Director of Nursing (DON) B confirmed R#1 experienced a fall with injury during a transfer when CNA J did not use the sit-to-stand lift's lower leg strap.During an observation and interview on 7/14/2026 at 12:59 PM, R#1 was seated upright in her wheelchair in her room. R#1 pointed to her right leg and reported it was broken after staff didn't have her legs strapped into the sit-to-stand lift during a transfer recently. R#1 reported she hit her right leg on the floor, her pain level was a 10 (0-10 pain scale; 0 represented no pain and 10 represented severe pain) at the time of the fall, and she had increased pain after the fall. During an observation and interview on 7/16/2026 at 10:45 AM, R#1 was seated upright in her wheelchair in her room. R#1 reported she was having pain in her right leg, pointed to her right leg, and reported her right leg pain was a 7 out of 10.During a phone interview on 7/14/2026 at 1:09 PM, CNA J reported she was assisting R#1 transfer on and off the toilet with a sit-to-stand lift in R#1's bathroom on 6/20/26. CNA J reported she used the sit-to-stand lift to assist with the transfer, the resident was leaning slightly to the left, when R#1 was standing up from the toilet her legs were not strapped/buckled as they should have been, R#1's right leg slid backwards and off the platform, and confirmed she had forgot to secure the strap again when she was getting off the toilet. CNA J reported she quickly got assistance from CNA E, RN N, and RN O who helped lower R#1 to the floor completely and then they used a different full body lift (a lift that suspends a resident in the air in a full body sling while transferring). to get R#1 off the floor. CNA J reported R#1's right foot was stuck between the toilet and the stand that goes over the toilet. CNA J stated, I believe so when asked if R#1 was in pain after the fall.During an interview on 7/15/2026 at 8:14 AM, RN O reported on 6/20/26, CNA J came to her, and reported R#1 had fell and went to her room to assist. RN O reported when she saw R#1 in her bathroom, the lower strap of the sit-to-stand lift and the torso sling's strap were not buckled/secured. RN O reported R#1 was holding onto the bathroom wall's grab bar with her right hand. RN O confirmed both the upper torso sling/strap and lower leg strap should be used for safety and to assist the resident properly. RN O reported R#1's left knee was bent resting on the sit-to-stand lift and her right leg was twisted behind her. RN O confirmed R#1's right foot was behind the platform on the floor and her right knee was resting on the edge of the foot platform. RN O reported R#1 reported her knee hurt with movement after the fall. RN O reported R#1's inner right knee had started to bruise and had a curved line mark/impression from having had her right knee resting directly on the edge of the foot platform. RN O confirmed R#1 no longer used a sit-to-stand lift and was transferred with a full mechanical lift. RN O reported when she came back to work the night shift on 6/21/26, day shift nursing staff reported R#1 had been having more pain with movement and when turned by staff it caused pain to her right femur area.During a phone interview on 7/15/2026 at 10:38 AM, CNA E reported on 6/20/2026, CNA J came out of R#1's room into the hall and requested her help with R#1 as she had just fell. CNA E reported upon entering R#1's bathroom she observed R#1 in an awkward position, R#1 was partially standing up in the sit-to-stand lift, her left leg was bent down behind her and kneeling on her right knee. CNA E reported R#1 was wincing, the wincing was new and not her usual behavior, and her arms were still holding onto the bar. CNA E confirmed R#1 was in more pain than usual at that time. CNA E reported when RN O was checking R#1's right leg R#1 was saying, Ouch. CNA E confirmed both feet were off the lift's foot platform and the lower leg safety straps were not in place.During an interview on 7/15/2026 at 3:48 PM, Therapy Director C confirmed facility staff should have used all straps on the sit-to-stand lift when R#1 was transferred on 6/20/26. Therapy Director C reported all residents at the facility who use a sit-to-stand lift should have their feet on the platform and use both straps when transferring.Review of R#1's physician progress note, dated 6/26/26, stated, .(R#1) .is seen today for readmission.after hospitalization for right hip fracture.Per hospital notes, The patient is an [AGE] year-old female in a skilled nursing facility who is on (sic; non) ambulatory. Apparently last night she was going from a sit to stand position and fell striking her right upper leg. She had pain today. An outpatient x-ray reportedly shows a right femur fracture of unknown location. She's sent here by EMS (emergency medical services; ambulance) for further evaluation. She states her leg does hurt. She's a poor historian.She points mostly to her mid (middle) to distal femur. Patient was hospitalized from [DATE] - 6/25/26 .Review of the facility's Fall Reduction Program policy, dated 4/14/2025, stated, .Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. All residents who are admitted are at risk for falls .Implement and indicate individualized interventions on Care Plan/Kardex . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the affected resident (R#1) was assessed and treated, identified and assessed other residents who had the potential to be affected, 1:1 education with the staff who improperly transferred R#1, all nurses and CNAs were educated on safe transfers and use of lift equipment including demonstration, policy and procedure review, initiated ongoing audits to monitor sit-to-stand lift use, and ongoing review of the audit findings at the facility's quality assurance meetings. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake 3064222.Based on interview and record review the facility failed to ensure a resident's responsible party/power of attorney was notified immediately following a fall with injury for 1 (Resident #1) of 3 residents reviewed for notifications resulting in a responsible party not being kept updated on a resident's condition and changes.Findings include:Resident #1 (R#1):Review of R#1's admission Record, dated 7/14/26, indicated R#1's Responsible Party (RP; a designated individual acting on the resident's behalf)/Power of Attorney (POA; legal document that gives an individual authority to make decisions on behalf of someone else) L was listed as Contact Type.Responsible Party.POA - Care (healthcare).Emergency Contact #1 (first to be called). R#1's Family Member M was listed as Contact Type.Emergency Contact #2. R#1 had pertinent diagnoses of right femur (thigh bone) fracture, osteoarthritis (occurs when the protective tissue that cushions the ends of your bones gradually wears away), obesity, muscle weakness, and cognitive communication deficit (an impaired ability to speak, listen, read, write, or socialize).Review of R#1's Advance Directive Durable Power of Attorney for Healthcare (Patient Advocate Designation) form, signed 7/15/22, stated, .Accepting the Role of Patient Advocate .I, (R#1), am assigning the Patient Advocate(s) listed below .I, (R#1's RP/POA L), have agreed to be the Patient Advocate for the person named above .Date: 07-15-2022 .During a phone interview on 7/9/2026 at 5:00 PM, R#1's RP/POA L reported she never received notification/a phone call that R#1 had a fall on 6/20/26. R#1's RP/POA L reported she became aware of R#1's 6/20/26 fall when the facility called her on 6/21/2026 at approximately 2 or 3 PM to inform her that R#1 was being sent to the hospital. R#1's RP/POA L confirmed she was the primary contact person, emergency contact number one on the call list, and expected to be notified timely after a fall. During an interview on 7/15/2026 at 2:09 PM, Social Work Director (SWD) P reported R#1 was deemed incapable of making medical decisions on 6/4/26. SWD P reported RP/POA L signed and returned the acceptance of being R#1's POA the week of 6/7-6/13/26. SWD P confirmed RP/POA L was the activated POA for R#1 on 6/20/26 and RP/POA L was the #1 (primary) emergency contact.During an interview on 7/16/2026 at 10:45 AM, R#1 was in her room and reported RP/POA L was her power of attorney and would have wanted RP/POA L to have been notified after the fall on 6/20/26.Review of Resident #1's #2996 Fall incident and accident report, dated 6/20/26, stated, .Date: 6/20/2026 18:45 (6:45 PM) .Incident Location: Resident's (R#1's) Bathroom .Witnessed assisted lowering to the floor. Resident slipped from sit-to-stand lift platform during transfer in bathroom. As an immediate intervention to prevent recurrence, staff will utilize all appropriate straps on the sit-to-stand lift while the resident is on the machine .endorsing pain to the right knee with movement. Skin tear and developing ecchymosis (bruise) noted to right knee .Agencies/People Notified .Substitute Decision Maker .(R#1 Family Member M who was not power of attorney/responsible party/emergency contact #1) .Date 6/20/2026 (at) 19:30 (7:30 PM) . Review of R#1's change in condition assessment, dated 6/20/26 at 6:45 PM, stated, .The change in condition, symptoms or signs I (facility staff making the notification) am calling about is/are .Falls .This started on: 06/20/2026 .What time of day did this start? Afternoon .Pain Evaluation .Is the resident cognitively able to rate their pain scale? Yes .Site .Right knee (front) .Description 10/10 ( 0=no pain, 4-5=moderate pain, 10=excruciating pain) pain .Name of family/healthcare agent notified: Daughter (Note: This was not R#1's Responsible Party/Power of Attorney L) .Date and time of family notification 06/20/2026 (at) 19:30 (7:30 PM) . Review of R1's progress notes, dated 6/20/26 and 6/21/2026, indicated R#1's RP/POA L was not notified of the 6/20/26 fall until R#1 was being sent out to the hospital on 6/21/2026 at approximately 4:00 PM. The progress note, dated 6/21/26 at 4:00 PM, stated, Patient in bed all shift, states pain right leg with movement. Remained still with leg supported by pillows. x-ray in to do film .possible fx (fracture) of right femur .send to ER (emergency room) for eval (evaluation) and treat .(R#1's RP/POA L) notified . (Note: R#1's RP/POA L was not notified immediately of the 6/20/26 fall and approximately 21 hours passed before the notification was made.)Review of the facility's Change of Condition - Resident Family/Responsible Party Notification policy, dated 4/12/26, stated, .Family and/or responsible party are notified anytime there is a change in the resident's condition or plan of care .notify family and/or responsible party any time there is a .Change in condition .The designated person on the face sheet will be the contacted party .Notification of any change in the resident's condition will be done in a timely manner .Notify appropriate party and record in resident's medical record.

Based on interview and record review, the facility failed to perform First Aid and Cardiopulmonary Resuscitation (CPR) per the standards of practice in 1 (Resident #140) of 4 residents reviewed for death resulting in an Immediate Jeopardy when on [DATE] at approximately 7:10 am, Resident #140, whose advanced directive indicated he was a full code (every possible life-saving therapy if a serious event occurs, such as cardiac or respiratory arrest) was found by facility staff in a pool of blood and without a heartbeat. Neither First Aid nor CPR was initiated, and Resident #140 was pronounced dead by Emergency Medical Services (EMS) at 7:36 AM. This deficient practice placed 67 residents that reside in the facility with the status of full code at risk or serious harm, injury, impairment, or death. Findings include: The Immediate Jeopardy began on [DATE] at approximately 7:10 AM when LPN Q and RN TT failed to initiate life saving measures to Resident #140 when he was found on the floor in a pool of blood without a heartbeat. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 12:56 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a scope of isolated and severity of actual harm that is not immediate jeopardy due to not all staff had received education and sustained compliance that has not been verified by the State Agency. Resident #140 Review of an admission Record revealed Resident #140 was originally admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease and essential hypertension (high blood pressure). Review of Resident #140's Code Status Form dated [DATE] and signed by Resident #140 revealed, I understand that by signing below that I will receive Cardiopulmonary Resuscitation (CPR) in the event that my heart stops or I stop breathing. By signing below as the legally responsible party I understand that the resident wishes are consistent with receiving CPR as described .Review of Resident #140's Progress Note dated [DATE] at 17:28 (5:38 PM) and documented by Licensed Practical Nurse (LPN) Q revealed, At 7:10 CNA (Certified Nursing Assistant) alerted this LN (Licensed Nurse) this pt (patient). (Resident #140) was on the floor in a lot of blood. LN immediately ran to room to see pt. lying in a very large pool of blood. LN checked signs of life, called to pt rubbing chest, no response. Looked for breath sounds, checked for a pulse and oxygen level. Nursing in room as 911 notified for stat (immediate) assistance. RN arrived on scene within a few minutes checking for signs of life, negative. Site was not deemed safe for CPR. Large pool of blood from chair at window side then to foot of bed wear (sic) pt. lay. Pt. last visited with in bed at 06:45 AM when he had asked for coffee. Pt appears to have self-transferred from bed without calling for assistance. Bandage site to right arm fistula (a surgically created connection between an artery and a vein, to provide a durable access point for hemodialysis) off and on floor. EMS (Emergency Medical Services) arrived at 7:30 AM. Pt pronounced by (Local hospital doctor) at 7:36 AM time of death . Review of Resident #140's EMS Care Report Summary dated [DATE] revealed, . Call received: 7:21 AM . Narrative History Text: Events leading to illness/injury: (EMS) called for 84 YOM (year old male) falls with unknown bleeding. Position Pt found/ Initial scene findings: EMS arrived on scene to find facility staff members outside the residence (sic) room with the door shut. Staff on scene said, we found him this way and called you guys. EMS found the PT lying supine on the floor at the foot of his bed with a large amount of approximately 4-5 pints (of blood) around him on the floor. Staff on scene reports the PT has a fistula to his L (left) arm and reports the PT had dialysis yesterday. PT last seen at approximately 06:45 this morning to obtain vitals, she reports when she left the PT was seated on the edge of his bed awake and acting confused at baseline for his medical history of Alzheimer's (a form of dementia). EMS personnel noted the PT was still warm to the touch with no signs of rigger (sic) mortis (stiffening of the joints and muscles of a body a few hours after death) or lividity (purplish-red skin discoloration appearing on the lower parts of a body after death, caused by gravity pulling blood into the capillaries as circulation stops) present. PT had no pulse and was placed on the cardiac monitor, and an Asystole (a state where the heart shows no electrical activity and stops beating) was obtained in 3 leads. ADDITIONAL ASSESSMENT NOTES (IF APPLICABLE): Lividity and rigor mortis not present. PT has no carotid or radial pulses present. Asystole (the heart has completely stopped beating, with no electrical activity or contractions) present on the 4 lead. Obvious evidence of Exsanguination (the process of bleeding out or losing so much blood that it results in death) present on scene with blood loss approximately 4-5 pints on the floor between 2 locations. PT has a known fistula to his Left arm for dialysis. PT LAST SEEN AT AND BY: ([DATE] 06:45 by the CNA) PRONOUNCED AT: 07:36:00. PT'S BODY LEFT IN CUSTODY OF: (local police department), DNR PRESENT? Unknown. SIGNS AND SYMPTOMS OF OBVIOUS DEATH: exsanguination signs present. SIGNS OF OBVIOUS TRAUMA NOTED? (PT was found lying on the ground at the foot of his bed with approximately 4-5 pints of blood on the floor around him with another small puddle to the Left of his bed. Blood spatter on the bed frame, blankets, wall, door, and floor.) OTHER SCENE RELATED FINDINGS (IF APPLICABLE):PT had a bloody saturated 2x2 on the floor to the left of his bed with a small pool of blood by the chair. A bloody hand print was noted on the dresser at the foot of the bed directly across from where the pt was lying. Bloody trail from what looks like walker tires are on the floor from the chair to the left of the PT's bed to where he is lying with his walker present at the foot of the bed. Nurse on scene states the PT has Alzheimer's at baseline and last night was confused and was looking for breakfast during the night. The vitals cart was present in the PT's room with a set of vitals showing on the screen when EMS arrived. CNA reported she seen him last at 6:45 and he was sitting on the edge of his bed . In an interview on [DATE] at 9:41 AM, LPN Q reported CNA RR told her to come check on Resident #140 because she had just found him in his room in a large pool of blood. LPN Q reported that when she entered Resident #140's room, she found him lying on the floor in a large pool of blood. LPN Q reported that she checked Resident #140 for signs of life by looking for breath sounds and checking his pulse, and she noted that he did not have a pulse. LPN Q reported that she thought Resident #140 was bleeding from his fistula site, but she did not assess to determine where the bleeding was coming from so that she could attempt to stop the bleeding. LPN Q reported that she made the decision to not start CPR because she felt that there was too much blood and we would have just been sloshing around in the blood. LPN Q was unable to report who called 911, or if there was a delay in calling 911. In an interview on [DATE] at 10:21 AM, Registered Nurse (RN) TT reported he was notified by a CNA that LPN Q needed assistance with Resident #140. RN TT reported that he grabbed the facility's crash cart and went to Resident #140's room where he observed Resident #140 lying on his back on the floor at the foot of his bed in a pool of blood. RN TT reported he checked Resident #140 for a pulse, and noted that he did not have a pulse, but he did feel warm. RN TT reported that he did not assess for the source of Resident #140's bleeding, and he did not initiate CPR because he felt like it was a biohazard to do so because of the amount of blood Resident #140 had lost. RN TT was unable to report who called 911, or if there was a delay in the facility calling 911. In an interview on [DATE] at 10:58 AM, CNA RR reported that on [DATE] she had gotten shift report from CNA X who had told her that Resident #140 was awake, and that she had just checked on him around 6:45 AM. CNA RR reported that around 7:00 AM, she entered Resident #140's room and found Resident #140 on the floor by his bed in a pool of blood. CNA RR reported that she tried to call out for help, but when staff did not come, she ran to find LPN Q. CNA RR reported that once LPN Q entered Resident #140's room, she stepped out of Resident #140's room. CNA RR reported that she did not call 911, and she was unable to report which staff member did. This writer attempted to contact CNA X on [DATE] at 9:15 AM. CNA X did not return this writer's call prior to survey exit. In an interview on [DATE] at 4:15 PM, CNA M reported that she was working on [DATE] when she heard LPN Q yelling out for help. CNA M reported that went to Resident #140's room where she saw a few other CNA's running from the room and saying that someone needed to call 911 and get help. CNA M reported that she ran to get more nurses and told RN TT that LPN Q needed help. CNA M reported that when she returned to Resident #140's room, she observed LPN Q checking Resident#140 for a pulse. CNA M reported that LPN Q looked overwhelmed and unsure of what to do. CNA M reported that she did not call 911 and she was not sure which staff member did. In an interview on [DATE] at 12:30 PM, RN Unit Manager (RN-UM) O reported that she was the on-call manager on the day that Resident #140 was found in his room. RN O reported that she was informed that staff had found Resident #140 when they were passing morning waters around 7:00 AM. RN O reported that there was no reason for staff to initiate CPR because Resident #140 had lost too much blood, and it was everywhere. RN O was not able to report if the staff that responded to Resident #140 had determined the cause of Resident #140's bleeding. RN-UM O reported that she did come to the facility to make sure the paperwork was good regarding Resident #140's death. RN-UM O reported that she did not think there was anything that the staff could have done differently when responding to Resident #140. RN-UM O was unable to report which staff member called 911, or if there was a delay in calling 911. In an interview on [DATE] at 12:12 PM, Director of Nursing (DON) B reported that she was aware of the incident with Resident #140 on [DATE]. DON B reported that she was informed that the nursing staff that found Resident #140 in a pool of blood did not initiate life saving measures because there were no signs of life in Resident #140, and there was too much blood loss to initiate CPR. DON B reported that the nursing staff thought that Resident #140's blood loss was from his fistula site. When this writer queried about how staff had determined how much blood Resident #140 had lost, DON B was unable to answer. When this writer queried as to how to the nursing staff knew that Resident #140's blood loss was from the fistula site, DON B was not able to confirm if nursing staff had assessed Resident #140's fistula site. DON B was unable to report which staff member had called 911, or if there was a delay in calling 911. DON B reported that she thought that the previous DON had completed an investigation into the incident, but she would need to find the paperwork regarding this. DON B was unable to provide any investigation reports prior to survey exit. In an interview on [DATE] at 12:21 PM, Nursing Home Administrator (NHA) A reported the facility did not complete an incident report, and the interdisciplinary team (IDT) did not meet to discuss the incident with Resident #140 because the facility had responded appropriately to the situation. NHA A reported Resident #140 was a full code, but there was no more blood to pump to his heart, so they could not do CPR. NHA A was not able to report how the nursing staff were able to determine that Resident #140 did not have enough blood for them to initiate CPR. Review of the facility's CPR policy last revised on [DATE] revealed, PURPOSE: To initiate Cardiopulmonary Resuscitation/CPR (using an AED device if available) for residents requesting full code or withholding cardiopulmonary resuscitation for residents who have declared a no-code status/DNR or who present with obvious signs of death per AHA. Procedure: .2. If a resident is noted to be without a pulse or respirations, the appropriate steps will be takenbased on Code status and other situations such as safety and any obvious signs of death. 3. The CPR certified professional will evaluate for responsiveness, if unresponsive they will activate the emergency response team. 4. The resident will be evaluated for pulse as well as respirations. 5. If the patient has a pulse but is not breathing rescue breaths will be provided. 6. If the patient does not have a pulse and they are assigned as a full code without obvious signs of death, chest compressions will be initiated with rescue breaths per AHA guidance . Review of Putting a stop to exsanguination ([DATE]) revealed, When blood is lost, the greatest immediate need is to stop further blood loss.Damage control resuscitation is now standard practice in many trauma settings. Damage control resuscitation is based on the principle that full, normal hemostasis does not necessarily need to be achieved at the first intervention. Part of this process is the recognition that there is not always time to get a patient to a secure, well-staffed and well stocked intensive care unit. The aim of damage control resuscitation is to maintain circulating volume, control hemorrhage, and correct the lethal triad until definitive intervention is appropriate. According to the 2024 American Heart Association and American Red Cross Guidelines for First Aid (2024 American Heart Association and American Red Cross Guidelines for First Aid | American Heart Association CPR & First Aid) , First aid for bleeding: When faced with life-threatening bleeding, the first aid provider should apply direct pressure followed by application of a tourniquet or wound packing if the location of the wound is amenable.Uncontrolled bleeding is the most important preventable cause of death in 35% of trauma patients and can occur before the arrival of emergency services. Life-threatening bleeding can be recognized by pooling of blood on the ground, blood that is rapidly flowing or spurting from the wound, bleeding that continues despite direct manual pressure, or bleeding that results in systemic symptoms such as drowsiness, dizziness, chest pain, or loss of consciousness. Because death can occur within minutes, first aid providers are essential in providing immediate care. Control of bleeding is a foundational first aid skill, and applying direct pressure is the mainstay of treatment. For extremity bleeding that is not effectively controlled with direct pressure, tourniquet application can be an appropriate intervention. Direct manual pressure is the hallmark of hemorrhage control. If available, hemostatic dressings (which contain materials that help promote blood clotting), pressure dressings, mechanical pressure devices, and tourniquets may augment the effectiveness of direct manual pressure or avoid the need for ongoing direct manual pressure.A person presenting with shock, including cardiogenic, hypovolemic, or hemorrhagic shock, may experience dizziness, difficulty breathing, chest pain, or skin mottling. While waiting for EMS, the first aid provider can position the person in a way to optimize circulation to vital organs such as the brain and to avoid decompensation. According to the 2025 American Heart Association Guidelines for CPR and ECC (CPR and ECC Guidelines | American Heart Association CPR & First Aid), Healthcare Professionals (HCPs) have a prima facie obligation to follow institutional policies regarding ethical issues in resuscitation in addition to the guidelines in this document. In turn, institutions have an obligation to develop ethically sound policies, educate HCPs on both policies and ethical guidelines, and provide the resources necessary to adhere to these standards and resolve difficult issues when they arise.Once initiated, resuscitation can be discontinued, but the decision not to initiate treatment is often irrevocable. Thus, HCPs should generally err on the side of providing resuscitation when uncertainty exists.focusing on the special circumstances as etiologies of cardiac arrest, provide and evaluate specific treatment options meant to be administered in addition to, and alongside, traditional resuscitation care. Unless otherwise specified, all patients should receive standard airway management, support of breathing, and treatment of hypotension, arrhythmias, and cardiac arrest consistent with local protocols and the resources available at the site of treatment. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. Resident #140 involved no longer resides in the center as of [DATE].2. 67 of 67 residents with a full code advanced directive have been assessed and deemed in no immediate need of first aide or CPR as of 12-9-25. 66 out of 133 residents with DNR advanced directives have been assessed and deemed as not in immediate need of first aide.3. The CPR policy as reviewed on [DATE] by NHA and DON and deemed appropriate and in line with American Heart Association guidelines.4. Education began on [DATE] with licensed nurses on the CPR policy, including assessment, first aid and initiation of CPR in all events unless rigorous has set in and or the body is cold. The individual directing the code will assign tasks including the immediate notification of the 911 system. Education continued at the beginning of each shift until all staff members had received the education. As of [DATE] 31 of 42 licensed nurses have been educated. All licensed nurses will be educated prior to their next scheduled shift.5. Licensed nurse's CPR certifications were reviewed on [DATE] and up to date.6. A code blue drill was completed on [DATE] that included the participation of 18 staff members. A code blue drill will be held every 12-hour shift for 3 days and then weekly for 12 weeks.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident mental and verbal abuse for 2 (Resident #19 and Resident #96) of 3 residents reviewed for abuse, resulting in Resident #19 experiencing verbal threats and having profanity directed toward him by Resident #96. Findings include:Resident #19Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE].Review of a Minimum Data Set (MDS) assessment for Resident #19 with a reference date of 10/15/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 /15, which indicated the resident was cognitively intact. Section E revealed Resident #19 did not exhibit physical or verbal behaviors directed toward others.Review of a Care Plan for Resident # with a reference date of 7/9/25 revealed the following focus/goal/interventions: Focus: I have an alteration in my MOOD state r/t (related to) decreased mobility.Goal: I will communicate my feelings as needed. Interventions: .Encourage me to interact with others. Resident #96Review of an admission Record revealed Resident #96 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction due to embolism of left cerebral artery (left sided stroke primarily affects the right side of the body that may also cause speech issues, trouble understanding and cognitive problems like reasoning and mood changes).Review of a Minimum Data Set (MDS) assessment for Resident #96 with a reference date of 10/7/25, revealed Resident #96 could not complete a Brief Interview for Mental Status (BIMS) due to cognitive limitations. Section B revealed Resident #96's speech was clear, he could use distinct intelligible words and was sometimes understood. Section C of the MDS revealed Resident #96's short- and long-term memory appeared impaired, and he was moderately impaired for decision making.Review of a Care Plan for Resident #96 with a reference date of 1/8/25 revealed the following focus/goal/interventions: Focus: Resident has severe cognitive impairment. Goal: Display appropriate response to situation. Interventions: Anticipate needs, redirect me as needed, minimize.overstimulation, use brief/simple cues and repeat as needed.During an observation on 12/9/25 at 9:51am, Certified Nursing Assistant (CNA) SS and CNA CC assisted Resident #96 into his wheelchair in his room.During an observation on 12/9/25 at 9:53am, Resident #96 was heard from the hallway saying in a loud tone of voice, I'm going to kill that M***ER F***ER to CNA SS and CNA CC as the CNA's exited his room. Resident #96 exited the room directly behind CNA SS and CNA CC. CNA SS stated Head down to the gym to Resident #96 and CNA SS and CNA CC stepped off to the side of Resident #96's doorway and began talking to each other. Resident #96 quickly self-propelled his wheelchair into Resident #19's room, stopped his wheelchair near Resident #19's bed and yelled loudly in a deep, emotionally charged tone of voice: I'm going to kill you, you M***ER F***ER. You're dead, you M***ER F***ER, You're Dead!. CNA SS entered the room and removed Resident #96 from the unit.In an interview on 12/9/25 at 12:31pm, Resident #19 reported Resident #96 had threatened him a total of 3 times in recent months. Resident #19 began to cry and stated, I shouldn't feel threatened in my own home. Resident #19 reported he kept his curtain pulled around his bed and watched the reflection on his roommates television to see if Resident #96 was entering his room. When queried why he watched for Resident #96, Resident #19 stated because I want to be ready for him so I can protect myself. Resident #19 reported the first time Resident #96 verbally assaulted him, he was fearful that Resident #96 was going to hit him, so he pushed his bedside table between himself and Resident #96. When further queried, Resident #19 reported he worried Resident #96 would try to physically assault him. Resident #19 reported staff were aware of the previous incidents in which Resident #96 threatened him and as a result, Resident #96 was supposed to be supervised when he was in the hallway. As he cried, Resident #19 reported he liked living there but following this incident, he was considering moving to another facility to protect his well-being.In an interview on 12/9/25 at 1:52pm, CNA CC reported there had been similar incidents in which Resident #96 threatened Resident #19. CNA CC reported during one incident, she heard Resident #96 yelling at Resident #19, saying he wanted to fight Resident #19. CNA CC confirmed she was not unsure if previous altercations between Resident #96 and Resident #19 had been reported.In an interview on 12/9/25 at 1:27pm, CNA SS reported she witnessed Resident #96 yelling at and directing profanity toward Resident #19 today but had also witnessed Resident #96 doing the same thing prior to today. CNA SS reported Resident #96 had been upset with Resident #19 for several weeks because he was bothered by someone's television and thought it was Resident #19's. CNA SS reported staff told Resident #96 repeatedly that Resident #19 did not play his television loudly, but Resident #96 continued to fixate on him. When queried about interventions that had been put in place to avoid Resident #19 being verbally abused by Resident #96, CNA SS reported she was not aware of any interventions the facility had implemented. CNA SS reported Resident #19 was crying after the altercation with Resident #96 on this date.In an interview on 12/10/25 at 10:48am, Unit Manager (UM) XX reported CNA SS informed him of an incident on 12/9/25 at approximately 9:55am during which Resident #96 had yelled and directly profanity at Resident #19. UM XX reported CNA SS told him during the incident, Resident #19 was yelling for help, and she removed Resident #96 from the room. UM XX reported he met with Resident #19 after the incident and described Resident #19 as emotionally upset by the incident. UM XX reported Resident #96 was always angry initially when he entered the hallway from his room, but he was not aware of any interventions that had been put in place to avoid Resident #96 directing his anger toward other residents, including Resident #19. UM XX confirmed any incident involving someone yelling and/or directing profanity at a resident should be immediately reported Nursing Home Administrator (NHA) A. UM X confirmed he reported the incident to NHA A after he spoke to CNA SS. UM X reported he was not aware of any other altercations between Resident #96 and Resident #19.Review of a Nurse's Note for Resident #19, written by UM X on 12/9/25 at 2:16pm revealed Follow up with resident regarding another resident across the hall entering his room and yelling.Resident stated.he felt safe at the moment. Informed resident we will follow up with the other resident.Resident was pleased in regards to what we discussed.In an interview on 12/10/25 at 2:34pm, Social Services Director (SSD) L reported Resident #96 had previously expressed frustration and anger about hearing something that he believed to be Resident #19's television. SSD L reported Resident #96 became fixated on his beliefs and could not be redirected. SSD L reported she was not aware of any incidents in which Resident #96 threatened Resident #19 and had not been informed about the incident on this date.In an interview on 12/10/25 at 11:18am, Physical Therapist (PT) HH reported Resident #96 had expressed ongoing anger about hearing someone's television and despite being redirected, continued to believe that Resident #19 was to blame. When further queried, PT HH reported Resident #96 had expressed anger and agitation about Resident #19 for more than a month. PT HH reported Resident #96 expressed he felt Resident #19 was acting deliberately disrespectful toward him, despite being told repeatedly that Resident #19 was not playing his television loudly. PT HH reported hall staff denied hearing anyone playing their television loudly.In an interview on 12/10/25, NHA A reported she was not aware of any previous altercations between Resident #96 and Resident #19. NHA A reported she spoke with Resident #19 several hours after the incident on 12/10/25 and confirmed the Resident #19 was emotionally upset by the incident. NHA A confirmed Resident #19 reported he would feel safer if Resident #96 was not in a room across the hall from him.Review of an Abuse Policy with a reference date of 3/15/23 revealed POLICY STATEMENT 1. (facility name omitted) will not tolerate verbal, sexual, physical or mental abuse.PROCEDURE: a. DEFINITIONS.iii) Mental Abuse includes, .harassment, and threats.ix) Verbal abuse refers to any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents. Verbal abuse includes.offensive or disapproving terms to any resident.

Based on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided consistently for 3 (Resident #62, 132, and 102) of 27 residents reviewed for dining resulting in decreased independence with dining, difficulty eating/drinking, and the potential for dehydration and/or weight loss.Findings include:Resident #62:Review of Resident #62's nutrition care plan, revised 9/30/25, stated, Focus.Nutrition risk r/t (related to) anoxic (deprived of adequate oxygen) brain damage, L (left) sided spastic hemiplegia (muscle stiffness and weakness on one side of the body).Interventions.two handled cups with sip lids.Review of Resident #62's brief interview for mental status score, dated 10/13/25, was 5 which reflected severe cognitive impairment. During an observation on 12/08/2025 at 12:19 PM, Resident #62 was eating lunch in the dining room with Certified Nurse Aid CC seated next to him. Resident #62 was independently taking fluids but required staff assistance to eat the food on his plate. Resident #62 had two double handle cups with sip lids but the cup containing red liquid, which was one fourth full, had a lid that was concave and a tiny hole the size of a standard straw (intended to hold a straw). Resident #62 was observed bringing the cup to his mouth but unable to get juice from the cup as the lid wasn't allowing fluids to leave the cup and enter his mouth when he tilted the cup. The lid on this cup was not a sip lid.During an observation on 12/08/2025 at 2:11 PM, Resident #62 was seated upright in his wheelchair in his room and was observed to be able to drink fluids independently with a double handle cup with sip lid. On his bedside table was a clear single handle cup with spout lid (a type of sip lid). Resident #62 was nonverbal and unable to answer questions.During an observation on 12/09/2025 9:02 at AM, Resident #62 was seated upright in his wheelchair in his room next to his bed. The bedside table was over the bed directly next to him in the wheelchair. The double handle cup with spout lid was placed out of his reach. The only drink within his reach was a disposable foam cup (no handles) with disposable lid (not a sip lid). This foam cup contained water.During an interview on 12/09/2025 at 1:09 PM, Registered Dietitian (RD) L confirmed the concave lid with hole, which Resident #62 was observed to have been provided on 12/08/2025 at 12:19 PM, was not a sip lid and he should have received a sip lid with his fluids. RD L confirmed dietary staff would provide the adaptive dining equipment served at meals for the residents. RD L reported Resident #62 should have received the adaptive dining equipment noted in his care plan, on his meal ticket, and in his diet order. RD L confirmed occupational therapy would have made the recommendation for the two handle cup with sip lid for Resident #62. During an interview on 12/09/2025 at 4:20 PM, RD L reported various unidentified certified nurse aides reported they used the disposable foam cup with water in Resident #62's room to fill the adaptive equipment, two handle cup with sip lid, when Resident #62 was in his room and wasn't expected to drink from the foam cup.Review of Resident #62's diet order, revised 8/28/25, stated, Directions.two handle cup with sip lid. Resident #132:Review of Resident #132's nutrition/hydration care plan, revised 11/21/25, stated, Focus.I am at risk for alteration in nutrition/hydration status r/t (related to) dementia (impaired cognition), hemiplegia/hemiparesis (inability to move one side of the body).and dysphagia (difficulty swallowing).Interventions.Two handled cup with sip top lid, spoon curved left.Review of Resident #132's brief interview for mental status score, dated 11/13/25, was scored 4 which reflected severe cognitive impairment. During an observation on 12/09/2025 at 12:26 PM, Resident #132 was observed dining independently in his room. Resident #132 was served two beverages, one brown and one white, in double handle cups with spout lid. A third beverage served was water which was served in disposable foam cup, disposable lid, and straw. Resident #132 was provided with straight/regular metal dining utensils. The fork, knife, and spoon were all straight and were not bent left. Resident #132 was observed eating his pureed food with his finger. Resident #132 was confused and was unable to answer questions. The meal ticket on his tray stated, ADAPT EQUIP (adaptive equipment): . 2 Handled Cup with Sip Lid, Bent Left Utensils.During an observation on 12/09/2025 at 4:47 PM, Resident #132 was in bed in his room with the head of bed elevated. On his bedside table placed over him was what appeared to be water in a disposable foam cup with disposable lid and straw. There were no two handle cups with sip lid on the tray table or observed in the room.During an observation on 12/10/2025 at 7:58 AM, Resident #132 was in bed in his room with the head of bed elevated. On his bedside table was what appeared to be water in a disposable foam cup with disposable lid and straw. There was not a two handle cup with sip lid on the tray table or observed in the room.During an observation on 12/10/2025 at 11:01 AM, Resident #132 was seated in his wheelchair at the table in the day room at the end of the 500 hall. Resident #132's beverage on the table directly next to him was served in a disposable foam cup, disposable lid, and straw. After immediately walking down to Resident #132's room it was observed that two adaptive two handle cups with sip lids were in his room. Review of Resident #132's physician order, revised 6/20/25, stated, .spoon curved left; 2 handle cup w/ (with) sip top lid.Review of Resident #132's Dietary Profile assessment, dated 11/21/25, stated, Utensils.Dining aides.bent L (left) utensils.Resident #102:Review of Resident #102's nutrition care plan, revised 11/18/25, stated, Focus.Nutrition risk r/t (related to) dementia.Interventions.Diet order: .Scoop plate.Review of Resident #102's brief interview for mental status score, dated 11/28/25, was scored 3 which reflected severe cognitive impairment.During an observation on 12/10/2025 at 12:21 PM, Resident #102 was observed eating lunch independently in the dining room. Resident #102 was served lunch on a regular plate and not a scoop plate (a type of dish specifically designed with a raised edge to make it easier to scoop food onto a utensil). There was food covering the outside lip of half the plate, with food pushed off the plate and onto the tablecloth surrounding the plate.Review of Resident #102's physician order, revised 11/7/25, stated, Regular diet.Directions.Scoop Plate. Review of Resident #102's Dietary Profile assessment, dated 11/13/25, stated, .Utensils.Dining aides.scoop plate.Eating Assistance.Independent.Review of the facility's activities of daily living (ADL) (daily life functions) policy, dated 7/1/2008, stated, Use adaptive equipment as directed PRN (as needed).

Based on observation, interview, and record review the facility failed to ensure Contact Precautions (Transmission based measure implemented to a resident known or suspected to be infected with a microorganism that can be transmitted by direct contact with other residents or indirect contact with environmental surfaces) were effectively in place for 1 resident (#1), and ensure that standard infection control practices were properly implemented for 2 residents (Resident #3 and #117) from a total of 5 residents reviewed for infection control practice, resulting in the potential for transmission of MDRO (multidrug-resistant organisms) and cross contamination of bacteria to a suspectable population.Findings include:Resident #1Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: sepsis (a life-threatening medical emergency caused by your bodies response to overwhelming infection) and MRSA (a type of infection that can be resistant to antibiotics therefore difficult to treat).Review of Resident #1's Physician Orders revealed, Transmission based precautions: contact precautions three times a day for MRSA infection. Start date: 12/5/25During an observation on 12/8/25 at 10:47 AM Resident #1's room was observed with contact precautions posted and gowns hanging on the door. The sign indicated to don gloves and a gown prior to entering the room. There were no gloves outside of the resident's room.During an observation and interview on 12/09/2025 at 9:07 AM Resident #1's room was observed again with contact precautions posted, gowns hanging on the door but no gloves outside of the room. Resident #1 reported that he had a bad infection in his foot and is getting an IV (intra venous) antibiotic for it. The resident asked this surveyor for assistance with his bed controls. This surveyor asked an unknown therapy staff member to assist the resident. Observed that staff member don a gown and then walk into the room and look for gloves.During an observation on 12/10/25 at 8:53 AM Resident #1's room was observed with a cart outside of the door that contained gowns and gloves.In an interview on 12/10/2025 at 9:04 AM, Infection Preventionist (IP) H reported that earlier that day a Certified Nursing Assistant (CNA) had made her aware that Resident #1 did not have gloves available outside of his room, therefore she made sure a cart with gowns and gloves was put in place right away. IP H reported that the resident had recently returned from the hospital with MRSA infection and was on contact precautions. IP H reported that with contact precautions staff would be required to don gloves and a gown prior to entering the resident's room and before making contact with anything inside of the room.Resident #3Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stage 4 pressure ulcer sacral region. Review of Resident #3's Physician Orders revealed, Enhanced barrier precautions as directed. This includes gown and gloves for high-contact resident care activities. Catheter, wounds. Start Date: 9/4/25.During an observation and interview on 12/08/2025 at 2:25 PM Resident #3 was lying in bed and CNA F and CNA Y were preparing to provide incontinence care. It was noted that Resident #3 had orders for enhanced barrier precautions due to a foley catheter and chronic wounds. Registered Nurse (RN) V was present in the room to complete pressure wound dressing change on the resident's bottom. Resident #3 had bandages covering wounds on both heels, bottom of left foot, right lower leg and upper buttocks. RN V reported that she was only changing the dressing on the resident's buttocks at this time. During cares CNA F was providing the direct care and CNA Y was assisting with positioning. CNA F was observed changing her gloves after incontinence care was completed but did not perform hand hygiene prior to donning clean gloves and resuming care. RN V donned 2 pair of gloves prior to starting the wound care, then discarded the top pair of gloves after removing the soiled dressing and then continuing wound care with the second pair of gloves that were already in place. RN V was not observed performing hand hygiene at any time during care. RN V verbalized to CNA F that she used the double glove technique so that she didn't have to stop and change gloves during care. In an interview on 12/10/2025 at 9:54 AM, CNA F reported that she did not perform hand hygiene between glove changes during Resident #3's care. CNA F reported that she knew of coworkers that double glove during care but did not know that it was a concern. In an interview on 12/10/2025 at 11:22 AM, RN V reported that she used the double glove method for safety and so that she can easily remove soiled gloves during care. RN V reported that she did not perform hand hygiene when removing soiled gloves if she had another pair of gloves on underneath them and was not aware that it would be an infection control concern. Resident #117Review of an admission Record revealed Resident #117 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary incontinence and overactive bladder. During an observation and interview on 12/10/2025 at 12:10 PM Resident #117 was lying in her bed. Resident #117 reported that the only time she gets rolled over and off her bottom was once every 8 hours. Resident #117 reported that she was wet with urine and the last time someone checked or changed her was at 5:30 AM (>6 hours ago) that day and that her bottom is getting sore. During an observation on 12/10/2025 at 12:45 PM, CNA C was in Resident #117's room preparing to provide incontinence care and get her up into her chair. CNA C donned gloves, removed the blanket and Resident #117 incontinence brief was visibly saturated with urine. CNA C detached the brief and began cleaning the front peri-area. The resident was then rolled onto her right side and the heavily saturated brief was removed. Resident #117's buttocks were observed red with creases from the brief and the bedding and there was a small superficial open area on the residents right inner thigh, that CNA C reported was previously a bigger wound. CNA C continued to clean the peri-area and buttocks, where a small amount of BM (bowel movement) was noted on the washcloths. CNA C did not change her soiled gloves. CNA C obtained cream from the resident's nightstand, by putting her gloved hand into the container, to scoop it out and applied it to the resident's buttocks. Then placed a new brief and the hoyer sling under the resident and rolled the resident onto her back. Then with the same gloves on CNA C obtained a different cream from the nightstand drawer and applied it to the resident's front peri-area. When care was finished, CNA C removed her soiled gloves, did not perform hand hygiene, then donned clean gloves to gather the soiled linens. In an interview on 12/10/2025 at 9:04 AM, IP H reported that she monitored infection control practices by the facility staff during daily rounds and occasionally observed wound care. IP H reported that staff are trained to change gloves any time they become soiled, whether it is visible or not and to perform hand hygiene after every time gloves are removed. IP H reported that if gloves become visibly soiled, staff are expected to wash their hands with soap and water, but hand sanitizer can be utilized at other times. IP H reported that double gloving is not an acceptable practice.

This citation pertains to 2660756 Based on interview and record review, the facility failed to ensure the physician notes reflected accurate representation of the resident's current condition and meaningful assessments of the residents' condition were completed for 1 (Resident # 142) of 27 residents reviewed for quality of care resulting in the lack of coordination of care and insufficient treatment for diabetes mellitus (a chronic disease where the body either doesn't make enough insulin or doesn't use it properly, leading to high blood sugar levels). Findings include: Resident #142Review of an admission Record revealed Resident #142 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes (a chronic disease where the body either doesn't make enough insulin or doesn't use it properly, leading to high blood sugar levels) and essential hypertension (high blood pressure). Review of Resident #142's Orders revealed, Blood glucose monitoring two times a day related to type 2 diabetes mellitus without complications for 7 days. Start date: 8/7/25. End date: 8/14/25. Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: .subcutaneously three times a day for dm (diabetes mellitus.) Start date: 12/23/24. Order status: discontinued. Review of Resident #142's Treatment Administration Record for August 2025, September 2025, and October 2025 revealed that Resident #142 did not have blood glucose monitoring documented after 8/14/25. It was also noted that Resident #142 did not have insulin orders documented as administered after 8/14/25. Review of Resident #142's Blood Sugar Summary indicated that Resident #142 did not have blood glucose results documented after 8/14/25. It was noted that Resident #142 had several elevated blood glucose levels documented which included 478.0 on 8/13/25, 307 on 8/12/25, 353 on 8/13/25, 298 on 8/13/25, and 254 on 8/8/25. Review of Resident #142's Physician's note dated 8/8/25 and documented by Nurse Practitioner (NP) MM revealed, DMT2 (diabetes mellitus type 2) : Last A1C 6.5% (test measures the average amount of sugar in your blood over the past few months). Continue Lantus (insulin) and ISS (insulin sliding scale). Monitor blood sugar trends. Elevated likely due to Prednisone (steroid) course, prednisone is tapering off so will hold off on adjustment of Lantus at this time. Continue ISS Review of Resident #142's Physician's note dated 9/4/25 and documented by Nurse Practitioner (NP) LL revealed, DMT2 (diabetes mellitus type 2): Controlled. Continue insulin and monitor blood sugar trends .Review of Resident #142's Physician note dated 10/8/25 and documented by Medical Doctor (MD) KK revealed, Type 2 diabetes mellitus: Euglycemic (normal levels of glucose in the blood), medically controlled. Continue with insulin and continue monitors with accu-checks. (blood glucose monitor) In an interview on 12/10/2025 at 12:27 PM, Licensed Practical Nurse Unit-Manager (LPN-UM) UU reported that Resident #142 had been readmitted to the facility after a short hospital stay in August 2025. LPN-UM UU reviewed Resident #142's hospital After Visit Summary with this writer and noted that the provider that re-admitted Resident #142 ordered blood glucose monitoring for 7 days. LPN-UM UU reported that the provider that assessed Resident #142 after 8/14/25 when the order for blood glucose monitoring was completed was responsible for re-ordering blood glucose monitoring and insulin for Resident #142. LPN-UM UU reviewed Resident #142's electronic health record (EHR) and confirmed that Resident #142 did not have blood glucose monitoring or insulin orders placed after 8/14/25. In an interview on 12/10/2025 at 12:17 PM, MD KK reported that he was not sure why Resident #142's insulin had been discontinued. MD KK reviewed Resident #142's blood glucose levels from August 2025 and confirmed that the blood glucose levels were not considered euglycemic. MD KK confirmed that he did assess Resident #142 on 10/8/25, and that he did notice at that time that the facility had not been checking Resident #142's blood glucose levels, but he did not look into it further, and that was an error on my part. MD KK confirmed that NP MM: and NP LL had also assessed Resident #142 after 8/14/25 and did not review her orders for blood glucose monitoring or insulin but had documented that Resident #142 was supposed to continue with blood glucose monitoring and insulin which she did not have active orders for.

This citation pertains to intake 2660756. Based on interview and record review, the facility failed to ensure that residents received necessary treatments and care for diabetes in accordance with professional standards of practice for 1(Resident #142) of 27 residents reviewed for quality of care resulting in Resident #142 missing blood glucose monitoring and insulin (a hormone produced in the pancreas, which regulates the amount of glucose in the blood) which placed Resident #142 at risk for serious health complications. Findings include: Resident #142Review of an admission Record revealed Resident #142 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes (a chronic disease where the body either doesn't make enough insulin or doesn't use it properly, leading to high blood sugar levels) and essential hypertension (high blood pressure). Review of Resident #142's Orders revealed, Blood glucose monitoring two times a day related to type 2 diabetes mellitus without complications for 7 days. Start date: 8/7/25. End date: 8/14/25. Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: .subcutaneously three times a day for dm (diabetes mellitus.) Start date: 12/23/24. Order status: discontinued. Review of Resident #142's Treatment Administration Record for August 2025, September 2025, and October 2025 revealed that Resident #142 did not have blood glucose monitoring documented after 8/14/25. It was also noted that Resident #142 did not have insulin orders documented as administered after 8/14/25. Review of Resident #142's Blood Sugar Summary indicated that Resident #142 did not have blood glucose results documented after 8/14/25. It was noted that Resident #142 had several elevated blood glucose levels documented which included 478.0 on 8/13/25, 307 on 8/12/25, 353 on 8/13/25, 298 on 8/13/25, and 254 on 8/8/25. Review of Resident #142's Physician's note dated 8/8/25 and documented by Nurse Practitioner (NP) MM revealed, DMT2 (diabetes mellitus type 2) : Last A1C 6.5% (test measures the average amount of sugar in your blood over the past few months). Continue Lantus (insulin) and ISS (insulin sliding scale). Monitor blood sugar trends. Elevated likely due to Prednisone (steroid) course, prednisone is tapering off so will hold off on adjustment of Lantus at this time. Continue ISS Review of Resident #142's Physician's note dated 9/4/25 and documented by Nurse Practitioner (NP) LL revealed, DMT2 (diabetes mellitus type 2): Controlled. Continue insulin and monitor blood sugar trends .Review of Resident #142's Physician note dated 10/8/25 and documented by Medical Doctor (MD) KK revealed, Type 2 diabetes mellitus: Euglycemic (normal levels of glucose in the blood), medically controlled. Continue with insulin and continue monitors with accu-checks. (blood glucose monitor) In an interview on 12/8/25 at 8:12 AM, Family Member (FM) JJ reported Resident #142 had discharged from the facility on 10/26/25. FM JJ reported that when Resident #142 discharged , the facility did not indicate that she needed blood glucose monitoring and insulin for her diabetes. FM JJ reported that within two days of discharging from the facility, Resident #142 fell ill, and went to hospital where it was discovered that her blood glucose level was in the 600's, and she required hospitalization. In an interview on 12/10/2025 at 12:27 PM, Licensed Practical Nurse Unit-Manager (LPN-UM) UU reported that Resident #142 had been readmitted to the facility after a short hospital stay in August 2025. LPN-UM UU reviewed Resident #142's hospital After Visit Summary with this writer and noted that the provider that re-admitted Resident #142 ordered blood glucose monitoring for 7 days. LPN-UM UU reported that the provider that assessed Resident #142 after 8/14/25 when the order for blood glucose monitoring was completed was responsible for re-ordering blood glucose monitoring and insulin for Resident #142. LPN-UM UU reviewed Resident #142's electronic health record (EHR) and confirmed that Resident #142 did not have blood glucose monitoring or insulin orders placed after 8/14/25. In an interview on 12/10/2025 at 12:17 PM, MD KK reported that he was not sure why Resident #142's insulin had been discontinued. MD KK reviewed Resident #142's blood glucose levels from August 2025 and confirmed that the blood glucose levels were not considered euglycemic. MD KK confirmed that he did assess Resident #142 on 10/8/25, and that he did notice at that time that the facility had not been checking Resident #142's blood glucose levels, but he did not look into it further, and that was an error on my part.

Based on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 1 resident (Resident #117) of 13 residents reviewed for ADL care, resulting in inadequate incontinence care and repositioning for meals and the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. Findings include:Review of an admission Record revealed Resident #117 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary incontinence and overactive bladder. Review of a Minimum Data Set (MDS) assessment for Resident #117, with a reference date of 11/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #117 was cognitively intact. Review of Resident #117's ADL Care Plan revealed, .actual ADL deficit. Date initiated: 9/3/25. Interventions: Boost resident at the beginning of each CNA shift to a 45 degree angle. Review of Resident #117's Skin Care Plan revealed, .urine retention, urge incontinence.MASD (moisture associated skin disorder) left inner thigh.Date initiated: 9/3/24.Interventions: Apply protective skin barrier after each incontinence episode.Encourage and assist me to make small, frequent shifts in my position per standards of care and as I allow.Please help me get turned and repositioned while in bed or in my wheelchair per standards of care and as I allow.During an observation and interview on 12/08/2025 at 12:10 PM Resident #117 was lying in her bed eating lunch. Resident #117's head of bed (HOB) was elevated to approximately 45 degrees, but her upper body was nearly flat on the bed due to being slouched down in bed so far. Resident #117 reported that she was very uncomfortable, but she had given up on asking to be boosted up in bed because staff just told her she was already high enough. Resident #117 reported that she had not received incontinence care yet that day and usually only gets assistance once a shift.During an observation and interview on 12/10/2025 at 12:10 PM Resident #117 was lying in her bed. Resident #117 reported that the only time she gets rolled over and off her bottom was once every 8 hours. Resident #117 reported that she was wet with urine and the last time someone checked or changed her was at 5:30 AM (>6 hours ago) that day and that her bottom is getting sore. Resident #117 reported that she had skin issues on her buttock from being wet all the time. Resident #117 reported that she usually gets out of bed and into her chair after lunch and then sits there with an uncomfortable fish net hoyer sling underneath her until after supper. Resident #117 reported that she was able to ask for assistance but was not always able to feel when she was wet, therefore preferred to be woken up during the day for incontinence care and repositioning every 2 hours.In an interview on 12/10/2025 at 12:25 PM, CNA F reported that Resident #117 required 2 people for cares and she had not been in the room yet that day to assist with any cares.In an interview on 12/10/2025 at 12:26 PM, CNA C reported that she had not been in to provide care to Resident #17 yet that day and reported that the resident preferred to sleep most of first shift and did not like to be woken up for incontinence care. CNA C reported that Resident #117 was able to let staff know when she needs care. During an observation on 12/10/2025 at 12:45 PM, CNA C was in Resident #117's room preparing to provide incontinence care and get her up into her chair. CNA C donned gloves, removed the blanket and Resident #117 incontinence brief was visibly saturated with urine. CNA C detached the brief and began cleaning the front peri-area. The resident was then rolled onto her right side and the heavily saturated brief was removed. Resident #117's buttocks were observed red with creases from the brief and bedding, and there was a small superficial open area on the residents right inner thigh, that CNA C reported was previously a bigger wound. CNA C continued to clean the peri-area and buttocks, where a small amount of BM (bowel movement) was noted on the washcloths.

Based on interview and record review, the facility failed to report injuries of unknown origin to the State Agency in a timely manner for 2 (Resident #19 and Resident #96) of 3 residents reviewed for abuse and reporting, resulting in the potential for ongoing mistreatment to go unrecognized.Findings include:Resident #19Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE].Review of a Minimum Data Set (MDS) assessment for Resident #19 with a reference date of 10/15/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 /15, which indicated the resident was cognitively intact. Section E revealed Resident #19 did not exhibit physical or verbal behaviors directed toward others.Resident #96Review of an admission Record revealed Resident #96 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction due to embolism of left cerebral artery (left sided stroke primarily affects the right side of the body that may also cause speech issues, trouble understanding and cognitive problems like reasoning and mood changes).Review of a Minimum Data Set (MDS) assessment for Resident #96 with a reference date of 10/7/25, revealed Resident #96 could not complete a Brief Interview for Mental Status (BIMS) due to cognitive limitations. Section B revealed Resident #96's speech was clear; he could use distinct intelligible words and was sometimes understood. Section C of the MDS revealed Resident #96's short- and long-term memory appeared impaired, and he was moderately impaired for decision making.Review of a Care Plan for Resident #96 with a reference date of 1/8/25 revealed the following focus/goal/interventions: Focus: Resident has severe cognitive impairment. Goal: Display appropriate response to situation. Interventions: Anticipate needs, redirect me as needed, minimize.overstimulation, use brief/simple cues and repeat as needed.During an observation on 12/9/25 at 9:53am, Resident #96 was heard from the hallway saying in a loud tone of voice, I'm going to kill that M***ER F***ER to Certified Nursing Assistant (CNA) SS and CNA CC as the CNA's exited his room. Resident #96 exited the room directly behind CNA SS and CNA CC. CNA SS stated Head down to the gym to Resident #96. CNA SS and CNA CC stepped off to the side of Resident #96's doorway and began talking to each other. Resident #96 quickly self-propelled his wheelchair into Resident #19's room, stopped his wheelchair near Resident #19's bed and yelled loudly in a deep, emotionally charged tone of voice: I'm going to kill you, you M***ER F***ER. You're dead, you M***ER F***ER, You're Dead!. CNA SS entered the room and removed Resident #96 from the unit.In an interview on 12/09/2025 at 2:43 PM CNA SS reported she told the nurse and Unit Manager (UM) XX about Resident #96 yelling profanities at Resident #19 immediately after the incident occurred.In an interview on 12/10/25 at 10:48am, Unit Manager (UM) XX reported CNA SS informed him of an incident on 12/9/25 at approximately 9:55am during which Resident #96 had yelled and directed profanity at Resident #19. UM XX reported CNA SS told him during the incident, Resident #19 was yelling for help, and she removed Resident #96 from the room. UM X confirmed he reported the incident to NHA A directly after he spoke to CNA SS. In an interview on 12/10/25, NHA A reported she was informed of the incident between Resident #96 and Resident #19 during the morning of 12/9/25. NHA A reported she was delayed in interviewing Resident #19 but upon doing so, saw the resident was emotionally upset by the situation. NHA A confirmed the resident reported he would feel safer if the facility ensured Resident #96 was not near him. Following the resident interview, NHA A reported the incident to the State Agency as possible abuse. NHA A confirmed the incident was not reported to the State Agency within 2 hours as required.Review of an Abuse policy with a reference date of 3/15/23 revealed .f) REPORTING/RESPONSE i) For the alleged violation involving abuse.the Center will report immediately but not later than two hours after the allegation is made, if the event involves abuse.to officials (including the state survey agency) .

This citation pertains to intake #2614156.Based on interview and record review the facility failed to adequately supervise, ensure safety and prevent an elopement of 1 (Resident #100) of 3 residents who were assessed to be at risk for elopement, resulting in an Immediate Jeopardy when Resident #100 left the premises on 8/30/25, alone, unbeknownst to staff and was returned on 8/31/25 after being missing for approximately 17 hours. The deficient practice placed all 17 residents a risk for elopement at risk for serious harm, serious injury, and/or death.Findings include:The Immediate Jeopardy began on 8/30/25 and was identified on 9/22/25 due to the facility's failure to adequately supervise, ensure safety, and prevent an elopement resulting in Resident #100 eloping from the building and was subsequently missing for approximately 17 hours.On 9/22/25 at 2:55 PM, the Nursing Home Administrator was verbally notified and received written notification of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/31/25, and the deficient practice corrected on 9/16/25 prior to the start of the survey and was therefore past noncompliance.Review of Incident Summary revealed On 8/30/25, around lunch time the facility staff were unable to locate Resident #100. A code 7 was paged overhead to initiate missing person drill. He was last seen in the facility with a navy blue shirt, blue jeans, and blue tennis shoes. The Administrator, Director of Nursing, Regional Director of Operations, guardian, and police were notified of the missing person. The police arrived at the facility to help initiate a missing person search. They combed through neighborhoods and added the missing person to local news stations. All areas of business, wooded areas, apartments were searched by staff and local police. Flyers were handed out to local businesses and the bus lines. The police called the local hotels. Facility called a local homeless shelter. The resident's room was searched. The police started using a drone to search & posted the missing person alert on their Facebook page. The sign out book was checked. The police were able to make visits to previous addresses with no success. At 4:40 am the resident entered a local hotel and told the front desk he just arrived. He did have brush & burs on him and they thought that was odd and notified the local police. The resident was located by the local police department and taken to the hospital for evaluation. The patient returned to the facility around 5:45 am. The patient was assessed and no significant injuries were noted. The patient was immediately placed on 1:1. A full head-to-toe assessment was conducted on-site who found no acute injuries or medical concerns.In an interview on 9/22/25 at 12:02 PM, Maintenance Director (MD) SS reported all exit doors to the outside have an alarm system and/or the wander guard system; most doors have both systems. The doors at the end of the 600 hall had a coded alarm, but no wander guard system. MD SS reported the wander guard system was installed on the 600 hall doors and the entire wander guard system was upgraded in the facility on 9/3/25, after Resident #100 eloped. MD SS reported he reviewed the report for the wander guard system from 8/30/25 and the report indicated that no wander guard alarm had occurred when Resident #100 was suspected of exiting the building.In an interview on 9/22/25 at 11:18 AM, Housekeeper (H) AA reported Resident #100 was always trying find a way out of the building. H AA reported on 8/30/25 Resident #100 asked her how to get to the motel to get his wife. H AA reported she notified Licensed Practical Nurse (LPN) HH that Resident #100 was exit seeking.Review of Social Service Note for Resident #100 dated 8/30/2025 at 8:03 AM, revealed .patient asked if he could be let out of the facility so that he could go back to the hotel that he was at last night . Patient stated that he has been trying to go and pick up his wife.Review of Social Service Note for Resident #100 dated 8/30/2025 at 8:47 AM, revealed .Patient observed going out of the courtyard doors.went (sic) to make sure the patient knew how to get back inside when he was ready. The patient cut across the courtyard and re-entered the facility at the 200 hall entrance (from the courtyard). Approx 10 mins (minutes) later patient was on the 500 hall asking for help to open the doors.In an interview on 9/22/25 at 1:31 PM, Social Work Director (SWD) S reported Resident #100 was admitted to the facility for sub-acute rehab (rehabilitation outside of an acute care hospital or following a hospitalization) and shortly after he admitted he was at the doors, in other resident's rooms, very confused, and it was obvious he was not appropriate for the setting. SWD S reported on 8/30/25 Resident #100 asked her during breakfast for directions to the hotel so he could get his wife. SWD S reported on 8/30/25 at about 8:45 AM, she observed Resident #100 go out the door into the courtyard and the door alarm sounded. SWD S reported the doors to the courtyard were not locked and the alarm would sound unless the code was entered before the door was opened. SWD S reported on 8/30/25 after breakfast she heard Resident #100 make a few laps around the facility and several times overheard him asking staff for directions to the hotel so he could pick up his wife. SWD S reported on 8/30/25 she was assisting with lunch service at approximately 11 to 11:30 am when she heard staff could not locate Resident #100 in the building. SWD S reported Resident #100 was located in the community the next day at about 4 AM and returned to the facility at approximately 5:45 AM.In an interview on 9/22/25 at 11:38 AM, Certified Nurse Assistant (CNA) DD reported Resident #100 was very hard to keep track of. CNA DD reported on 8/30/25 Resident #100 was messing with the door and set off the alarm. In a telephone interview on 9/22/2025 at 2:38 PM, LPN HH reported on 8/30/25 she was Resident #100's assigned nurse. LPN HH reported Resident #100 was all over the place and was exit seeking, and someone was always bringing him back to the unit that morning. LPN HH reported Resident #100 had previously been on one-to-one supervision because he was going into other resident's rooms. When queried regarding Resident #100's one-to-one supervision, LPN HH reported Resident #100 was not on one-to-one supervision on 8/30/25 and she was not able to implement one-to-one supervision. LPN HH reported either someone in management or the RN (Registered Nurse) charge nurse implemented any needed one-to-one supervision interventions.In an interview on 9/23/25 at 11:45 CNA GG reported on 8/30/25 she was assigned to Resident #100, and she recalled that he was out of his room and walking around the whole morning. CNA GG reported on 8/30/25 she last observed Resident #100 at approximately 10:15 AM and when she began passing lunch trays on the hall, she was unable to locate Resident #100. CNA GG reported she walked a lap of the building and was unable to locate Resident #100, then notified the other CNA on the unit with her and they both walked a couple of laps looking for Resident #100 and still couldn't locate him. They then informed LPN HH, and a Code 7 missing resident was called overhead and all the staff started looking for Resident #100. In an interview on 9/23/25 at 1:39 PM, CNA Q reported on 8/30/25 Resident #100 appeared anxious and was standing at the door to the service hall, watching.In an interview on 9/23/25 at 1:42 PM, CNA XX reported on 8/30/25 at about 10 AM, Resident #100 was on the 300 hall and asked her if he could go home. CNA XX reported she escorted Resident #100 back to the 600 hall.In an interview on 9/23/25 at 1:48 PM, CNA T reported on 8/30/25 she observed Resident #100 trying to exit the facility through a door to the courtyard on the 200 hall.In an interview on 9/22/25 at 9:41 AM, Director of Nursing (DON) B reported Resident #100 was pleasant and notably confused and had walked the facility since he had admitted . DON B reported Resident #100 looked like a visitor but he was a resident with a room on the 600 Hall. DON B reported she believed Resident #100 exited through the doors at the end of the 600 hall when a visitor entered the code to disarm the door alarm and held the door for Resident #100.In an interview on 9/22/25 at 11:29 AM, LPN W reported Resident #100 would just get up and go and he wandered around the facility often.In an interview on 9/22/25 at 11:50 AM, LPN K reported Resident #100 looked like a visitor that someone would hold the door for when exiting the building.In an interview on 9/22/25 at 11:32 AM, Social Work (SW) GGG reported Resident #100 was admitted to the facility with a guardian in place and the need for placement in long term care. SW GGG reported Resident #100's discharge plan after completing rehab was to transfer a long-term memory care/secure unit. In an interview on 9/22/25 at 11:46 AM, Director of Infection Control (DIC) O reported Resident #100 had significant dementia, did lots of wandering, exit seeking, and was frequently looking for home and his wife. In an interview on 9/24/258 at 12:25 PM, DON B reported her expectations were that staff redirected a resident who was exit seeking, assist them to activities, address any needs such as thirst or hunger, or the need for a bathroom. DON B reported the staff could implement a one to one, you can always do more, you cannot do less. DON B reported the staff did not implement one to one supervision for Resident #100 on 8/30/25 because he was not leaving or pulling on doors, he wasn't looking for anything or anyone, he was just wandering.In an interview on 9/24/25 at 12:50 PM, Nursing Home Administrator (NHA) A reported her expectations were that staff redirect a resident who was exit seeking, implement activities or other interventions, even a one to one supervision. NHA A reported on 8/30/25 the staff should have implemented one to one supervision for Resident #100 and they did not. NHA A reported there was more we could have done on the preventative side before Resident #100 eloped, and we didn't.In an interview on 9/22/25 at 3:05 PM, Clinical Care Coordinator/Registered Nurse (CCC/RN) BB reported Resident #100 had really nice clothes and looked like a visitor. CCC/RN BB reported Resident #100 could have been mistaken for a visitor and someone just held the door for him. CCC/RN BB reported she recalled that on the evening of 8/29/25 Resident #100 was agitated and looking for his [AGE] year-old son. CCC/RN BB stated I have no idea how he got out of the building, but I know he got out. I have no idea what else we could have done to prevent it.In an interview on 9/22/25 at 3:15 PM, [NAME] President of Operations (VPO) BBB stated It's an unfortunate situation, thankfully Resident #100 was safe and unharmed; there was nothing else the facility could have done to prevent this situation.Review of an admission Record revealed Resident #100 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen), dementia (a loss of cognitive functioning), cognitive communication deficit (communication disorder due to a brain injury), anxiety, and alcohol abuse.Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 8/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #100 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). 3Review of the Elopement Assessment dated 8/7/25 revealed Resident #100 was at risk for elopement. The Assessment indicated Resident #100 showed indications of exit seeking behavior at time of assessment that included asking where to go and the need to locate family members or go to work.Review of the Elopement Care Plan dated 8/12/25 revealed Resident #100 was at risk for elopement. Interventions included: On 8/12/25.check wander guard bracelet for placement q (every) shift.initiate wander alert system, initiate wander guard book, reassure if resident feels lost, abandoned or disoriented. Added on 8/13/25: . 1:1 (one to one) as deemed necessary by NHA/DON (nursing home administrator/director of nursing) for increased exiting attempts.Resident #100 was discharged from the facility on 9/4/25. An effort to contact Resident #100's guardian was made on 9/22/25 at 11:00 AM. A message was left on voicemail, and no return call was received by the time of survey exit. Review of Elopement: Assessment and Safety Essentials by [NAME] Struck, RN, published 5/1/13, Provider Magazine revealed While wandering in a facility can present harmful situations.the opportunities for injury multiply after a resident elopes from the nursing facility. Additional risk assessment should be performed after there is any change in the resident's condition.(assessment) should include physical, psychological and historical factors.a resident's history is of paramount importance in the assessment process.factors that signal concern include.problem with adjustment to the facility.stating a desire to go home or feeling imprisoned.hovering near exits.The Immediate Jeopardy that began on 8/30/25 was removed on 8/31/25 when the facility completed the following steps in the written plan for removal for the Immediate Jeopardy that was received on 9/23/25 at 12:29 PM and was verified on 9/23/25: On 8/30/25 - Code 7 was paged overhead indicating missing resident. Staff began completing a head count and searching for missing resident inside and outside the facility. Administration was notified. Police were notified. All doors, alarms, and wander guard system were tested, and all functional. All wander guards were verified for placement and function.A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified and had care plans in place. Elopement book was reviewed to ensure all residents at risk had pictures and information in place. Facility elopement and missing person policy were reviewed.All staff present in the facility on 8/30/25 were educated on the elopement policy and the missing person policy. A plan was put in place to educate every staff member prior to their next working shift.Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily. The code to the 600 hall door was changed by the maintenance director.A sign was placed on the 600 hall door indicating it was not an exit, and visitors should enter and exit through the main entrance.Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.Resident #100 was placed on one to one after returning to the facility until he discharged from the facility.Facility ensured elopement drills were conducted daily for 3 days.Facility ensured elopement drills were conducted weekly The deficient practice was corrected on 9/16/25 after the facility completed the following that included education of all staff by 9/16/25:All wander guards were verified for placement and function.A facility wide audit of elopement risks was completed to ensure all residents at risk had been identified.Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.A total of 17 residents were identified as at risk for elopement. 4 residents with wander guard placement and 13 were on the secure unit.The facility elopement books were reviewed to ensure all at risk residents had pictures and information located in the books.The facility policy for elopement and/or exit seeking management and missing person policy were reviewed and deemed appropriate. All staff present in the facility on 8/30/25 were educated on policy, warning signs of elopement, how to identify an at risk resident, what to do if a resident is exit seeking, how to redirect an exit seeking resident, who to notify if a resident is exit seeking, and each staff member was given a laminated check list related to missing resident to attach to their name badge. Education of all staff members was completed 9/16/25, except for 22 staff members who were on approved leave. The 22 staff members on leave would be educated upon their return to work. Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement.Facility confirmed all door alarms and wander guard system were operating properly and were monitored for functionality daily. The code to the 600 hall door was changed by the maintenance director. Daily door alarm checks continued.A sign was placed on the 600 hall door indicating it was not an exit.Facility ensured signs were posted to educate visitors on the need to avoid assisting any residents through a door.Resident #100 was placed on one to one until resident discharged from the facility.Facility ensured elopement drills were conducted daily for 3 days.Facility ensured elopement drills were conducted weeklyElopement policies, procedures, educations, assessments and root cause were reviewed in QAPI.

Based on interview and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #106 and #107) of 3 residents reviewed for dignity/respect, resulting in feelings of frustration and the potential for decreased self-esteem and decreased quality of life.Findings include:Resident #106Review of an admission Record revealed Resident #106 was a female, with pertinent diagnoses which included: major depressive disorder, recurrent, unspecified. Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #106, with a reference date of 6/30/25 revealed a BIMS score of 15, out of a total possible score of 15, which indicated Resident #106 was cognitively intact.In an interview on 8/25/25 at 11:36 AM, Resident #106 reported call light wait time could be as much as 1/2 hour. Resident #106 reported she has had to wait so long for staff to answer her call light that she has soiled her brief. Resident #106 reported she has also had to wait a long time for staff to change her brief, and it made her feel degraded.In an interview on 8/25/25 at 11:46 AM, Certified Nurse Aide (CENA) F reported Resident #106 does not refuse cares.In an interview on 8/26/25 at 1:07 PM, CENA T reported Resident #106 does not refuse cares. Resident #107Review of an admission Record revealed Resident #107 was a female, with pertinent diagnoses which included: other specified depressive episodes. Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #107, with a signed date of 8/20/25 revealed a BIMS score of 11, out of a total possible score of 15, which indicated Resident #107 was moderately cognitively impaired.In an interview on 8/25/25 at 11:46 AM, Resident #107 reported she has had to wait a long time for staff to change her brief. Resident #107 stated, last night, it seemed like I sat there forever. Resident #107 reported it made her feel like an old lady having to wait to get her brief changed.In an interview on 8/25/25 at 2:34 PM, CENA U reported resident #107 does not refuse cares.In an interview on 8/26/25 at 3:03 PM, Licensed Practical Nurse (LPN) R reported residents sometimes complained about long call light wait times.In an interview on 8/26/25 at 3:05 PM, CENA V reported there had been some residents who complained to her about long call light wait times.

Based on interview and record review the facility failed to maintain Quality Assurance and Performance Improvement Program (QAPI) that developed and implemented effective corrective actions and conduct meaningful surveillance to prevent adverse effects from medication erros in 2 of 2 residents (Resident #2 and Resident #9) reviewed for QAPI, resulting in the potential for serious adverse outcomes for all residents who receive medications from facility staff. Findings include: Review of Medication Error Report for Resident #2, dated 12/8/24 at 19:58 pm, (7:58 pm) completed by Registered Nurse (RN) II revealed . Resident administered roommate's (Resident #5) medications .(including) buspirone HCl tablet 10mg x 2, (anti-depressant), clonazepam oral tablet 0.25 mg (anti-psychotic), apixaban oral tablet 5 mg (anti-coagulant/blood thinner), Senna oral tablet 8.6 mg (laxative), senna- plus 8.6-50 mg (laxative/stool softener), Tropism Chloride oral tablet 20 mg (treats over active bladder and urinary incontinent), Atorvastatin 20 mg (cholesterol medication), insulin 8 units injection subcutaneous (diabetes/high blood sugar), Latuda oral tablet 40 mg (depression associated with bipolar disorder), Melatonin 3 mg x 2 (two tablets) (sleep aid), Morphine Sulfate 15 mg (narcotic pain medication) . Review of Medication Error Report for Resident #9 dated 1/10/2025 at 10:31 am, completed by RN S revealed after giving am medication realized that I had given another resident's medication to (Resident #9). (Resident #9) received losartan 25 mg (blood pressure medication), magnesium 400 mg (vitamin), metformin 1000 mg (diabetes medication), pantoprazole DR 40 mg (stomach acid reducer), Senna-Docusate 8.6-50 mg (laxative and stool softener) two tabs . Review of the facility QAPI records revealed no documentation that the facility identified deficient practice related to medication errors, no process for analysis of the cause of medication errors, no plan for to correct the deficient practice, and no indication the facility would monitor, evaluate, or audit the correction. In an interview on 3/18/25 at 11:33 am, Director of Nursing (DON) B reported medication errors are a general topic for all QAPI meetings. DON B reported the medication errors that occurred in December and January were mentioned in the monthly QAPI meetings. When queried, DON B reported that nothing further was done to analyze the cause of medication errors. In an interview on 3/19/24 at 9:04 am, DON B, Nursing Home Administrator NHA A and Regional Clinical Nurse (RCN) PP were present in DON B office and NHA A reported that the mention of medication errors occurred in both January and February QAPI meetings, but there was no analysis into why it occurred or how to prevent medication errors from occurring in the future. NHA A reported all nursing staff was educated regarding medication errors at the all-staff meeting on January 15, 2025, and that there had not been an all-staff meeting in December. In an interview on 3/19/25 at 9:45 am, DON B provided a typed word document that revealed Timeline for medication errors .12/8/24 .administered incorrect medication .root cause: did not verify resident identity .1/10/25 .administered incorrect medication root cause: did not verify resident identity . DON B confirmed that she had just created this documented timeline for the multiple medication errors that had occurred. The facility was unable to provide any root cause analysis created by the QAPI team by the time of exit.

Based on observation, interview, and record review the facility failed to ensure staff implemented infection control measures by: 1). Implementing enhanced barrier precautions (EBP) for a resident with a urinary catheter in 1 (Resident #2) of 1 resident reviewed for EBP implementation and 2.) provide adequate storage of a CPAP (continuous positive airway pressure) mask for 2 (Resident #5 and Resident #6) of 2 resident reviewed for CPAP mask use, resulting in the potential for the introduction of infection, cross contamination, and disease transmission. Findings include: Resident #2 Review of an Admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE]. On 3/13/25 at 1:05 pm, a urinary drainage bag was noted on Resident #2 bed frame, indicating the use of a urinary catheter. No signage was noted outside of the room indicating the use of enhanced barrier precautions. Review of Order Summary for Resident #2 on 3/13/25 revealed Foley catheter 16 fr (French) for buttock wound, started on 2/14/25 . there was no noted order for EBP. Review of Care Plan for Resident #2 on 3/13/25 revealed no noted care plan for EBP. On 3/17/25 at 10:27 am, Resident #2 was observed being transferred via a mechanical lift from bed into a shower chair by Competency- Evaluated Nurses Assistant (CENA) M' and Hospice Aide (HA) JJ. Neither staff member was wearing a gown. On 3/17/25 at 10:56 am, HA JJ was observed in Resident #2's room, removing the sheet from the bed and was not wearing a gown or gloves. In an interview on 3/18/25 at 9:50 am, CENA N and CENA Q reported that EBP was implemented for any resident who had a catheter. CENA N reported that staff should wear a gown and gloves during care when they will touch the resident, such as showers, incontinent care, transferring, and wound care. In an interview on 3/18/25 at 10:44 am, Infection Preventionist/Registered Nurse (IP/RN) J reported a resident who had a foley catheter should be in EBP. In an interview on 3/18/24 at 10:59 am, IP/RN J was queried regarding when Resident #2 was placed into EBP and IP/RN J stated about a half an hour ago. IP/RN J reported she had missed when Resident #2's foley catheter was ordered and did not update Resident #2 EBP status. IP/RN J reported she had entered the order for EBP and had updated Resident #2 care plan as well. Resident #5 Review of an Admission Record revealed Resident #5 was a female who was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 12/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #5 was moderately cognitively impaired. (BIMS score 8-12 indicates moderate cognitive impairment). On 3/13/25 at 1:09 pm, Resident #5's CPAP mask was noted to be laying on the floor between the bed and the wall. On 3/17/25 at 10:28 am, Resident #5's CPAP mask was noted to be laying on the over the bed table with no barrier and the mask appeared to be smudged with oil. In an interview on 3/17/25 at 2:55 pm, Resident #5 reported she uses her CPAP nightly, and the staff assist her to put it on. Resident #5 reported the staff takes care of her CPAP mask when she takes it off in the morning. Resident #6 Review of an Admission Record revealed Resident #6 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included obstructive sleep apnea. On 3/13/25 at 12:50 pm, Resident #6's CPAP mask was noted to be laying uncovered on the top of the dresser with no barrier under it. In an interview on 3/13/25 at 12:55 pm, Resident #6 reported his CPAP machine was brand new and he had never used it and he didn't' know anything about how it worked. Review of Order Summary for Resident #6 revealed .CPAP on at night, off in the am with a start date of 3/10/25. On 3/17/25 at 9:05 am, Resident #6's CPAP mask was noted to be lying on top of the dresser, with a washcloth and towel covering it. Resident was noted to be wearing a gown and sleeping in bed. In an interview on 3/17/25 at 3:30 pm, CENA X and CENA FF reported they did nothing with resident CPAP masks. In an interview on 3/17/25 at 3:12 pm, LPN K reported that CPAP masks should be stored in a bag or in a basin when not in use. In an interview on 3/18/25 at 11:15 am, Director of Nursing (DON) B reported her expectations were that CPAP masks were stored with a barrier of some kind when not in use.

This citation pertains to intake# MI001500378 Based on observation, interview and record review, the facility failed to follow the court appointed resident representative decisions as the rights of the resident who was adjudged incompetent by the court in 1 (Resident #4) of 1 resident reviewed for abuse, resulting in Resident #4 (who functioned at the level of a 6 year old child) experiencing feelings of frustration, confusion, and anger after witnessing ongoing conflict between facility staff and her family members/representatives. Findings include: Review of an Admission Record revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: moderate intellectual disabilities (observable developmental delays, which may be accompanied by physical impairments), cerebral palsy (congenital disorder of movement, muscle tone, or posture) and major depressive disorder (persistent sad mood that impacts daily living). Further review revealed Family Member (FM) TT and FM UU served as co-guardians for Resident #4. Review of the court document labeled Letter of Co-Guardianship of individual with Developmental Disability dated as amended on 2/12/25 (for financial language) revealed FM TT and FM UU were appointed as plenary guardian of Resident #4. According to the American Bar Association, Generally, if a court determines a person has a disability, they may appoint (1) a guardian of the person, if it has been properly shown that because of their disability they lack sufficient understanding or capacity to make or communicate responsible decisions concerning the care of themselves .A plenary guardianship is a guardianship in which the court gives the guardian the power to exercise all legal rights and duties for the ward, after the court finds the ward to be incapacitated. People often mistake the guardian of the person as referring only to the authority to make healthcare decisions. However, the scope of these duties is far more extensive. The guardian of the person may make medical decisions, oversee the residential placement of their ward (with court approval), ensure that the ward receives proper professional services . Review of a Speech Therapy Evaluation for Resident #4 with a reference date of 2/21/25 revealed Clinical Impressions .Pt (patient) is goal directed .Pt's thinking is concrete .problem solving abilities are impaired and pt has limited insight .pt has difficulty with understanding problems, hazards or precautions. Review of a Comprehensive Level II Evaluation for Resident #4 with a reference date of 4/29/24 revealed Strengths and Resources: (Resident #4's) guardians appear to be strong advocates in ensuring she is receiving appropriate care and remains happy . (Resident #4) meets DSM (Diagnostic and Statistical Manual) criteria for Intellectual Disability .deficits in intellectual functions .adaptive functioning .onset of deficits was during developmental period. Review of a Minimum Data Set (MDS) assessment for Resident #4 with a reference date of 1/3/25, revealed Section D of the MDS revealed Resident #4 expressed feeling down, depressed, or hopeless during 7-11 days of the 14-day assessment period. Review of an MDS assessment for Resident 34 with a reference date of 10/3/24 revealed Resident #4 expressed feeling down, depressed, or hopeless never or less than 1 day during the 14-day assessment period. Review of a Care Plan for Resident #4 with a reference date of 7/2/24, revealed a focus/goal/interventions of: Focus(es). I have an alteration in my MOOD state r/t (related to) depression. When staff explain boundaries or rules, I will frequently make accusations against staff .I frequently tell different stories to different people. Goal: I will communicate my feelings. Interventions: .Do not interview resident and sister in presence of each other .as they have a HX (history) of feeding off each other .involve resident in decisions related to care . Review of a Behavioral Care Provider Note for Resident #4 with a reference date of 9/5/24 revealed .Her (Resident #4) sister is her guardian .She denies depression or anxiety .(Resident #4) has presented with manipulative behaviors such as telling her sister one account and staff another, which causes friction between all parties .Interventions staff could implement .Do not involve (Resident #4) in discussions between her sister and staff as it upsets (Resident #4). Review of a Social Services Initial Assessment for Resident #4 with a reference date of 7/3/24 revealed The patient is capable of making her basic needs and preferences known. Her guardian is tasked with complex decision making regarding the patient's health and wellbeing .The patient has a very supportive and involved family . In an interview on 3/17/25 at 10:55am, FM TT' reported she had voiced several concerns to the facility about Resident #4 spending time with a facility staff member (Scheduler EE), receiving notes of affection from Scheduler EE, and being referred to by Scheduler EE as her goddaughter but the facility had not intervened. FM TT reported she felt the relationship was inappropriate and that she had concerns for Resident #4's psychosocial wellbeing. FM TT reported one thing she hoped to avoid for Resident #4 was overhearing the staff gossip that took place while staff members interacted with Scheduler EE. FM TT reported Resident #4 repeated the information she heard and when asked, Resident #4 reported she heard it while Scheduler EE was checking staff in. FM TT reported although Resident #4 often didn't understand everything, she always paid close attention to what other's said and could pick up on the emotion involved in statements. FM TT reported during one meeting, in which Resident #4 was present, Director of Nursing (DON) B accused her of sucking the life out of (Resident #4). FM TT reported she felt the comment was inappropriate and added to Resident #4's emotional distress. In an interview on 3/17/25 at 11:20am, FM TT reported she also told the facility she was not comfortable with Scheduler EE referring to herself as Resident #4's godmother or calling the resident her goddaughter. FM TT reported using those terms would be confusing to Resident #4 as they would imply the scheduler was a family member. Review of an email written by FM TT to DON B dated 12/23/24 revealed (Resident #4) is mentally disabled .She must not hang out in (Scheduler EE s) office. Review of an email written by FM TT to DON B dated 12/24/24 revealed .as far as (Scheduler EE), it all started out good but not letters to god daughter from god mother I think is going a little bit to (sic) far . Review of an email written by FM TT to DON B dated 2/10/25 revealed I am requesting (Resident #4) not be in (Scheduler EE s) office .I feel that is a completely inappropriate relationship between (facility name) staff and a (facility name) resident .As (Resident #4's) guardian all private interactions between (Scheduler EE) and (Resident #4) must cease immediately. This includes but not limited to (Resident #4) being in (Scheduler EE s) office alone and (Scheduler EE) passing notes to (Resident #4). During an observation on 3/17/25 at 3:21pm, Resident #4 sat next to Scheduler EE in the scheduler's office. No other staff were present. In an interview on 3/17/25 at 3:38pm, Nursing Home Administrator (NHA) A reported FM TT had made several complaints about Resident #4 spending time with Scheduler EE, receiving notes from staff members and Resident #4 being referred to as Scheduler EE s goddaughter. NHA A reported FM EE felt the situations were inappropriate. NHA A then reported she felt FM TT doesn't want anything that makes (Resident #4) happy. NHA A reported based on Resident #4 voiced that she wanted to be called goddaughter but then added her (Resident #4's) wishes would go back and forth. NHA A reported the facility did not comply with FM TT s directions related to Resident #4 spending time alone with Scheduler EE, receiving notes from staff, or being referred to as Scheduler EE s goddaughter. NHA A reported Resident #4 had been present for a meeting with FM TT and facility staff and had become really upset during conflicts. In an interview on 3/17/25 at 10:40am, Scheduler EE reported Resident #4 regularly spent time in her office, and Scheduler EE enjoyed talking with her. Scheduler EE stated (Resident #4) brings me joy. Scheduler EE reported she liked to help Resident #4 manage her stress by helping her express her thoughts in a journal. Scheduler EE reported she transcribed Resident #4's thoughts in the journal for her. Scheduler EE reported she felt Resident #4 functioned as a [AGE] year-old child, rather than a 6-year-old as was documented in her medical record. Scheduler EE reported Resident #4 called her Godmother and she referred to Resident #4 as Goddaughter. Scheduler EE reported the facility allowed her to continue writing notes to Resident #4, and that she gave Resident #4 a note on this date that read BEE HAVE. In an interview on 3/17/25 at 1:11pm, Ombudsman QQ reported she had met with Resident #4 on several occasions. Ombudsman QQ confirmed that Resident #4 was inconsistent with statements regarding her wishes but had voiced that she enjoyed seeing Scheduler EE. In an interview on 3/18/25 at 2:19pm, FM TT reported Resident #4's mood had declined in recent months, and she began demonstrating behaviors she had never had before including breaking her cell phone three times, bouts of anger, refusal to see family members. In an interview on 3/18/25 at 2:54pm, Regional Director of Operations (RDO) RR reported staff members should fill out a concern form anytime a resident or family member had a concern. RDO RR reported the expectation was that the NHA would work to resolve any concerns and that the NHA kept him informed when concerns arose. RDO RR reported he was not aware FM TT wanted the staff to stop writing notes to Resident #4 and he expected that the NHA would have ensured the staff stop writing notes to the resident immediately. RDO RR reported he was aware that the stress of the situation impacted Resident #4 negatively. In an interview on 3/19/25 at 9:18am, FM UU reported Resident #4 was very soft hearted and could be easily lead astray. FM UU reported in recent months Resident #4's temperament had changed, and she'd become irritable, broken 3 cell phones, and at times refused to see FM UU and FM TT. FM UU reported until recently, she and Resident #4 were always very close, and Resident #4 would talk to her about her stressors. FM UU stated (Resident #4) is a different person in the last few months. FM UU reported she was concerned Resident #4 had become stressed and confused by the statements she'd heard facility staff say during meetings with her family. FM UU reported during one meeting DON B said Resident #4's family member was sucking the life out of her by not allowing her to do certain things. FM UU reported Resident #4 did not have the capacity to understand the complicated situation related to her family's concerns. FM UU described the environment for Resident #4 as unhealthy because she could not understand it when facility staff told her she had certain rights that she did not understand. In an interview on 3/19/25 at 10:51am, Social Work Director (SW) P reported Resident #4's mood had declined in recent months, and she appeared exhausted and defeated. SW P reported during a meeting with several facility staff, Resident #4's family members and Resident #4, a staff member told her she had the right to be friends with whomever she liked. SW P reported when she was asked what her wishes were, Resident #4 burst out crying and said she did not know what she wanted. When queried regarding non-direct care staff taking measures to attempt to assist a resident with their stress level, SW P reported it was not appropriate for those staff members to do so. In an interview on 3/19/25 at 12:02pm Medical Director (MD) SS reported Resident #4 did not have the capacity to consent to a relationship because she could not distinguish between a healthy versus a dysfunctional relationship. MD SS confirmed Resident #4 functioned as a 6-year-old child and as a result, he would expect the facility to honor the wishes of her guardians, including taking steps to ensure Resident #4 did not interact with Scheduler EE. In a second interview on 3/19/25 at 12:27pm, Scheduler EE reported Resident #4 displayed extreme mood swings in recent months and voiced she was stressed about the conflicts between the family and the staff. Scheduler EE reported she was aware FM TT did not want Resident #4 to receive notes from staff or spend time with her, but she felt Resident #4 enjoyed those things, so she wanted to continue those activities. Scheduler EE stated I feel it's inappropriate, regarding FM TT s wishes for Resident #4. Scheduler EE reported the facility developed a daily schedule for Resident #4 to spend time in her office doing tasks with her and required that the door be kept open. When further queried about how Resident #4 began completing tasks for her, Scheduler EE confirmed no member's of the Interdisciplinary Team had initiated that as a part of her plan of care. In an interview on 3/19/25 at 12:56pm, DON B reported she was aware that Resident #4 continued to receive notes from and spend time with Scheduler EE almost daily. DON B reported the facility allowed these activities to continue despite the wishes of Resident #4's guardian/family member because DON B felt it was within the resident's rights. DON B then stated, If it makes (Resident #4) happy, then FM TT is going to squelch it. DON B then stated, I'm not a psychiatrist, but I think (FM TT) has (name of psychiatric condition omitted) and I think she needs professional help. DON B confirmed that FM TT clearly expressed she did not want Resident #4 to spend time with Scheduler EE, did not want Resident #4 to be referred to as the goddaughter of Scheduler EE, and did not want staff to write notes to the resident. DON B confirmed no steps had been taken to follow these requests. When further queried, DON B confirmed the facility had not pursued any options for meeting Resident #4's needs while also complying with FM TT's wishes. DON B confirmed that Resident #4 cannot consistently make decisions for herself, and the facility should follow the wishes of the guardian. DON B confirmed FM TT did not want Resident #4 to take part in meetings regarding her care, that a behavioral health provider had recommended the resident should not be included, but DON B had been present for more than 1 meeting of this type in which Resident #4 was present. When further queried, DON B reported the facility felt Resident #4 had a right to be present for meetings regarding her care. DON B confirmed the meetings involving Resident #4's family and facility staff were intense at times and that Resident #4 had become emotionally upset during the meetings. When queried regarding DON B making a comment that her family member was sucking the life out of her, DON B stated I don't recall those words, but I did say she was draining the fun out of everything for (Resident #4). Using the reasonable person concept, though Resident #4 had decreased ability to verbally express her emotional distress due to her developmental barriers, she clearly experienced frustration, mental anguish and confusion from the ongoing conflict between the facility and the resident's family members, as well as the comments made in her presence. This mental anguish has the potential to continue well past the date of the incidents based on the reasonable person concept.

This citation pertains to Intake #MI00149109 Based on interview and record review the facility failed to maintain professional standards of nursing practice related to medication administration for 2 (Resident #2 and Resident #9) of 11 residents reviewed or professional standards of nursing practice resulting in both Resident #2 and Resident #9 being administered another resident's medications. Findings include: Resident #2 Review of Medication Error Report for Resident #2, dated 12/8/24 at 19:58 pm, (7:58 pm) completed by Registered Nurse (RN) II revealed . Resident administered roommate's (Resident #5) medications . In a telephone interview on 3/17/25 at 3:45 pm, RN II reported that on 12/8/24, Licensed Practical Nurse (LPN) T came from another hall to help her pass medications. RN II reported she was pulling medications (preparing them from the medication cart per the orders in the EMAR (electronic medication administration record) and giving the prepared medications to LPN T who was then administering the medication to the residents. RN II reported that she prepared all of Resident #5's evening medications, handed the medication cup to LPN T who then administered Resident #5's medications to Resident #2. RN II reported that the documentation in Resident #2 and Resident #5's EMAR were her initials indicating that she had administered Resident #2 and Resident #5's medications to them on 12/8/24, but it was LPN T who was administering mediations to residents. RN II reported that the nurse that prepares the medications should be the nurse who administers and documents the medications according to the 5 rights of medication administration. RN II reported passing medications with another nurse has not happened since. In an interview on 3/18/25 at 10:15 am, LPN T reported on 12/8/24 she was assisting RN II to administer medications and she administered them to the wrong resident. LPN T reported RN II prepped Resident #5's medications, gave them to her and she gave Resident #5's medications to Resident #2. When queried about medication administration practices, LPN T reported the nurse who pulls the medication should administer them and the nurses need to use the 5 rights, such as right resident, right medication. LPN T stated I will never help anyone pass meds again. In an interview on 3/18/25 at 11:05 am, DON B reported her understanding of the medication error was that LPN T went to help RN II and they were dividing and conquering to pass the medications. LPN T was given the cup of medications after RN II pulled the medications, and LPN T when into the room. DON B reported that the nurse who pulls the medications should be the nurse who administers the medications. DON B reported she expected the nurses to use the rights of medication administration. DON B reported that she spoke to both LPN T and RN II and assigned education to only LPN T for a one-to-one education on the topic of medication administration. Review of LPN T documented one-to-one education dated 12/10/24 revealed education included regarding medication errors: nurse must verify meds with 2 identifiers, ensure correct dose, frequency, time, route, patient, drug and documentation, take your time. The one-to-one education was signed by LPN T. Also included in LPN T one-to-one education was a form that revealed 10 rights of drug administration right drug, right patient, right dose, right route, right time and frequency, documentation, history and physical, drug approach and right to refuse, drug-drug interaction and evaluation, education and information There was no one-to-one education provided for RN II by the time of exit. Resident #9 Review of Medication Error Report for Resident #9 dated 1/10/2025 at 10:31 am, completed by RN S revealed after giving am medication realized that I had given another resident's medication to (Name Omitted) Resident #9 . In a telephone interview on 3/18/25 at 1:01 pm, RN S reported she mixed up the identity of Resident #9 with Resident #10. RN S reported that Resident #9 and Resident #10 both use reclining wheelchairs, were both in the dining room, and they were in close proximity to each other when she administered the wrong medications to Resident #9. RN S reported she knows who Resident #9 and Resident #10 are. RN S reported she received one-to-one education, and it included the 5 rights of medication administration. RN S reported that right resident was one of the rights to medication administration. In an interview on 3/18/25 at 12:44 pm, DON B reported when the medication error occurred for Resident #9, RN S was distracted by behaviors and other residents while she was in the middle of her medication pass. DON B reported that RN S had worked with Resident #9 for a long time and knew the residents in that part of the building well. DON B reported her one-to-one education for RN S was more detailed than the education for the medication error that occurred in December (for Resident #2's medication error), because there were different circumstances. Review of one-to-one education for RN S dated 1/10/2025 revealed .ensure the five rights of medication administration are adhered to. Every time you administer a dose, it's important to keep the five rights of medication in mind. This is one of the easiest ways to prevent medication errors in nursing and should be reviewed upon each administration of medication. These rights' include: the right resident .the right drug .the right dose .the right route .the right time . RN S is noted to have signed the one-to-one education. In an interview on 3/19/25 at 1:40 pm, Life Enrichment Aide (LEA) V reported that Resident #9 did not speak, and she did not believe she would be able to verbalize her own name. In an interview on 3/19/25 at 1:45 pm, Clinical Care Coordinator/Licensed Practical Nurse (CCC/LPN) DD reported he did not believe Resident #9 would verbalize her own name. CCC/LPN DD reported to identify a resident for medication administration the nurse should look at the picture in the medical record, and the name on the door of their room. When queried, regarding how to identify a resident who was unable to answer or verbalize or confirm their own name, CCC/LPN DD stated that's a good question, let's go ask the nurse, I would like to know how to also. In an interview on 3/19/25 at 1:50 pm, LPN C reported to identify a resident for medication administration she would look at the picture in the medical record and use the name on the door and administer medication per the 5 rights. In an interview on 3/19/25 at 1:55 pm, RN I reported to identify a resident for medication administration she would use the name on the door and then ask another staff if she did not know the resident. In an interview on 3/19/25 at 2 pm, DON B reported she would verify the name and picture in the medical record, and make sure the name on the medications matched. DON B reported she would use the resident name on the room door, and make sure the face in the bed matches. DON 'B stated the nurses who work the long-term halls know who the residents are. DON B reported that her expectations were that the nurses' verified the identity of the residents before they administered medications and administered medications they had prepared. Review of facility policy Section IID: Specific Medication Administration Procedures with a revision date of January 2015, revealed . 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered. Methods of identification include: .b. checking photograph attached to medical record . c. if necessary, verifying resident identification with other facility personnel .C. Documentation .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . Lippincott's online Nursing Center 2015 reflected 8 rights of medication administration: 1. Right patient 5. Right time 2. Right medication 6. Right documentation 3. Right dose 7. Right reason 4. Right route 8. Right response

This citation pertains to Intake #MI00149109 Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors in 2 (Resident #2 and Resident #9) of 2 residents reviewed for significant medication errors resulting in Resident #2 experiencing an altered level of consciousness, lethargy (decreased alertness and response), decreased oral intake, decreased blood pressure, and the need for supplemental oxygen. Findings include: Resident #2 Review of an Admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes (a long-term condition where the body does not use insulin properly and there is too much sugar circulating in the blood), hypertension (high blood pressure), and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 1/2/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #2 was cognitively intact. (BIMS score 13-15 indicates cognitively intact). Review of Medication Error Report for Resident #2, dated 12/8/24 at 19:58 pm, (7:58 pm) completed by Registered Nurse (RN) II revealed . Resident administered roommate's (Resident #5) medications .(including) buspirone HCl tablet 10mg x 2, (anti-depressant), clonazepam oral tablet 0.25 mg (anti-psychotic), apixaban oral tablet 5 mg (anti-coagulant/blood thinner), Senna oral tablet 8.6 mg (laxative), senna- plus 8.6-50 mg (laxative/stool softener), Tropism Chloride oral tablet 20 mg (treats over active bladder and urinary incontinent), Atorvastatin 20 mg (cholesterol medication), insulin 8 units injection subcutaneous (diabetes/high blood sugar), Latuda oral tablet 40 mg (depression associated with bipolar disorder), Melatonin 3 mg x 2 (two tablets) (sleep aid), Morphine Sulfate 15 mg (narcotic pain medication) . In a telephone interview on 3/13/25 at 12:10 pm, Family Member (FM) MM reported he was notified via telephone on 12/8/24 at about 7:45 pm by Licensed Practical Nurse (LPN) T, a nurse who was working at the facility that night and was told that she had administered Resident #2's roommates'(Resident #5) medications to Resident #2. FM MM reported he inquired as to what medication was given to his mother, Resident #2 and LPN T denied answering that question. FM MM reported the facility had never communicated to him what medications Resident #2 received that day. FM MM reported for 3 days he attempted to reach staff, including Nursing Home Administrator (NHA) A and Director of Nursing (DON) B, at the facility to get an update on Resident #2's condition and had to leave messages, or was rushed off the phone by staff. FM MM reported he felt as if he was being brushed off, ignored, and that Resident #2's condition was not a concern for the staff. FM MM' reported he was frustrated by the lack of communication from the facility, as he resides out of state and was not able to visit Resident #2. FM MM reported he had to reach out to Resident #2's hospice provider to assess Resident #2 and to receive an update on her condition via a telephone call after Resident #2 was assessed, where he was assured by a hospice nurse that Resident #2 was doing ok and was coming out of it (the adverse effects of the medication error). During an interview on 3/13/25 at 1:05 pm, Resident #2 greeted this surveyor and stated her name. When queried, Resident #2 reported she recalled a time a while back when she was out of it but she did not recall any further details. In a telephone interview on 3/13/25 at 2:48 pm, FM NN reported she visited her mother, Resident #2 on Tuesday, December 10, 2024, two days after the medication error occurred and Resident #2 was completely out of it, hallucinating, hard to wake up, unable to stay awake. FM NN stated my mother did not know who I was. FM NN reported that Resident #2 knew all her children on sight and was usually very talkative. FM NN reported on that day Resident #2 was wearing oxygen and that Resident #2 had not needed oxygen in several months. FM NN reported she felt completely helpless when she saw Resident #2 in that condition and was not sure Resident #2 would come out of it. In a telephone interview on 3/17/25 at 9:34 am, FM OO reported he visited his mother, Resident #2 the day after the medication error occurred and Resident #2 was in never never land. FM OO reported Resident #2 appeared to be spaced out and could not comprehend who he was or what he was saying. FM OO reported he spoke to Clinical Care Coordinator/Licensed Practical Nurse (CCC/LPN) DD and was assured that the medications Resident #2 received were not that potent and that Resident #2 would come out of it in about 8 hours. FM OO reported it was two and a half weeks before Resident #2 was completely coherent during visits again. In an interview on 3/17/25 at 1:30 pm, LPN BB reported that Resident #2 did have a medication error a few months back. LPN BB reported two nurses were working together to pass the medications to the residents on the hall and Resident #2 got Resident #5's evening medications. LPN BB reported she had not received any education regarding medication administration after that incident. In a telephone interview on 3/17/25 at 3:45 pm, RN II reported she had stayed over to help out into the evening shift to cover the hall where Residents #2 and #5 resided as there was not a staff member for the assignment. RN II reported that she was behind with the medication pass, and that LPN T came from another hall to help her. RN II reported she was pulling medications (preparing them from the medication cart per the orders in the EMAR (electronic medication administration record)) and giving the prepared medications to LPN T who was then administering the medication to the residents. RN II reported that she prepared all of Resident #5's evening medications, handed the medication cup to LPN T who then administered Resident #5's medications to Resident #2. RN II reported Resident #5 takes several medications in the evening, and that she had prepared all of Resident #5's medication that were due at that time and gave them to LPN T to administer. RN II reported they were most concerned with Resident #2 reaction to receiving insulin and morphine sulfate. Review of Resident #2's medical record revealed no noted documentation regarding her being administered the wrong medications on 12/8/24. Review of Nurses Notes for Resident #2 revealed 12/9/24 17:37 (5:37 pm) Resident was tired today-she would respond to questions and would wake up upon asking questions but the minute we left the room she went back to sleep. Denied breakfast and lunch . 12/9/24 23:25 (11:25 pm) Resident lethargic this shift. Resting in bed sleeping with even respirations noted. No facial grimacing or groaning, resident does not seem to be in any pain. Vitals assessed with low BP (blood pressure) of 96/60 but resident remains stable. Remains on 2L O2 (2 liters of oxygen) via NC (nasal cannula) with sat (oxygen saturation) of 97 (90-100 indicates adequate oxygenation). Resident was able to take all scheduled medications PO (by mouth) with meds crushed in pudding . 12/10/24 4:25 am Resident remains lethargic, however every time resident awakes for vital checks she gradually seems more alert VSS (vital signs stable) and documented throughout shift. Review of Resident #2's medical record revealed no noted documentation of a provider visit following the medication error that occurred on 12/8/24. Review of Facility Visit and Collaboration Form for Resident #2 dated for 12/10/24 at 19:40 (7:40 pm) revealed .PRN (as needed) visit per son's request . indicating Resident did not look good today . her RR (respiratory rate) was 17 bpm (beats per minute), slightly irregular .oxygen at 2L via nasal cannula .she focused on this RN throughout visit, but did not say any words .offered her a some water with a cup and straw . did not appear to know how to use the straw .spoke with Competency-Evaluated Nursing Assistant (CENA) AA and CENA HH who reported that (Resident #2) has been more tired and out of it these past few days . In an interview on 3/18/25 at 11:05 am, DON B reported her understanding of the medication error was that LPN T went to help RN II pass medications, it's a long hall (indicating there are many residents on that hallway) and I don't remember what happened, and they were dividing and conquering to pass the medications, LPN T was never assigned to work that hall, and LPN T got the cup of medications after RN II pulled the medications, and LPN T when into the room. Resident #2 was on one side, and Resident #5 was on the other side and LPN T gave Resident #5's medications to Resident #2. DON B stated there didn't appear to be any negative outcome. DON B reported that she spoke to both LPN T and RN II and assigned education to only LPN T for a one-to-one education on the topic of medication administration. When queried, DON B reported that all nursing staff were not educated on medication administration at that time, but it was a topic of the all-staff meeting on 1/15/25. Review of LPN T documented one-to-one education dated 12/10/24 revealed education included regarding medication errors: nurse must verify meds with 2 identifiers, ensure correct dose, frequency, time, route, patient, drug and documentation, take your time. The one-to-one education was signed by LPN T. Also included in LPN T one-to-one education was a form that revealed 10 rights of drug administration right drug, right patient, right dose, right route, right time and frequency, documentation, history and physical, drug approach and right to refuse, drug-drug interaction and evaluation, education and information There was no one-to-one education provided for RN II by the time of exit. Resident #9 Review of an Admission Record revealed Resident #9 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: alzheimer's disease and dementia. Review of Medication Error Report for Resident #9 dated 1/10/2025 at 10:31 am, completed by RN S revealed after giving am medication realized that I had given another resident's medication to (Resident #9). (Resident #9) received losartan 25 mg (blood pressure medication), magnesium 400 mg (vitamin), metformin 1000 mg (diabetes medication), pantoprazole DR 40 mg (stomach acid reducer), Senna-Docusate 8.6-50 mg (laxative and stool softener) two tabs . Review of Active Discharge Planning Note for Resident #9 dated 1/10/25 at 10:51 am revealed (Resident #9) received Losartan 25 mg, Magnesium 400 mg, Metformin 1000mg, Pantoprazole DR 40mg, Senna-Docusate 8.6-50 mg 2 tabs this am. Doctor informed, ordered to recheck VS (vital signs) in 4 hours. Will continue to monitor. No other documentation noted in Resident #9's medical record regarding Resident #9 receiving wrong medications on 1/10/25 or continued monitoring. In an interview on 3/18/25 at 12:44 pm, DON B reported when the medication error occurred for Resident #9, RN S was distracted by behaviors and other residents while she was in the middle of her medication pass and RN S informed DON B immediately after it happened. DON B reported her one-to-one education for RN S was more detailed than the education for the medication error that occurred in December (for Resident #2's medication error), because there were different circumstances. DON B reported that all staff were educated on 1/15/25 regarding medication errors during an all-staff meeting. In a telephone interview on 3/18/25 at 1:01 pm RN S reported she mixed up the identity of Resident #9 with Resident #10. RN S stated there are always things going on and there is a resident who is after everyone else's food, there are a lot of behaviors, and the television can be too loud, all those things can distract from medication administration. RN S reported that Resident #9 and Resident #10 both use reclining wheelchairs, were both in the dining room, and they were in close proximity to each other when she administered the wrong medications to Resident #9. RN S reported that she received one-to-one education regarding the medication error. In an interview on 3/19/25 at 9:45 am, DON B provided a typed word document that revealed Timeline for medication errors .12/8/24 .Resident #2 administered incorrect medication .root cause: did not verify resident identity .12/10/24 LPN T one-to-one education .1/10/25 .Resident #9 administered incorrect medication root cause: did not verify resident identity .1/15/25 nurses educated at monthly staff meeting . DON B confirmed that she had just created this documented timeline for the multiple medication errors that had occurred. In an interview on 3/19/25 at 2 pm, DON B reported that her expectations were that the nurses' verified the identity of the residents before they administered medications. Review of facility policy Section IID: Specific Medication Administration Procedures with a revision date of January 2015, revealed . 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered. Methods of identification include: .b. checking photograph attached to medical record . c. if necessary, verifying resident identification with other facility personnel .C. Documentation .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, or serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen. Findings include: During an initial tour of the kitchen, at 9:31 AM on 10/8/24, an open bottle of lemon juice was found stored on a dry storage shelf with spices and seasonings. Observation of the bottle found that roughly 20% of the contents was left. The contents were observed milky and discolored and further observation of the manufacturer's label found that the item states Refrigerate After Opening. The bottle was shown to Dietary Manager (DM) EEE and was discarded at this time. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. During a tour of the kitchen, at 9:36 AM on 10/8/24, it was observed that four full pans were found stacked and stored wet on the clean pots and pans storage rack. When asked if there was a drying rack that staff would use, DM EEE stated that staff should let the pots and pans fully dry on the rack by the three-compartment sink. According to the 2017 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD . During a tour of the meal service, starting at 11:32 AM on 10/8/24, it was observed that [NAME] FFF was found to be plating residents meals wearing gloves and having artificial fingernails roughly an inch in length. After plating numerous resident meals, some of [NAME] FFF nails were found to have broken through her gloves and were observed protruding through the finger tips. The surveyor watched as more than a dozen plates were plated while [NAME] FFF had her nails coming out of her gloves. During this time, it was also observed that the handle of the mechanical scoop used for Mac and Cheese and the tongs for the green beans, occasionally fell into the product between plating and stayed in the dishes until each product was needed on another plate. During meal service, at 12:25 PM on 10/8/24, it was observed that [NAME] GGG stepped in to start serving food on the line. During this service it was observed that cook GGG had plated green beans and realized that the resident's meal ticket would need a different vegetable, discarded the green beans back into the steam table and continued plating the resident's tray as needed. According to the 2017 FDA Food Code section 2-302.11 Maintenance of Fingernails (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. According to the 2017 FDA Food Code section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the FOOD with their handles above the top of the FOOD and the container . According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 -3-306.

This citation pertains to intake MI00146660. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs for 6 (Resident #19, Resident #20, Resident #71, Resident #333, Resident #51, and Resident #60 ) of 3 residents and residents from the confidential group interview reviewed for staffing, from a total sample of 27 residents, resulting in long call light wait times and resident care needs not being consistently met with the potential for unmet care needs for all residents residing in the facility. Findings include: During an interview on 10/10/24 at 1:00 PM, Scheduler RR reported that she was responsible for scheduling nurses and certified nursing assistants (CNA's) in the facility based on the acuity and needs of the residents. Scheduler RR reported that she had received workload concerns from the facility staff all the time. Scheduler RR reported that she had received the most complaints about staffing on the facility's 200 and 500 hall, which seemed to have the heaviest workload for staff. This writer informed Scheduler RR of the observations of residents on the 200 hall that had not received any morning care by 12:30 PM. Scheduler RR reported that she felt that the residents needs not being met timely on the 200 hall was not a staffing issue, but an issue with one particular CNA. Scheduler RR reported that there was one CNA that was very precise with care, and did everything the right way and took more time with each resident than she should. This writer queried on how much time Scheduler RR felt was appropriate for a CNA to spend with each resident, and Scheduler RR reported that she was not able to report how much time she felt was appropriate. Scheduler RR reported that she was not a clinical staff member, so she did not know what kind of care assistance each resident on the 200 hall required, or an estimated time that should be allotted for staff assignments. Scheduler RR reported that she had never gone to the hall to observe cares and assignments for staff, and that this would be something that nursing management would need to do. Scheduler RR reported that she would never consider moving the CNA to another hall with residents that required less care because the residents on the 200 hall loved her because she did a good job. Scheduler RR confirmed that the CNA that she felt took too long had also voiced concerns to her about not being able to manage the workload on the hall. Scheduler RR reported that she did not have the pull to adjust the schedule to accommodate the halls that had a heavier work load with more staff, and that was up to nursing management. 41027 Resident #19 Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 8/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #19 was cognitively intact. Review of Resident #19's Care Plan revealed, Focus: .At risk for urinary/bowel incontinence r/t (related to) parkinson's .I have actual ADL (activities of daily living) deficit r/t parkinson's (a disorder of the central nervous system (brain and spinal cord) that causes difficulty with movement.) .Interventions: .non ambulatory, bed bath/shower: Monday & Thursday 1st shift, Transfer 1 PA (person assist) .Bed mobility 1 PA . During an observation and interview on 10/08/24 at 11:55 AM in Resident #19's room, the resident was lying flat in his bed, his pants were visibly wet and there was a strong odor of urine. Resident #19 reported that when he asks staff for assistance, they tell him that they will be right back, but they never do. Resident #19 reported that he wasn't going to ask for assistance anymore, unless it was an emergency because all the good staff don't work in the facility anymore, and there's not enough of the other staff. Resident #19 reported that he would not be getting out of bed either, because there was never anyone available when he wanted to lay back down. During an observation and interview on 10/10/24 at 11:36 AM in Resident #19's room, the resident was lying flat in his bed, with a sheet wrapped around the bottom half of his body, and there was a strong odor of urine in the room. Resident #19 reported that he preferred a shower vs. bed bath, but had not gotten a shower yet this week, and that he likely would not get it that day either. In an interview on 10/10/24 at 12:03 PM, Certified Nursing Assistant (CNA) AA reported that at times Resident #19 would decline assistance, but that she had not gotten a chance to check in with him yet that day. CNA AA reported that she started her shift at 6:30 AM and tried to get into Resident #19's room before noon, but that she had no time that day. CNA AA reported that Resident #19 was supposed to have gotten a shower that morning. During a subsequent observation and interview on 10/10/24 at 01:42 PM in Resident #19's room, the resident was lying in bed and there was still a strong odor of urine. Resident #19 reported that he had not received any assistance yet that day and stated, .my requests have been put in, and that's usually all that happens .it would be nice to get some attention and get cleaned up. Review of Resident #19's Shower Task indicated that he had received 3 showers since 9/12/24. Resident #20 Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #20 was cognitively intact. Review of Resident #20's Care Plan revealed, Focus: Skin Management - At risk for additional skin breakdown .hx (history) of Stage 4 sacral ulcer, hx of Stage 4 pressure ulcer right medial foot .MASD (moisture associated skin damage) buttocks to my intergluteal cleft .Interventions: .assist me with floating my heels .Please help me get turned and repositioned while in bed or in my wheelchair as needed .Focus: I have actual ADL deficit .Interventions: .non-ambulatory .bed mobility 2 PA . During an observation and interview on 10/08/24 at 12:01 PM in Resident #20's room, the resident was lying in his bed. Resident #20 reported that he would like to get up into his chair everyday, but that there is not enough staff to help him. Resident #20 reported that when he presses his call light, the staff shut it off and say that they will be right back, but don't come back. Resident #20 reported that staff talk about being short handed, and that he hears them talking in the hall about who has enough time to do things, or which resident's that they still need get to. Resident #20 reported that occasionally staff will offer him to get out of bed, but then make it sound like its going to be a difficult task, so he doesn't always ask. Resident #20 reported that he would like to get out and/or see what they have going on in activities, but its such a big ordeal to get him in and out of bed, that he rather not even try. During an observation on 10/08/24 at 02:49 PM Resident #20 was observed in his wheelchair in his room. During an observation and interview on 10/10/24 at 11:47 AM Resident #20 was lying in his bed, positioned on his left side with a pillow tucked under his right side, wearing a facility gown. Resident #20 reported that he was up in his chair the day before for a couple of hours, and when he wanted to lay back down, there was no one available, but that eventually staff from another hall came to help. Resident #20 reported that he had not had any cares provided yet that day, and that he had been in the same position since the day before. Resident #20 reported that his room is always the last room that staff come to when they do their rounds, and sometimes they don't come at all. In an interview on 10/10/24 at 12:03 PM, CNA AA reported that she had not gotten a chance to check on Resident #20 yet that day. CNA AA reported that there were 3 aides on the hall that day, and she still did not have time to get to every resident, every 2 hours. In an interview on 10/10/24 at 12:11 PM, Clinical Care Coordinator (CCC) G reported that there was sufficient staff that day, and that Resident #19 and #20 both should have been rounded on and provided cares 2-3 times since 6:30 AM that day. During an observation on 10/10/24 at 01:02 PM in Resident #20's room, CNA AA was preparing to provide cares and get the resident out of bed and into his wheelchair. At 1:16 PM Licensed Practical Nurse (LPN) P entered the room to assist with turning and incontinence care. There was a foul odor when Resident #20 was rolled onto his side. Resident #20's soaker pad, underneath him was observed soiled with brown and red liquid substance, the bottom sheet was soiled, and his incontinence brief had blue lines, indicating that it was wet. 41424 In a confidential interview for resident council on 10/10/24 at 11:08 AM, Thirteen residents reported the call light wait times were long, and the facility was short staffed especially on nights and weekends. Nurses were having to cover two hallways and report they can't get to the resident's requests for assistance. Medications were being delivered late because of the staffing issue. Four residents reported they had to wait for someone to take them to the restroom and were concerned about soiling themselves. Residents reported they were told to go to the bathroom in their briefs. One resident reported that was degrading to soil their brief on purpose and they were not a child. It was reported there were times the call light wasn't answered for approximately an hour. Multiple residents reported the staff shut off the call light and say they will come back and then they don't come back to assist the resident. Resident #71: Review of an Admission Record revealed Resident #71 was a female with pertinent diagnoses which included cerebral palsy with spastic quadriplegia, depression, legal blindness, and moderate intellectual disabilities. In an interview on 10/9/24 at 12:12 PM, Family Member (FM) YY reported the staff were not doing rounds every two hours as they were supposed to do, Resident #71 had redness and a rash due to not being taken to the restroom and not being changed. Resident #71 reported second shift was not very good at toileting or changing her every two hours. Resident #333: During an observation on 10/08/24 at 11:52 AM, Resident #333 was observed seated in her wheelchair. In an interview, Resident #333 reported she required staff assistance to get into bed and she had to wait until 12:30 -1:00 AM before staff came and assisted her to bed. She reported she had turned on her call light and was told that she didn't need to turn it on again. Resident #333 reported she thought her call light had been turned off or it was not working since no one had come to assist her to bed. Resident #51: Review of an Admission Record revealed Resident #51 was a female with pertinent diagnoses which included ulcer of right lower extremity, lymphedema, kidney disease, chronic pain, deep vein thrombosis (blood clot) and migraine. In an interview on 10/09/24 at 08:50 AM, Resident #51 reported the facility did have short staffing, sad that staff had to work by themselves on this unit. Resident #51 reported on the weekends the facility was short staffed all three shifts. Resident #51 reported she had an injury to her ankle one Sunday as the CNA was rushing to get me ready for church and she was the only one, that should never happen that she had to be by herself. We were rushing and she was helping me get dressed for church and get out of here on time to go to church. My ride was here and we were rushing to get the entrance and my foot got caught in the wheelchair and my ankle was hurt. Review of Physician's Note dated 9/30/24 at 1:37 PM, revealed, .ASSESSMENT/PLAN: Right ankle pain -patient noted injury one week ago where ankle was caught in her wheelchair. Suspected to be sprain at that time. Patient noting continued pain with ambulation and movement. Will order x-ray to r/o (rule out) acute process or occult fracture -encourage supportive care, rest and elevation .-continue pain regimen as seen below .-monitor for improvement . Resident #60: Review of an Admission Record revealed Resident #60 was a male with pertinent diagnoses which included stroke, cognitive communication deficit, pain in right ankle and joints of right foot, cellulitis of right lower limb, and muscle weakness. Review of current Care Plan for Resident #60, revised on 9/5/24, revealed the focus, .Risk of falls r/t (related to) COPD, HTN (high blood pressure), PVD (peripheral vascular disease) . with the intervention .Septic arthritis of right ankle .WBAT (weight bearing as tolerated) with RLE (right lower extremity with surgical boot .Ambulation with 1 PA (physical assist) . Review of Physician's Note dated 10/8/24 at 3:28 PM, .Continue to assist with ADLs as needed and provide a safe environment . In an interview on 10/08/24 at 02:48 PM, Resident #60 reported the staff took a long time to come to assist him when he needed to use the restroom and he soiled himself and needed to have his clothes changed. Resident #60 was upset by this as he can use the bathroom and needed their help to get there because of his foot/ankle was broken. Resident #60 reported he was also receiving antibiotics by IV in his PICC line (Peripherally inserted central catheter (PICC) was a thin flexible tube that's inserted into a vein in the upper arm and threaded into a large vein near the heart). In an interview on 10/10/24 at 02:07 PM, Licensed Practical Nurse (LPN) T reported the call lights' were sent to pagers for the CNAs, there were screens which informed the staff of the call lights for any room in the building and could hop around the corner to assist. LPN T reported the staff try to answer the call light within 15 minutes at the most. The screens let staff know how long the call light had been activated. In an interview on 10/10/24 at 02:10 PM, Certified Nursing Assistant (CNA) NN reported the staff should have an immediate response to the call light system. CNA NN reported the call light system was for the residents to alert staff they needed assistance, it could be for several things, like water or ADL (activities of daily living) care. In an interview on 10/10/24 at 02:11 PM, Clinical Care Coordinator (CCC) F reported the expectation to answer within 10-15 minutes. The CNAs were alerted via the pager system. The call light system used to ensure patient needs were met when they arise.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted and resident dignity in 2 (Resident #60 and #71) of 3 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: Resident #60: Review of current Care Plan for Resident #60, revised on [DATE], revealed the focus, .Risk of falls r/t (related to) COPD, HTN (high blood pressure), PVD (peripheral vascular disease) . with the intervention .Septic arthritis of right ankle .WBAT (weight bearing as tolerated) with RLE (right lower extremity with surgical boot .Ambulation with 1 PA (physical assist) . In an interview on [DATE] at 02:48 PM, Resident #60 reported the staff took a long time to come to assist him when he needed to use the restroom and he soiled himself and needed to have his clothes changed. Resident #60 was upset by this as he can use the bathroom and needed their help to get there because of his foot/ankle was broken. Resident #60 reported he was also receiving antibiotics by IV in his PICC line (Peripherally inserted central catheter (PICC) was a thin flexible tube that's inserted into a vein in the upper arm and threaded into a large vein near the heart). In an interview on [DATE] at 02:07 PM, Licensed Practical Nurse (LPN) T reported the call lights' were sent to pagers for the CNAs, there were screens which informed the staff of the call lights for any room in the building and could hop around the corner to assist. LPN T reported the staff try to answer the call light within 15 minutes at the most. The screens let staff know how long the call light had been activated. In an interview on [DATE] at 02:10 PM, Certified Nursing Assistant (CNA) NN reported the staff should have an immediate response to the call light sytem. CNA NN reported the call light system was for the residents to alert staff they needed assistance, it could be for several things, like water or ADL (activities of daily living) care. In an interview on [DATE] at 02:11 PM, Clinical Care Coordinator (CCC) F reported the expectation to answer within ,d+[DATE] minutes. The CNAs were alerted via the pager system. The call light system used to ensure patient needs were met when they arise. Resident #71: Review of an Admission Record revealed Resident #71 was a female with pertinent diagnoses which included cerebral palsy with spastic quadraplegia, depression, legal blindness, and moderate intellectual disabilities. Review of current Care Plan for Resident #71, revised on [DATE], revealed the focus, .I have a history of trauma .I have an alteration in my MOOD state r/t (related to) depression . with the intervention .Allow me to express my feelings, observe for any changes in my mood and my response to treatment, make a referrla to psych services/supportive therapy as needed .provide me reassurance when I am feeling anxious, depressed, tearful, or angry . In an interview on [DATE] at 12:04 PM, Family Member (FM) YY reported on Sunday ([DATE]) she was contacted by Licensed Practical Nurse (LPN) Q and he told me what he had said to her. LPN Q told her that he said to (Resident #71) that her sister died last night. FM YY reported she did not understand what made him randomly say that to her. Resident #71 reported, That was a cruel joke .He made me cry .Make me upset I think about it all the time .I had a hard time sleeping thinking about it This writer obseved Resident #71 attempt not to cry. FM YY reported we requested a couple months ago for her to see someone and now she had been traumatized again. In an interview on [DATE] 03:08 PM, Director of Nursing (DON) B reported she had receieved a phone call from LPN HHH informed Resident #71 was crying and upset as LPN Q had told her, her sister had passes away last night per Resident #71. DON B reported she spoke to LPN Q and he informed her they were bantering back and forth and with his odd sense of humor had told her sister had passed away, she didn't like that and told him it was not funny, she became angry and she wheeled back to her hallway. DON B informed LPN Q the allegation would need to be investigated, he asked if he should call FM YY and inform her of the incident and to apologize. DON B reported he contacted FM YY and apologized. In an interview on [DATE] at 03:39 PM, Licensed Practical Nurse (LPN) Q reported he blurted it out to Resident #71, he heard her sister passed and it was thoughtless bantered back and forth, darkest of humor blurted it out and said he reported he immediately said he was just joking, LPN Q reported (Resident #71) smiled and wheeled away. LPN Q reported shortly after he heard she was crying, upset, and prett worked up. LPN Q asked if I could give her a hug, as she was a [NAME], but she told me, No. LPN Q reported he was told later she had the brain function like a child and he did not realize that as he doesn't work with her. LPN Q reported he had crossed the line, and it was below the belt.

This citation pertains to intake MI0014870. Based on interview and record review, the facility failed to prevent significant medication errors for 2 (R102 and R105) of 3 residents reviewed for medication errors, resulting in a change in condition, emergent transfer, and hospitalization for R102 and the potential for change in condition for R105. Findings include: According to R102's medical records diagnoses included multiple sclerosis (MS) (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), and epilepsy (seizure). According to Seizures and multiple sclerosis more than an epidemiological association (Review) - PMC (nih.gov), Multiple sclerosis (MS), the most common inflammatory pathology of the central nervous system (CNS) . MS is associated with significant comorbidities .neurological disorders such as epilepsy, have a higher prevalence in patients with MS . Review of R102's Order Summary [DATE], reported: - Levetiracetam (Keppra)oral tablet 1000 mg, give 2 tablets by mouth 2 times a day (BID) related to epilepsy -Clobazam oral tablet 10 mg, give 1 tablet by mouth at bedtime (HS) related to epilepsy -Glatiramer Acetate subcutaneous (under the skin) solution prefilled syringe 20mg/ml. Inject 1 ml subcutaneously one time a day related to Multiple Sclerosis . epilepsy. Review of R102's Medication Administration Record (MAR), dated [DATE]-[DATE], reported the resident did not decline/miss any doses of Clobazam, or Levetiracetam. However, she was documented as refusing a dose of Glatiramer on [DATE]. Review of R102's MAR, dated [DATE]-[DATE], reported the resident did not decline/miss any doses of Clobazam, or Levetiracetam. However, she was documented as refusing a dose of Glatiramer on [DATE] and [DATE]. It was noted both on the January and February 2024 MAR the same nurse documented the medication refusal for Glatiramer with no other medications, all by mouth, refused. Review of R102's Care Plan revision [DATE], reported a focus on ADL (activities of daily living) deficit related MS and seizure disorder, with refusing at times care, medication, and meals. The goal was to actively participate in activities using interventions that included reapproaching with refusals. Review of R102's Progress Note [DATE] 10:15 (AM) reported speaking with the resident's daughter who had concerns about her mother's medication. Review of R102's Progress Note [DATE] 12:53 (PM) reported the resident was having multiple seizures that morning and one the night before. The on-call physician had been notified and gave the okay to send to the ED (emergency room ). Daughters were notified at this time. Review of R102's Progress Note [DATE] 19:12 (7:12 PM), reported a daughter came into the facility and picked up 5 Glatiramer Acetate injections as hospital is unable to get them. Review of R102's Progress Note [DATE] 13:15 (1:15 PM), reported a daughter returned 5 vials of medication. Review of a Concern/Grievance Form for R102 reported the date of concern occurred on [DATE]. The person receiving the concern was NHA A on [DATE]. R102's daughters came to the facility to discuss with NHA A possible missed medication administration and lack of communication from the facility. An investigation/review/and action taken reported the facility was only able to confirm documented missed doses of any medications. The facility shared with the family members R102 only refused her Glatiramer injections once in February (2024). It was noted there was no mention of the two missed doses in January (2024). Review of R102's Emergency Department (ED) to Hospital Admission notes, dated: -[DATE], reported the ED physician described the resident as disoriented and was concerned for intracranial (brain) process given the recurrent seizures. Diagnosis at time of hospital admission was 1. Seizures 2. Subdural hemorrhage (bleeding in the brain) possibly related to seizure activity; no trauma suspected. Keppra (antiseizure medication) level was below therapeutic level at 2.5. EMS reported the nursing facility noted 12 seizures in total since morning ([DATE]). EMS was informed by the facility R102 no reported missed dose of her seizure medications. EMS noted 3 seizures enroute with right-sided tonic-clonic movement with altered mental status (AMS). Reportedly R102 had no missed doses of medications however, Keppra dose was low on labs drawn in the ER (<2.5). She was admitted for further medical management. -Updated note [DATE]: Keppra level undetectable on admission which is likely cause of break through seizures .She is now residing in a facility that administers her medications so unclear why she would not be receiving Keppra . -Patient's seizure secondary to noncompliance to medications .It was noted there was no documented refusals of Keppra in R102's MAR for January and February 2024. During an interview on [DATE] at 2:15 PM, Family Member (FM) D stated, My mother (R102) has taken Glatiramer shots daily for [AGE] years for MS. She has seizures because of the MS. Before my mother was fully admitted to the facility, we were told by (Director of Nursing (DON) B) the facility would not pay for it, that me or my sister (co-guardians) would have to get the medication from a pharmacy and bring it to the facility. Glatiramer comes to a special pharmacy in a cooler, and I take it to the facility. It must be kept in the refrigerator. (Licensed Practical Nurse (LPN) I) called me at 8:30 AM on [DATE], telling me my mother was having seizures that started during the night. I asked why my mother was having seizures. (LPN I) said when she left on Wednesday ([DATE]) the same number of Glatiramer shots were in the refrigerator when she came back after a day or two off along with a full box. Each box holds 30 shots. The medications have lot numbers that I keep track of. The facility never asked for any paperwork for lot# or quantity. (LPN I) told me there had been 4 shots from the previous lot number plus another full box. Each box has 30 shots. She told me she had broken a syringe and had to use another one so there were 2 left of lot #4 and a full box of lot #5 on [DATE]. So that would be 32 shots on [DATE]. Fifteen minutes after (LPN I) first called me 15 minutes later she called me back and said the facility was not able to stop the seizures and was sending my mother to the hospital. EMS (Emergency Medical Services) came to the facility to get our mother. My mother was admitted to the ER (emergency room /Hospital) at 9:45 AM. I talked directly to the intake nurse at the hospital who told me the facility shared with EMS they witnessed 12 seizures. Then EMS witnessed 3 seizures during transport. I went to the facility the day or so and took 5 of the Glatiramer shots from the full box lot #5 up to the hospital because I did not know if they would have them. The hospital said they already had them, so I took them back to the facility. I had a conversation then with (Nursing Home Administrator (NHA) A and the Assistant Director of Nursing (ADON) who said she put them in the refrigerator. They told me my mother was refusing her medications. No one told me she was refusing. No one at the facility told me she was not getting her medication. The only time my mom has had seizures like this before. She had seizures on [DATE] but not 12. The only time a seizure would be provoked if she did not get her medications. My mother was at the hospital from [DATE] until [DATE]. The hospital found a brain bleed during testing and was then admitted . The staff there talked to my sister about her seizures and said there was an advancement with her MS. My overall frustration with the facility lies with lack of their communication. Every time my mom has a seizure it puts her 10 steps back. Her last seizure was on her birthday last year. Her husband had recently died , and she was pretty upset. But she did not have multiple seizures. The facility was so complacent with thinking a sorry would help. There are other people's parents in the facility. We are putting our trust in people to take care of our parent. It was clearly my mother was not getting her medication for months. To know there was a whole month plus longer of shots that my mom went without is scary. That box with lot #5 should have been used. The facility never gave me a receipt when I delivered the medications. Lot #4 was for the month of January. I had just recently gone to the facility for a care conference on [DATE]. They said she was stable at that time. I state, lot #4 and lot #5 because when I get the boxes, they had printed on them Lot # A 080004 had 4 as the last number. It was dated for [DATE] with a quantity of 30 shots. The next shipment was to be for [DATE]. On [DATE] she would have had a week of shots left over but she had 30 left over. My mother was not cared for like she was supposed to be. They caused my mother harm and caused her to have multiple seizures. During an interview on [DATE] at 10:00 AM, Pharmacist K stated MS is a degenerative disease of the myelin sheath (insulating layer, or sheath that forms around nerves, including those in the brain and spinal cord) around nerves which causes the body to attack the nerves as a foreign body. Glatiramer acts like a substitute insulator/replacement around the nerves, so the body is less likely to attack the nerves. The medication is an amino acid that replaces sheaths of the nerves and alters the antigen. It is possible the medication could help the body not to have seizures. Not getting the Glatiramer will cause the gradual degeneralization of the nerve sheath. Not getting medication is not ideal. During an interview and record review on [DATE] at 1:32 PM, Corporate Clinical Consultant (CCC) L, NHA A, ADON M and Director of Nursing (DON) B reviewed R102's medical chart with DON B stating, (R102) had medication refusals on [DATE], [DATE], and February 2 (2024) all by the same nurse. When a nurse documents DD in the MAR/TAR, is means the medication was declined and that auto-populates a progress note that states the resident declined the medication. I do not see any other medications were declined that day. I am not familiar with (R102) giving any reason for refusing. When (R102) first came to the facility, the facility could not get the medication (Glatiramer) through our pharmacy or the specialized pharmacy, so the family supplied it. The family brought the medication in on 200 hall where the resident lived. It had to refrigerated. The facility let (Family Member (FM) D) take 5 syringes of the medication on [DATE] and then she returned them on [DATE]. I investigated the reason 1-box of 30 syringes and 4-syringes were left. There was a total of 25 medication syringes left with no explanation why. There was an issue of why the medications were left over. It appeared typically (LPN I) was on when new boxes came in. The boxes were not dated when they came in, but there were always a few syringes left and 1 new box. Documentation does not show of any other medication refusals only the three we already talked about. The on-coming nurse said (R102) had a seizure, one, during the night from the information she got from the night (NOC) nurse. (LPN I) was the on-coming, she documented (R102) had multiple seizures that morning per her progress note. She called the on-call physician with the okay to send to the ER. DON B reviewed the progress notes and physician orders to verify. ADON M reviewed the order stating, The order to send (R102) to the ER was not put in medical records until [DATE]. Further review of R102's medical records with NHA A, CCC L, ADON M and DON B, DON B stated, (LPN) J was the NOC nurse on [DATE] assigned to (R102). She did not document in (R102) medical records about the seizure. Nor did she contact the guardians. If it is in the middle of the night and unless it was a Grand Mal seizure, I would not call and wake up the family and would wait and tell them in the morning. (R102) did not have frequent seizures. NHA A stated, The daughters came in the Monday after. ,d+[DATE] (2024) and expressed their number #1 concern was communication to call (FM E) first, then call (FM D). DON B stated, There was no documented missed doses of her Keppra or Topamax (anti-seizure medications) in January or February (2024). Policy states we do not have to notify the physician unless the refusal is two consecutive days. During an interview on [DATE] at 2:40 PM, LPN I stated, I work at the facility and took care of (R102). The family would bring in the Glatiramer syringes about every month or two. I would write on the box to contact family when getting low. I never dated or numbered the box when it came in. The family's pharmacy would label it with her name. When I got report on ,d+[DATE] (2024) from the NOC nurse, I was told she had a seizure during the night. Around 7:,d+[DATE]:30 AM an aide told me she was having a seizure, it was more a focal seizure (nerve cells in the brain send out sudden, excessive, uncontrolled electrical signals). She had more seizures, probably a good handful, maybe five. The aides told me she would start shaking. She would tell me to call her daughters. I called the on-call doctor and was told to continue to monitor her. (R102) continued to have seizures so I messaged the doctor and sent her to ER. I did not put the order in. I forget to do that. I called the family after she had the first or second seizure for me. They were surprised she had a seizure because they were not called during the night. They were pretty upset she had seizures. They were upset because she had not had a seizure in a long time. I cannot assume a nurse did not give a medication and document they did. However, I am aware of a nurse, (LPN N) not giving medications. I brought it up to the Unit Manager (UM O), that other residents complain (LPN N) does not give medications and documents she does. If a resident refuses medication, the nurse is to document the reason why. After two refusals in a row, the doctor is to be called. The computer generates a progress note of refusal. I told (NHA A) and (DON B) during the time of (R102's) incident about (LPN N). I showed the DON the card stock that 2 days prior to [DATE], another nurse, (UM O) signed she administered medications that were not in the facility. It was (R105's) methocarbamol that was the card stock. Another resident told me she was not getting medications from (LPN N) and I told (UM O) within the last few months. I was not asked to, nor did I fill out any forms or statements for any of this. R105 Review of R105's medical records revealed the resident had a diagnosis of rheumatoid arthritis. Review of R105's Order Summary reported [DATE], Methocarbamol ((Robaxin) muscle spasms/pain) oral tablet 500 mg give 1 table BID. Review of R105's MAR, [DATE]-[DATE] reported Methocarbamol was documented as OS (out-of-stock) on consecutive days and scheduled times ,d+[DATE] and ,d+[DATE] (2024), was given on both scheduled times on ,d+[DATE], then documented as OS on consecutive days and scheduled times ,d+[DATE] and ,d+[DATE] (2024). A telephone call was placed on [DATE] at 3:13 PM to LPN N with no answer and a message was left to call surveyor back. No return call was made by end of survey, [DATE] at 5:30 PM. During an interview on [DATE] at 3:17 PM, LPN P stated, If a resident refuses a note is made in the eMAR (electronic medical record system). DD means a resident declined medication and a progress note is auto-populated. I typically let the physician know verbally in the unit each morning. They have a red communication folder the nurse the can write a note in there. I do not know if all the nurses use it. I received an education in the last month about calling guardians when a resident refuses medication. I regularly cared for R102, and she did not like taking the shot medication. I could [NAME] with her with ice cream or snacks. She had refused meds from me a few times. I am very thorough in my documentation. I recall the January and February 2024 refusals of the injection. I let the MAR document in the progress note of the refusal. I do not remember if I reapproached the resident. She told me around Christmas time she did not like being poked. I do not know if I documented that. I noticed just prior before she (R102) left the facility, (LPN N was hired and was put on the 200 hall with (R102). That was the time I noticed more of the Glatiramer syringes were left than should have been. There were never more than 2 boxes in the refrigerator. (LPN I) and I noticed there were more than normal. I do not recall telling (UM O or DON B) of the extra doses There was higher volume of stock of Glatiramer syringes in the refrigerator than normal. During an interview and record review on [DATE] at 3:53 PM, DON B stated, (LPN N) was officially let go today. She has not worked here at all this month. DON B texted the facility's scheduler for the last day the LPN worked which was [DATE]. DON B continued stating, At no time before (R102's) incident did I know (LPN N) was not passing medications. I was looking closely at her. I asked (LPN I) who brought it to my attention after [DATE] that the Glatiramer syringes were not being used. I asked (LPN I) directly if she had any ideas about the quantity of the Glatiramer that was left. She told me there was more there than should be. She thought (LPN N) was not giving the medications because there was more than should be. (LPN N) did not work at all in November (2023) and came back [DATE] (2023). She worked 5 times on (R102's) unit. She worked 10 times in [DATE]. After I questioned (LPN N) about the over number of syringes she started calling in. (LPN I) asked me to look into (LPN N) if she was giving mediations or not giving them because she speculated (LPN N) was not giving the medication. (LPN I) did not mention (R105) not getting medications from (UM O). I asked (LPN I) if she shared it with anyone else. She said she had not. I talked to her about she should have shared this earlier. It was either (LPN N or LPN I) giving (R102) the daily shot. I did not think it might be (LPN I) not giving it. I cannot think of any other nurse that talked to me about (LPN N) not giving medications. I asked (LPN N) some questions about medications, and she last worked [DATE]. She had inconsistencies in her job performance. Her work was getting sloppy. During an interview on [DATE] at 4:16 PM, UM O stated, I was the Unit Manager while (R102) was here at the facility. I did not know anything about her not getting her MS medication. No one said anything to me about her not getting it or of any other residents not getting their medications. I do fill in to give medications. During an interview on [DATE] at 4:30 PM, R105 reported she thought she was getting her medications. I'm not sure really what I get. I trust the nurse to give me what I need.

Based on observation, interview, and record review, the facility failed to 1.) provide appropriate wound care treatment and preventions for 2 residents (Resident #112 and #4) of 2 residents reviewed for non-pressure related skin conditions and 2.) adequately identify and monitor a foot injury for 1 resident (Resident #109) of 1 resident reviewed for accident hazards, resulting in the actual worsening of diabetic ulcers for Resident #112, the potential of worsening wounds for Resident #4, and a delay in treatment for a foot injury for Resident #109. Findings include: Resident #112 Review of an Admission Record revealed Resident #112 admitted to the facility on [DATE] with pertinent diagnoses which included cellulitis of left lower limb and diabetes mellitus with foot ulcer. Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of 8/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #112 was moderately cognitively impaired. Further review of same MDS assessment revealed Resident #112 required the assistance of one person with personal hygiene and bed mobility. Review of a current skin management Care Plan focus for Resident #112, initiated 8/22/2023, revealed resident was admitted to the facility with diabetic foot ulcers. Review of a current skin management Care Plan intervention for Resident #112, initiated 8/22/2023, revealed staff were directed to assist Resident #112 with floating his heels. Review of Resident #112's current active Physician's orders on 10/2/2023 at 3:07 PM revealed .paint (2nd) toe on right foot with betadine and cover with dry dressing change (every day) and (as needed) . betadine paint to bilateral heels (twice a day) . In an observation and interview on 10/2/2023 at 3:07 PM in Resident #112's room, Resident #112 was resting in bed with no dressing on his left or right foot. Resident #112's left foot heel had a black wound, and his left 2nd toe was black. Resident #112's heel and toe appeared to have betadine painted on them. Resident #112's heels were not floated. Registered Nurse (RN) JJ reported he painted betadine about 20 minutes ago and needed to check the order to verify whether a dressing was indicated. RN JJ reviewed the active orders and reported he would add a dry dressing. RN JJ reported the order for right 2nd toe dressing appeared to be incorrect and he would review this with the Assistant Director of Nursing (ADON). In an interview on 10/4/2023 at 8:46 AM, RN JJ reported Resident #112 did not have a dressing on his left 2nd toe wound on 10/2/2023 when he arrived that morning. RN JJ reported this was his first time taking care of Resident #112. RN JJ reported he had cleansed the wounds with normal saline and applied betadine paint upon arrival and was planning to check the treatment orders. In an interview on 10/2/2023 at 3:42 PM, ADON C reported the physician's order was placed incorrectly for the right 2nd toe and she was correcting the order to read the left 2nd toe. In a wound care observation and interview on 10/3/2023 at 7:47 AM in Resident #112's room, Wound Doctor H reported Resident #112 had significant vascular problems with his legs and could not feel his pedal pulses. Wound Doctor H reported resident had been referred for a vascular consult and wound treatment would continue as betadine on affected areas and covering the toes on left foot. Resident #112's heels were not floated. ADON C reported resident's wounds had worsened since admission, with the left 4th toe also being newly reddened. In an observation on 10/3/2023 at 3:41 PM in Resident #112's room, heels were not floated. In an interview on 10/4/2023 at 9:40 AM, ADON C reviewed Resident #112's wound measurement progression provided in a wound timeline. ADON C reported Resident #112's left heel and left 2nd toe have worsened. Review of wound measurements indicated Resident #112's left heel wound measured 2.2 by 2.3 cm when he admitted to the facility on [DATE] and measured 5.56 by 6.89 cm on 10/3/2023. In an interview on 10/4/2023 at 11:01 AM, ADON C reported Resident #112's order for right 2nd toe dressings was incorrect and this order was corrected on 10/2/2023 to the left 2nd toe. Resident #112's September Treatment Administration Record (TAR) revealed wound care was not documented as completed on 9/15/2023, 9/17/2023, 9/18/2023, 9/19/2023, the morning of 9/21/2023, the morning of 9/22/2023, the evening of 9/24/2023, or the morning of 9/26/2023. ADON C reported there is no documentation in the electronic medical record of these wound treatments being performed and there was no rationale documented regarding why they were not performed. ADON C reported she is managing wounds currently at the facility but is busy with many other duties as the facility is currently down 2 unit managers. ADON C reported she is responsible for placing all wound orders and is also the unit manager for the entire facility, with the help of the Director of Nursing. In an observation on 10/4/2023 at 11:21 AM in Resident #112's room, Resident #112 had no dressing on his left foot and his heels were not floated. In an interview on 10/4/2023 at 11:22 AM, Licensed Practical Nurse (LPN) S reported she was not aware the dressing was not in place. LPN S reported the nurse practitioner had looked at Resident #112's foot that morning but did not tell her that the wounds were left open to the air. In an observation on 10/4/2023 at 2:21 PM in Resident #112's room, Resident #112's heels were not floated. In an interview on 10/4/2023 at 2:30 PM, Certified Nursing Assistant (CNA) OO reported she was taking care of Resident #112. CNA OO reported she was not aware of any interventions being done for resident's feet or heels. CNA OO stated I don't know, the nurse would know. CNA OO stated I haven't seen his heels floated. In an interview on 10/4/2021 at 2:32 PM, LPN S reported she was not aware of any interventions for Resident #112 to float his heels. Resident #4 Review of an Admission Record revealed Resident #4 admitted to the facility on [DATE] with pertinent diagnoses which included diabetes mellitus and chronic venous insufficiency. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 8/8/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #4 was cognitively intact. Review of a current skin management Care Plan focus for Resident #4, with a revision date of 8/14/2023, revealed Resident #4 was receiving treatment for chronic venous ulcers to his lower extremities. Review of Resident #4's Physician Orders active 10/2/2023 revealed .wash bilateral legs with soap and water, apply xeroform to open areas, apply ABD and wrap with kerlix, light compression ace wrap to legs at all times remove with cares, change daily and (as needed) . In an observation and interview on 10/2/2023 at 1:36 PM in Resident #4's room, Resident #4 reported staff had not changed his leg dressings in over 3 days. Resident #4 reported his dressings were ordered to be changed daily, but this was not taking place. Resident #4's legs were observed to have socks over ace wraps, with the top of the ace wraps stained with yellow and brown drainage. In an interview on 10/3/2023 at 8:36 AM, ADON C reported Resident #4 told her on 10/2/2023 that his dressings had not been changed since Thursday. Review of Resident #4's Treatment Administration Record (TAR) revealed Resident #4's leg dressings were not documented as being completed or attempted on 9/8/2023, 9/9/2023, 9/15/2023, 9/16/2023, 9/20/2023, 9/22/2023, 9/23/2023, and 10/1/2023. In an interview on 10/4/2023 at 9:55 AM, ADON C reported Resident #4's leg dressings are ordered to be completed daily. Review of facility policy/procedure Wound Management Program, revised 8/17/2023, revealed .Purpose . To eliminate, modify, or minimize factors that place residents at risk for skin breakdown . Policy . To assure that residents who are admitted with, or acquire, wound receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing . initiate treatment according to physician guidance . update care plan to reflect new risks and interventions . 41027 Resident #109 Review of an Admission Record revealed Resident #109 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes mellitus (too much sugar in the blood) with diabetic neuropathy (nerve damage in legs and feet that causes pain). Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 8/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #109 was cognitively intact. In an interview and observation on 10/03/23 at 09:09 AM, Resident #109 was tearful and reported that her left foot and left big toe really hurt and stated, .I hurt it a couple months ago .I was lowering my bed and I smashed my foot . Observation of Resident #109's left foot revealed the end of the foot and the toes were purple. Resident #109 reported that she reported the injury immediately and had been telling facility staff for weeks that it wasn't getting better . Review of Resident #109's Physician's Note dated 7/14/2023 at 10:04 PM revealed, .Patient was seen for an persistent acute issues .Resident also reports that she injured her left great toe several days ago and now is having pain and swelling of her foot .ASSESSMENT/PLAN: .Left foot pain .Will place order for buddy taping left great toe and 2nd toe as well as icing TID (3 times a day) for 7 days. Continue tramadol (narcotic pain medication) as scheduled and acetaminophen (over-the-counter pain medication) . Discussed elevation of LLE (left lower extremity). Will continue to monitor. Review of Resident #109's Nurses Notes dated 7/28/2023 at 6:00 PM revealed, Late Entry: This resident c/o (complains of) pain in her right (sic) great toe. Noted the right (sic) great toe is swollen, purple in color and moderately painful. Medical provider to follow up with resident. In an interview on 10/04/23 at 11:01 AM, Resident #109 reported that her left foot and toe hurt all the time and she had not heard from facility staff about what the doctor was going to do. In an interview on 10/04/23 at 11:13 AM, Licensed Practical Nurse (LPN) F reported that Resident #109 injured her left foot about a month ago, and complains of pain frequently on second shift. LPN F reported that she asked Nurse Practitioner (NP) J about it on 9/29/23 and NP J was going to order an x-ray, but LPN F noticed as of that day the x-ray had not been completed. LPN F reported that she had spoke to NP J again and the orders were now in place for an x-ray. Review of Resident #109's Physician Orders revealed, 10/04/23 at 10:20 AM, review of new orders put in today: ok for right (sic) foot xray due to injury 2 mths (months) ago with persistent pain, discoloration, and swelling. No directions specified for order. Pending Confirmation. 10/4/2023 . In an interview on 10/04/23 at 11:17 AM, NPJ reported that she had seen Resident #109 a week ago and that was when the resident had first reported the foot injury that occurred 2 months ago. NP J reported that she ordered an x-ray and to apply ice and elevate the foot. NP J reported that she did not enter the orders in the computer until today. NP J did not recall having known about the injury previously, but then remembered once this surveyor referenced the visit notes from July 2023. In an interview on 10/04/23 at an unknown time, DON reported that NP J had changed Resident #109's x-ray to a STAT (immediate) order for today, and corrected the body site to left foot.

This citation pertains to intakes MI 553, MI 553, MI 554, and MI 817. This citation has 2 DPS Statements DPS A Based on interview and record review the facility failed to ensure a gait belt was used for 2 (Resident #273 and #53) of 12 residents reviewed for accidents and hazards resulting in bruising, and sprained right knee and hip. Findings include: Resident #273: During an interview on 08/31/22 04:08 PM, Director of Nursing (DON) B confirmed a gait belt should be used to get a resident off the floor or when assisting to stand up from a chair. DON B confirmed staff shouldn't have done either transfer (off the floor or out of chair) by grabbing Resident #273's wrists. Review of Resident #273's skin alteration assessment (incident/accident report; bilateral wrist bruising investigation), dated 6/27/22, stated, .Resident observed to have bruises to bilateral inner wrists .Resident states staff member placed hands of (on) wrists to assist her out of chair . Education provided to staff on proper transfers .Injuries Observed at Time of Incident .Injury Type .Bruise .Notes: Resident noted to have a small bruise on the thumb side of her right and left wrist. Review of Resident #273's nurse progress note, dated 6/28/22, .Resident states that she was assisted up from her reclining chair. Resident states that she then observed slight bruising to her wrist the next day .Orders per MD (medical doctor) to observe area and monitor for healing. Review of Resident #273's physician progress note, dated 6/27/22, stated, .Staff states that she fell recently while up ambulating on her own .Was also noted that when the patient was lifted off the floor staff grasped bilateral wrist to pull her up and she now has bruising on the wrist. Patient notes minimal pain of the wrist .Injury to bilateral wrists with ecchymosis (discoloration of skin; typically bruising). Review of Resident #273's nurse progress note, dated 6/28/22, stated, Reported that cena (certified nurse aide) found 2 bruises dark purple to left and right wrist. resident (Resident #273) not sure what happen. Cena noted them yesterday. Review of Resident #273's activities of daily living care plan, revised 7/7/22, stated, transfer 1PA (one person assist) . Review of Resident #273's brief interview for mental status score, dated 4/16/22, was scored 5 which reflected severe cognitive impairment. Review of the facility's transfer techniques policy, dated 7/1/2008, stated, Purpose: To transfer a resident safely .Use gait belt or other transfer devices . R53 According to the Minimum Data Set (MDS) dated [DATE], R53 scored 12/15 on her BIMS (Brief Interview Mental Status) had clear speech making her needs known, understood others, required extensive assistance of two-plus persons physical assistance to transfer on/off toilet, was not steady moving from a seated to standing position; only able to stabilize with staff assistance, used a walker or wheelchair for locomotion, had no impairment in her upper or lower extremities, with diagnoses that included [CONDITION(S)] disease, COVID-19, and [CONDITION(S)]. Review of R53's Incident Report #1215 dated 6/30/2022 14:36 (2:36 PM) reported the resident had a fall in her bathroom during transfer. CNAs stated they lowered the resident to the floor when resident's legs got weak. R53 stated her right knee was twisted and refused to allow staff to get her up. Resident requested EMT and visit to ER. R53 is her own person. An ambulance was called. Level of pain was 3/10 and was ambulatory with assistance after incident. Resident was oriented to person, situation, place, and time. Review of R53's Care Plan 4/8/2022 Risk for Falls related to hypertension, [CONDITION(S)], and OAB. Reported the goal set was to minimize injury related to falls by assessing and treating pain. Review of R53's Care Plan 5/3/2022 ADL (Activities-of-Daily Living) deficit, reported the goal set was to participate in ADLs daily with an intervention that included Hoyer (mechanical lift) for transfers initiated 4/8/2022 and revised on 7/19/2022 (transfer specify 1, 2 PA (person assist), full lift, sit to stand (mechanical lift) initiated 4/8/2022). During an interview on 8/31/2022 at 2:30 PM R53 stated, I fell in the bathroom while not wearing a gait belt. I needed to go to the bathroom. (CNA O and CNA N) came to help me. I told them I could not walk but I could walk before I got Covid a few weeks before. I still cannot walk. With the CNAs, I stood up to pivot and asked them for a gait belt right away. They told me no, it was almost time to pass trays. I kept insisting for a gait belt and they said they did not have time. I used the bathroom then turned on the red call light and waited. It took me a while to use the bathroom and that was okay; they went to pass lunch trays. I do not know how long it was. When (CNA O and N) came back to help me I stood up and I tried to pivot. I did not have a gait belt on. I could not move my legs or the walker. My right knee went out and I went down. The CNAs said I did not fall. I did not want the mobile x-ray to come to me. I did not want facility staff to evaluate me. The ambulance, fire department, and EMS came. I am obese so the fire department got me up. I went to the ER, and they did an x-ray on my knee and hip and told me I had a knee and hip sprain. I know it was the facility's fault I fell . They did not put a gait belt on me. During an interview on 9/01/22 at 11:43 AM, DON B stated, (CNAs O and N) were transferring (R53) from the toilet to her wheelchair. The resident told the staff her legs were getting weak, and staff slid her to the ground. Depending on resident's wishes, a gait belt is used. If a resident does not want a gait belt, they do not have to have one used. I do not know if a gait belt was used when (R53) fell in the bathroom. I do not remember her being on the toilet for one and a half hours. During an interview on 9/01/22 at 12:58 PM, CNA N stated, (R53) said she had to use the bathroom while (CNA O) and I were passing lunch trays. We told her we were passing lunch trays, but she insisted she go to the bathroom, so we put her on the toilet. (R53) rang the call light from the bathroom within 10 minutes. (R53) did not fall. (CNA O) was in front of the resident and I was behind her with the wheelchair. We told her to step back into the chair. She said No, I'm going to fall to the ground, and we guided her down. We did not use a gait belt with her. I do not know what her transfer status was then but now she is officially a mechanical lift. During an interview on 9/01/22 at 1:36 PM Registered Nurse (RN) I stated, (R53) was lowered to the floor by two CNAs (N and O) in the bathroom. I was not in with the resident during the incident but right after it happened. (R53) was being transferred from the toilet to the wheelchair by the two CNAs without a gait belt. There should always be a gait belt in use when a resident is being transferred when not using a mechanical lift. The resident did not want staff to move her or evaluate her. I evaluated her the best I could and what she would allow. EMS came to move her off the floor and took her to the hospital. Review of R53's Progress Note Review of R53's Progress Note 6/30/2022 14:47 (2:47 PM) reported the resident had a fall in bathroom during a transfer. The CNA's stated they lowered the patient to the floor. Resident stated her right knee twisted. Patient refused staff to get her up. Patient requests EMT and visit to ER to assess knee. Review of R53's Progress Note 6/30/2022 21:02 (9:02 PM) Physician's Note .Staff reported the patient was sitting on the toilet for approximately an hour and a half. When staff went to help her get up and get back into bed, she had a fall. She states she landed on her right knee and is having significant pain there .Staff attempted to get the patient off the floor, but she refused. Patient feels unsafe with anyone but EMT getting her off the floor. She is requesting to be transferred to the emergency department .sitting on the restroom floor .There is tenderness with palpation and patient yells out with attempts at range of motion .Fall with pain to the right knee. I did encourage the patient to allow staff to get her off the floor and to obtain an x-ray in-house. Patient refused this recommendation and requested transport to the emergency department. EMS was called for transfer and further evaluation workup in the ED (emergency department) . Review of R53's Hospital After Visit Summary dated 6/30/2022 reported the resident sustained a sprained right knee and hip for a fall at the facility. DPS B Based on interview and record review, the facility failed to ensure resident safety in regards to fall prevention in 1 of 12 residents (Resident #327) reviewed for falls, when Resident #327 was not assessed for fall risk, the care plan was not adequately developed for current fall risk status and staff did not have sufficient knowledge of resident care needs, resulting in a fall, surgery and hospitalization for cervical (neck) spine fractures, and the potential for further decline in physical, mental and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #327 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Right BKA (below knee amputation), muscle weakness and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #327 was not available due to short 7 day stay. Review of Resident #327's Electronic Health Record indicated that he had a previous short stay in the facility and was discharged on [DATE]. Review of Resident #327 Incident Report dated 8/29/22 at 00:05 (12:05 A.M.) revealed, Patient yelling help. Nurse entered room, patient on floor. Patient fell out of bed, bed was high-had bed remote in hand. Patient was observed on back, complained of head and neck pain. Resident had been assisted with care approximately 10 minutes prior and staff had lowered bed to lowest position 911 called . Review of Resident #327's Hospital Records dated 8/29/22 revealed, ED (emergency department) to Hospital Admission (CURRENT) .Chief Complaint: FALL, Assessment/Plan: DIAGNOSIS at time of disposition: 1. Fall from ground level .fracture of seventh cervical vertebra (spine) .fracture of first cervical vertebra . In an interview on 09/01/22 at 09:51 A.M., Licensed Practical Nurse (LPN) II reported that she heard a noise from Resident #327's room that sounded like the bed being raised up and stated, .I went in there and he was on the floor .his bed was very high . LPN II reported that Resident #327 said that he'd hit his head but did not complain of any pain, and his ROM (range of motion) and neuro's (neurological check) were normal. LPN II reported that she had never taken care of Resident #327 prior to that day, was not aware of his fall risk status, and in report she was told that he was confused and calling out for help a lot that day. In an interview on 08/31/22 at 03:25 P.M., Certified Nursing Assistant (CNA) GG reported that she was working when Resident #327 fell on [DATE] and stated, .I had just saw him on rounds around 11-11:30 P.M I didn't go in the room . CNA GG reported that she was not familiar with the residents that she was assigned to that night and stated, .the second shift CNA (CNA OO) and (LPN II) weren't familiar with the residents either . CNA GG reported that at the time of Resident #327's fall, she was on another hall talking to other staff and stated, .I was asking them if they knew anything about the patients . CNA GG reported that LPN II yelled for help from Resident #327's room and stated, .she (LPN II) wanted me to help her get him up off the floor .(LPN II) said that she was going to check him out .I knew better than to try to stand him up . CNA GG reported that she had trouble finding a hoyer lift that worked; CNA GG and CNA NN retrieved a hoyer lift and tried to transfer Resident #327 into bed, but he started saying that his head hurt and that he thought he needed a neck brace. CNA GG reported that she went and got LPN II and that's when they decided to send him to the hospital. This surveyor attempted to interview CNA OO on 09/01/22 at 08:44 A.M. CNA OO did not return the call. In an interview on 08/31/22 at 02:43 P.M., CNA U reported that Resident #327 was only in the facility for about a week before he fell and went to the hospital and stated, .he was very anxious .always calling out for help .he was scared . In an interview on 09/01/22 at 12:30 P.M., DON reported that she received a call from LPN II on 8/29/22 after Resident #327 was sent to the emergency room reporting that she had observed him on the floor. DON stated, .(Resident #327) has a lot of behaviors .he would call out for help a lot .he didn't like to be alone .I don't believe the behaviors contributed to his fall at all . DON reported that Resident #327 did not have a fall assessment on record and the care plan was not updated for falls. Review of Resident #327's Fall Risk Assessment, no fall risk assessment completed. Review of Resident #327's Fall Care Plan revealed, Risk for falls r/t (related to) hx (history) of Falls, Rt BKA. Date Initiated: 03/20/2020 Revision on: 08/25/2022. INTERVENTIONS: Assess and treat pain. Date Initiated: 03/20/2020 Revision on: 08/25/2022. Call light accessible. Date Initiated: 03/20/2020. labs/xrays. Date Initiated: 03/20/2020 Revision on: 08/25/2022. Orient to surroundings Date Initiated: 03/20/2020 Revision on: 08/25/2022. The care plan was revised from Resident #327's previous stay (>2 years ago). Review of Resident #327's Behavior Care Pan revealed, Behavior Trauma Date Initiated: 03/25/2020 Revision on: 03/25/2020. INTERVENTIONS: Concerns Include - Transportation Accident, Physical Assault, Severe Illness Triggers for Trauma Care include: persons with Alzheimer's Disease, bad weather Date Initiated: 03/25/2020 Revision on: 03/25/2020. There was no care plan related to Resident #327's current behaviors. Review of Resident #327's Admission assessment dated [DATE] at 18:23 (6:23 P.M.) revealed, .legally blind .ADL's .Bed mobility: Extensive Assist, Transfer: Total dependence .Pain: 4/10 .Location: buttocks .What makes the pain worse? laying in one spot .Mobility/Safety: .RT (right) BKA, use mech lift (hoyer lift) . Review of Resident #327's Nurses Note dated 8/28/2022 at 15:10 (3:10 P.M.) revealed, Resident having behaviors throughout late morning and early afternoon. Frequently yelling out for help, not using call light and being disruptive. RN tried talking to resident to stop behaviors and use call light. Talk ineffective as resident keeps yelling out for help. Review of Resident #327's Nurses Note dated 8/28/2022 at 12:01 P.M. revealed, Resident resting in bed. Less noted behaviors today, but still frequently cries out for help, and becomes emotional . Review of Resident #327's Nurses Note dated 8/27/2022 at 12:36 P.M. revealed, Resident crying and moaning during lunch, states he feels like he is going to throw up. Nurse went to get [MEDICATION(S)] (medicine for nausea) while aide began changing resident. Resident became very agitated and upset with staff, stating he doesn't want to be man-handled twisted in knots or have someone shove their finger up my (word omitted). Staff educated resident that his brief was soiled with stool and that staff had to turn him to clean him up. Resident states he wants to call the state department and shut us down for not taking care of him. Resident also refusing [MEDICATION(S)] because he doesn't know what he is being given, then begins crying .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety in 1 of 8 residents (Resident #106) reviewed for safety/supervision, from a total sample of 8 residents, resulting in an Immediate Jeopardy when on 5/22/2020 at approximately 6:30 AM, Resident #106 exited the facility, unbeknownst to facility staff, during a generator test and the alarms for Main entrance, 200 hall and 600 hall exit doors ceased to work unknowingly to staff, and was found by a staff while walking in the west side of the parking lot heading towards the main drive, approximately 80 feet from facility front door and within approximately 1/2 mile of Alpine Drive. The resident was returned to the facility by staff at approximately 7:00 AM. This deficient practice placed 9 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of facility policy ELOPEMENT AND/OR EXIT-SEEKING MANAGEMENT revised date 10/11/2019, revealed, .KEY TERMS: Elopement: When a resident leaves a safe or secure area going into an unsafe area without assistance or supervision. PURPOSE: To promote the safety of residents by assessing and managing elopements, thereby minimizing risk. PROCEDURE: 1. Identify resident risk for elopement and implement interventions as needed .b. IDT (interdisciplinary team) to complete the Elopement Assessment following admission, quarterly, and with significant changes. 2. Initiating safety procedures. A. Place an exit guard bracelet on the resident if facility has a wander guard/code alert system .Monitor alarming devices including bracelet and doors for function and expiration routinely. Review of a complaint, intake #MI 696, indicated alleged neglect when a resident eloped from the facility and staff failed to report it to the State Agency. Review of a Face Sheet revealed Resident #106 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 5/20/2020, revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #106 was cognitively impaired. Further review of MDS indicated no wandering behaviors had been exhibited. Review of an email correspondence received on 6/23/2020 at 12:34 PM from Nursing Home Administrator (NHA) A, revealed, There are no incident reports for (name withheld/Resident #106) in the last 6 months. Review of Resident #106's ELOPEMENT AND/OR EXIT SEEKING BEHAVIOR RISK ANALYSIS dated 5/22/2020 at 3:21PM indicated there had been no change in the resident's elopement risk from last review and was at risk for elopement and interventions had been reviewed. Review of an elopement timeline for Resident #106 provided by Nursing Home Administrator (NHA) A indicated on 5/22/2020 was observed outside 600 hall exit after doors failed to lock after generator load test. Review of Resident #106's Care Plans revealed Focus . history of exit seeking-- will not consistently allow code alert (wander guard) placed on person .Revision on: 01/08/2020 .Goals did not indicate a goal for exit-seeking .Interventions . Door alarm utilized to notify staff when resident leaves room. Date Initiated: 05/21/2020 . Review of Resident #106's Kardex revealed, Safety .Res (resident) had been noted to have increased restlessness aeb (as evidenced by): ambulation and desire to leave after visits from the guardian. SS (social services) will notify staff when next visit is scheduled, and res will be placed on 1:1 . Review of Resident #106's Progress Note dated 5/19/2020 10:26 revealed, Social Service Note DOCUMENT QUARTERLY/ANNUAL NOTE, RESIDENT ISSUES/CONCERNS and FOLLOWUP, ROOM CHANGES: Assisted resident in video chatting with public guardian via facetime. Interaction at baseline . Further review of resident's progress notes did not indicate Resident #106 had been placed on 1:1 after his conversation with guardian. Review of Resident #106's Progress Note dated 5/22/2020 07:00 revealed, Nurses Note DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT: REs was walked out of the unit at 0700 . Review of Resident #106's Progress Note dated 5/22/2020 07:30 revealed, . was anxious and took a walk out to the parking lot area . During an interview and observation on 6/23/2020 at 12:15 PM, Licensed Practical Nurse (LPN) AA stated, There is a motion detector on (Resident #106's) door. I have heard he has tried to leave the facility. When he pokes his head out his room or anyone enters/exits the alarm at the nursing station goes off. Observed at the 600-hall nursing station a portable alarm the size of a small vertical tissue box. During an interview on 6/23/2020 at 1:40 PM, Certified Nursing Assistant (CNA) D stated, I take care of (Resident #106). He wanders around the unit and down halls. He has gone out of the building a few times. He has a motion detector on his door. On May 22nd (2020) I was working and in a resident's room providing care. The nurse was in another resident's room. The power went out. I heard (Resident #106's) alarm go off and could not stop resident care. I stayed with the resident I was assisting. It was only me and the nurse on the unit at that time. CNA staff only have pagers and cannot call out on them. The nurse's have facility portable phones. I didn't know at that time if the nurse had heard (Resident #106's) alarm. Staff are to go check on him when his alarm goes off. During an interview on 6/23/2020 at 2:00 PM, CNA I stated, (Resident #106) has left the building twice that I know of. Once he went out with a resident that smokes and that resident called the facility to tell staff (Resident #106) was outside. The other time he left the facility he had taken his wander guard off with nail clippers. I was working both times but did not have to write statements per the nurse. I can't tell you when these dates were. During an interview on 6/23/2020 at 2:00 PM Charge Registered Nurse (CRN) C stated, I was working on the 600-hall on the day (Resident #106) left the building, May 22nd (2020). I was in another's resident's room doing care and I didn't hear the motion detector alarm. (CNA D) was in another resident room. (CCC G) told me she saw him going out the 600-hall door and go outside. She had eyes on him and brought him back. When I go into a room, I do not carry the motion detector alarm with me. The alarm does not go to pagers. It is kept at the 600-hall nursing station. If I'm passing medications I'll take it with me; it is mobile. (Resident #106) likes to get out and get fresh air. He is very active. My understanding was because staff was with him and eyes were on him, I didn't need to do an incident report. It was either the DON or (CCC G) who documented in the nurse's notes. During an interview on 6/23/2020 at 2:18 PM CCC G stated, I am the Clinical Care Coordinator for 300-, 500-, 600-halls. I was taking temperatures at the front desk around 7:00 AM on May 22nd (2020). (Cook F) came in and told me someone was in the parking lot that looks like he should not be out there. I saw him him. He had a hat and coat and carrying some papers. He was standing behind a row of cars. I went outside and up to him and explained to him he had to come inside the building. I got him back in after a few minutes of talking to him. I do not know how long he had been outside. He was assigned to the 600-hall at the time and he went out the 600-hall entrance. That is my best guess because that is where he was found. He will not wear a wander guard. He takes them off. We figured out after he talks to his guardian it is a trigger for him that he wants to leave. The motion detector on his door was in place at that time. There should have been an incident report done. I did not do one on him. I would think the nurse would have done the incident report. I did an elopement screen assessment that day. The nurse talked to his guardian. During an interview on 6/23/2020 at 2:58 PM Cook F stated, I pulled up outside the facility and saw a man standing outside on the sidewalk in front of the therapy gym by the 600-hall exit door. I knew it was (Resident #106) and ran inside the main lobby. I had to use a radio to call for help because no one was at the front desk. I could see him through the front doors, and he was walking across the parking lot then. No one responded so I went to our dementia hall, the 100-hall, which was right by the front lobby. At that time, I could not see him anymore because the door is down the hall and around a little corner. Housekeeping W came to the 100-hall door when I knocked on it. I told her I needed her help. She went outside with me. I told another housekeeper to get help. I don't know her name. Housekeeping W stayed up front to watch him through the doors. CCC J was coming in the lobby from the outside and saw him once she came in. CCC G came to the front lobby and went outside to get (Resident #106). I stayed inside because no one was up front to check me in for COVID-19 screening. I could not go near him because I did not have a mask on. When I got to the kitchen, I told my manager I saw resident. I did not write a statement. During an interview on 6/23/2020 at 3:08 PM, Charge Registered Nurse (CRN) C stated, The incident with (Resident #106) was about 7:00-7:30 in the morning on May 22nd (2020). Since COVID-19, the lab does not come in to draw blood. I was drawing blood that morning on a resident; I do not know who. I did not hear the motion detector alarm for (Resident #106). The alarm does not go to a pager. There was me and one (1) CNA on the unit that morning. The motion detector goes off on its own when someone passes by it. There is a sensor that tones for about 3 times and then it stops. I believe (Resident #106) was back on the unit by the time I got done drawing blood. Both me and CNA D were busy at the time the alarm went off. We were both in other resident rooms with the doors closed. That day I had 1 CNA. I did the assessment on (Resident #106) as soon as he was back in his room. I made sure he was okay. I called his daughter per his request and notified her. She talked to him. (Social Worker (SW) E called his guardian. I believe I called the provider and got no new orders. CCC G was aware (Resident #106) left the building and we both talked to the DON. I did the nurses note after CCC G or the Director of Nursing (DON) B told me to. I do not remember who told me. Because at the time, there was a communication glitch I was told to do the nurses note. I do not know who did the morning care for (Resident #106). He is independent with his care. The CNA would have done the care if needed. I came on at 6:30 AM that morning. I saw him at 6:30 AM, his door was open, and he was in the room. The motion detector was still on desk when it went off and not on the medication cart. The medication cart was with me. (Resident #106) is an elopement risk. During an interview on 6/23/2020 at 3:23 PM, CCC G stated, I come in at 6:00 AM if I am taking temperatures for COVID-19 staff screening. I was doing staff screening that day. I was in the front lobby. I do not remember if I screened Cook F that morning. I was sitting at the desk up front. I did not see (Resident #106) until I went outside. (Resident #106) has always been an elopement risk. He will not wear a wander guard. There are a lot of issues with him; he will not let staff put one on him. He was a 1:1 (one person always assigned to observe resident) for a long time before the motion detector was installed. I assumed he was on a 1:1 at that time because he does his own tube feedings, he keeps the extra tube feeds for a snack. Yes, I am the Clinical Care Coordinator for (Resident #106's) unit. He has behaviors of exit seeking. (Cook F) came in that morning to be COVID-19 screened and said someone was in parking lot that did not look like he should be out there. (Resident #106) was behind the cars in the second row of the front parking lot. I called (DON B) and she told me to start the 1:1 on him. I told the nurse (CRN C) because she was in another resident's room and the CNA was in another room too. The motion sensor goes off automatically and dings like a doorbell. Administration would have known of (Resident #106's) leaving the building by 9:00 that morning in morning meeting. Review of facility Punch Detail indicated on 5/22/2020, that Cook F punched into work at 7:11 AM, CNA D punched in at 5:25 AM, CRN C punched in at 6:11 AM, and Housekeeping W punched in at 5:54 AM. During an interview on 6/23/2020 at 3:35 PM NHA A stated, All that was reported to me about (Resident #106) was that he left out the 600-hall door. I do not know who reported it to me. I was told he was supervised the whole time and brought back in. CCC G was in the front lobby taking temperatures and CCC J was getting out of her car and coming into the facility. It was during morning shift change and a lot of people were coming in and out of the building. Dietary staff saw him in the parking lot. I was here that morning and talking to (DON B) in her office when we were both notified at the same time. I cannot remember if we were notified by phone or someone came in. I did not report it to the State Agency. Because he did not leave the premises, he was supervised by staff the whole time and had eyes on him the whole time. There was no incident report done because it did not feel like an elopement because staff was with him. Either (CCC J, CCC G, or Cook F) all had eyes on him. They were outside with him. The nurse did a note. The social worker should have done a note. At the time, the doors were not locked and did not alarm at that time. Shift started that day for CNAs at 6:30 AM and nurses come in at 6:45 AM. During an interview on 6/23/2020 at 4:02 PM, CCC J stated, On May 22nd (2020), I parked my car outside the 600-hall door. I came in the front door. I did not see (Resident #106) in the parking lot when I got of my car. As soon as I got into the front lobby. (CCC G) was in the back office; not sitting at the front desk. The dietary person (Cook F) was coming off 100-hall. I did not see anyone with her. CCC G and I both went out to get (Resident #106). I believe there were 3 of us in the parking lot. I was standing by the front lobby doors I was holding the door open. When (CCC G) brought him in I went to my office. I did not write a statement or document it. (CCC G) took care of everything. I did not do an incident report. I did not notify anyone. I have had training on reporting. His CCC (CCC G) was there and he is not my resident. During an interview on 6/24/2020 at 9:55 AM, NHA A stated, We had a problem the day (5/22/2020) (Resident #106) left the building. The generators were being tested and when the power came back on the doors were no longer locked on the 200 and 600 halls exit doors. Observed on 6/24/2020 at 10:20 AM the front lobby reception area looking West towards parking lot. Surveyor was unable to see out windows facing the West parking due to rows of brown paper bags clipped on string across windows. When standing inside the lobby to immediately exit facility, there were two (2) sets of doors. Surveyor unable to see the West side of parking lot from inside of lobby at first set of doors due to the brick wall. Inside foyer, between the two (2) sets of doors, surveyor unable to see West side of parking lot due to large bush blocking view. Once inside front entrance lobby at front desk screening station, Cook F would have had to go down the hall approximately 20 feet and around a corner to enter code and gain access to the 100-hall to summons assistance from housekeeping. Cook F eyes-on Resident #106 would have been blocked by the interior walls, paper bags across windows, two (2) sets of doors and a large bush. During an interview on 6/24/2020 at 10:58 AM CNA D stated, The power went out and the generators kicked on the morning of May 22nd (2020). It got dark on the unit. This was the beginning of my shift and was after shift change. My shift starts at 6:30 AM. The charge nurse was already passing medications at that time. (Resident #106) does not need morning care. I did his temperature between 6:30 and 7:00 am. Temperatures cannot be logged into the computer until 7:00 AM. I was in a resident's room when the power went out. I thought all the doors would stay locked. So, I kept working with the resident. (CCC G) told me (Resident #106) had left the building and brought him back to the unit. When I saw him first thing that morning he was in his room, happy and watching television. It was when I first came on shift. (Resident #106) is a fast walker and mobile. He likes to walk and be outside. He has had a wander guard on him several times and fights to have it put on. The motion detector cannot always be heard at the end of the 600-hall. If the other staff is off the hall, I'll take the motion detector alarm with me or stay on the hall so I can hear it. It is hard to hear the motion detector alarm when in a room with a resident. I'm not given a phone or radio to keep in communication with the other staff if I do hear the alarm or they need to get a hold of me. During an interview and observation on 6/24/2020 at 11:32 AM with Maintenance Director R and Maintenance U, Maintenance U stated, On May 22nd (2020) at 6:30 AM I performed a monthly generator test of the entire facility. I shut off the main feed of electricity so the generator will operate. The power went off and for 3-4 seconds there was a delay before the generator kicks on to switch the power back on. The 600-hall entrance has two sets of doors and the inner doors have a mag lock. They are on a timer. Before COVID-19 they were on a timer. They would unlock at 8:00 AM and lock back up at 6:00 PM. When COVID-19 started we set the timer so everything on that door would be locked all the time, except for 4 seconds on May 22nd (2020). I started the generator test at 6:30 AM that morning. That day, the timer failed sometime during this time and the doors stayed unlock. I made a round of the facility, a nurse told me the 600-hall entrance was not locked. Observed and participated with Maintenance Director R and Maintenance U in measuring from the outside of 600-hall exit/entrance door to end of the second row of parking in West parking lot. Distance measured at 64 feet. The second row to the beginning of the main drive was approximately an additional 10-15 feet. Review of facility, Daily Census indicated nine (9) residents were assigned to the 600-hall on 5/22/2020, two (2) of which were identified as elopement risks. During an interview on 6/24/2020 at 12:27 PM Social Worker (SW) E stated, I am the social worker for (Resident #106). At times he is an elopement risk. He has gotten out of the facility. The last time he got out was May 22nd (2020). Pre-COVID-19 shut-down there was furniture in the 600-hall common area and he would sit by the door with his hat and coat. It was concerning to staff that he would get so close to the door. He has a language barrier (Vietnamese speaking). To my knowledge he has only gone as far as the light pole in the west parking lot. He had a wander guard on would take it off. Which is the reason a motion detector was put on his room. I did not see (Resident #106) outside on May 22nd (2020). I do not have notes about (Resident #106) leaving the facility on May 22nd (2020). I do not remember who told me he left the building. There was an IDT discussion about him leaving the building soon after. I do not have notes on it. During an interview on 6/24/2020 at 1:52 AM, Housekeeping W stated, I came in around 7 AM on May 22nd (2020) and was in the 100-hall to get some water to drink. (Cook F) knocked on the 100-hall door and said (Resident #106) was out of the facility. You cannot see the front lobby when you go to the 100-hall door let alone outside. I went out the main front doors. No one was at the front desk. I was the only one out there with him at that time. He was heading out the main parking lot down the main drive. He is a fast walker. He had a coat and hat on carrying a couple of packed bags. A few seconds later Clinical Care Coordinator (CCC) G came out to help. I was not asked to write a statement. I did not report to anyone because (CCC G) took over. I did tell my supervisor when she came in later that morning. I have been trained on Code 7 elopement protocol. No one knew (Resident #106) was out-of-the building until (Cook F) saw him. During an interview on 6/24/2020 at 3:00 PM DON B stated, I don't know who notified me about (Resident #106) going out of the building. Reporting should be done right away, but in this case, from what I understand, staff had eyes on him, and he did not go very far. I do not know if an incident report was done. The Administrator did the investigation. During an interview on 6/25/2020 at 5:00 PM, Maintenance Director R stated, (Resident #106) has a motion detector on his door. The alarm goes off at the nurse's station. On 6/24/2020 at 2:25 PM, Nursing Home Administrator was notified of an Immediate Jeopardy that began on 5/22/2020 and was identified on 6/24/2020 when Resident #106, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 6/25/2020, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 5/22/20, Resident #106 was returned to the facility and was assessed for injuries, none noted. 2. On 5/22/20, the Guardian, Administrator, and Director of Nursing were notified of the incident. 3. On 5/22/20, Maintenance staff was notified of resident exiting the center and immediately began checking all door exits to assure proper function. It was identified that the door had disengaged during a generator test and was manually reset by 7:20AM. 4. On 5/22 at 1:000 PM the system was hardwired to prevent further occurrence. 5. On 5/22/20, resident was placed on 1:1 to determine further needs for safety. 6. On 6/24/2020 current residents were re-assessed for elopement risks and care plans and interventions were updated as appropriate. One (1) resident, (R107), did not have care plan updated and was not received until after surveyor exited facility on 6/25/2020. 7. On 6/24/2020, doors within the facility that are equipped with code access were checked to assure proper function. Resident's individual alarm was evaluated to assure proper alarming mechanism. 8. On 6/24/2020, re-education on elopement was initiated. Eighty-two (82) of 161 staff completed education by 3:00 PM day shift (6/24/2020). One hundred twenty-eight (128) of 161 staff completed education by 6/24 (2020) midnight shift. Staff not receiving education by 7AM on 6/25 (2020) will receive education prior to next shift worked. 9. Elopement books were reviewed to reflect current resident assessments. This was completed in conjunction with elopement assessment beginning on 6/24/2020 and 100% completed. This included function and placement of wander guards or additional alarms systems currently in place. 10. Elopement drills were held on 6/24 (2020) PM shift, 6/24 (2020) midnight shift and 6/25 AM shift. Any concerns were discussed with staff at the time of drill. 11. The above plan was discussed at QAPI meeting on 6/24 (2020) with the Medical Director, ED, and Regional Support staff. Althought the immediate jeopardy was removed on 6/24/20, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the fact the facility had not yet completed all education and sustained compliance had not yet been verified by the state agency.

This citation pertains to intake # MI 959 and # MI 910. Based on interview, and record review, the facility failed to implement interventions to prevent falls and complete comprehensive fall investigations in 2 of 7 residents (Resident #101 & Resident #104) reviewed for falls, from a total sample of 7, resulting in a fall with major injury and an incomplete investigation into an unwitnessed fall. Findings include: Review of the policy and procedure Falls Process utilized by the facility prior to 9/1/19, no date, revealed .Our community's protocol is that each of these items are completed in their entirety. EVERY FALL MUST INCLUDE AN INTERVENTION .Immediately after fall -Assess for injury -First aid as indicated -Assisted to appropriate area (bed, chair) using a mechanical lift .Follow Fall Care Path .Post fall huddle .Implement immediately - new fall intervention -Utilize the 5 whys .Complete RLS Voice - Falls incident report .Communication -Nursing notes -24 hour report -Change in mobility-Therapy screen/referral -Care plan update -Resident Summary -Manager, physician & responsible party notification -Must call the on-call manager at/near the time of the fall .VS (Vital Signs) and Neuro (Neurological) checks for 72 hours, if unwitnessed .Acute charting for 72 hours .If there is an injury, obtain order for treatment and enter into (computer system) .Monitor pain .Monitor for bruising or other evidence of injury .Review MEDICATION ORDERS FOR [REDACTED].Neurological assessment to be completed .VS to be included . Review of the Care Path for falls, updated 6/2018, revealed .Fall .Unintentional change in position coming to rest on the ground or onto the next lower surface .Take Vital Signs .Initial Nursing Evaluation for injury and/or Mental Status Changes .Do not move off floor until examining for head and spine injury .Suspected fracture or new bone deformity . Resident #101 Review of a Face Sheet revealed Resident #101 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/23/18, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated the resident was cognitively intact. The MDS assessment revealed Resident #101 required extensive assistance for bed mobility, toileting, and transfers, and had one fall with no injury since admission. Review of a Care Plan Report for Resident #101, effective 11/27/18, revealed the problem .I have confusion and forgetfulness at times. My cognition can fluctuate due to the time of day . Review of a Care Plan Report for Resident #101, effective 11/16/18, revealed the problem .Potential for injury associated with falls R/T (related to) loss of safety awareness, weakness, unsteady gait . with interventions which included .Orient me to surroundings & introduce other residents .Complete fall risk assessment and modify care plan as needed .Use assistive devices as described on resident summary for mobility and ADL (Activities of Daily Living) tasks .Provide supervision/assistance when transferring, ambulating, and toileting as described on the resident summary .Administer medications as ordered .Monitor ability to use call light. If unable to use, assess need for additional fall risk reduction interventions and implement as needed .Maintain clutter free environment .Keep call light within reach . all effective 11/16/18. Additional interventions included .Frequent rounding . effective 11/19/18, and .Keep bed at low position while patient is in bed. Assistive rails to both sides of bed. Mats to both sides of bed . effective 11/27/18. Review of a Resident Summary for Resident #101, printed 9/17/19, revealed no modifications had been made to the sections titled General, Activities, ADL Care/Bathing, Bathroom, Communication, Infection Concerns, Misc/Other Concerns, Mobility/Specialized Devices, Natural Sleep, and Skin Care. Resident #101's Resident Summary revealed the only areas that contained resident specific information/modifications were related to Dining, Mood Behavior, Spiritual, and Safety, which contained the intervention .Frequent rounding . with no additional interventions noted related to safety and fall prevention. Review of a Clinical Note for Resident #101, dated 11/16/18 at 6:43 p.m., revealed .Resident confused. Attributed to UTI (Urinary Tract Infection) .Attempts to self transfer, frequent checks as resident is a fall risk . Review of a Clinical Note for Resident #101, dated 11/16/18 at 11:12 p.m., revealed .Resident continues to talk in circles forgetting what he has been told and asking the same questions. 1:1 for safety as resident wants to get up not realizing he can't walk. Resident not comprehending his legs are too weak to walk . No intervention noted in Resident #101's Care Plan Report related to the implementation of 1:1 supervision on 11/16/18, and no details in regard to when this intervention was discontinued. Review of a Clinical Note for Resident #101, dated 11/17/18 at 4:23 a.m., revealed .Increased supervision by staff r/t (related to) attempts to get OOB (out of bed) .Very forgetful . Review of a Clinical Note for Resident #101, dated 11/18/18 at 8:18 p.m., revealed .Resident confused and verbally agressive toward staff. He thinks this is his residence and is accusing staff and other residents of trespassing on his property. When staff try to have him sit or not go into other rooms, resident gets aggressive .Resident self transferring in room from recliner chair to bed. Wife called stating she talked to him on the phone earlier and he wasn't himself, not making sense . Review of an Original Summary Fall Event report, dated 11/19/18, revealed Resident #101 was found on the floor by staff on 11/19/18 at 2:15 a.m. in his room, in front of his wheelchair. Per the report, Resident #101 did not sustain any injuries, and the new intervention was for .Frequent checks as he is very confused and disoriented . Review of a description of the incident revealed .He was transferred back to bed .Resident unable to say where he is or name the month . No staff statements were included with the fall investigation. Review of a Clinical Note for Resident #101, dated 11/19/18 at 3:36 a.m., revealed .Heard loud thud at 0215 (2:15 a.m.). Resident observed sitting on the floor in front of his wheelchair. States he was going outside to chop some wood .He was evaluated for injuries, none were found .(Resident #101) is unable to say where he is or what month it is .About a half hour later he was again observed trying to get out of bed .Wife has also observed recent changes in his mentation as if he doesn't know her . Review of a Clinical Note for Resident #101, dated 11/20/18 at 4:45 a.m., revealed .Resident with attempts to self transfer this shift .Observed wandering on different unit during the night . Review of a Clinical Note for Resident #101, dated 11/20/18 at 10:01 p.m., revealed .Alert to self only .Attempts to self transfer with staff assisting back into wheelchair . Review of a Clinical Note for Resident #101, dated 11/21/18 at 7:20 a.m., revealed .Awake most of noc (night) .Standing in hallway. Staff keeping constant supervision d/t (due to) poor safety awareness. Agitated when staff attempting to redirect . Review of a Clinical Note for Resident #101, dated 11/23/18 at 9:54 p.m., revealed .Wanders through hallways with staff supervising. Self transferring . Review of an Original Summary Fall Event report, dated 11/24/18, revealed Resident #101 was found on the floor by staff in his room on 11/24/18 at 5:00 a.m., in front of his walker. A description of the incident revealed Resident #101 .had made it all the way from the other side of the room with the walker and fell in front of the bathroom door. He was wearing socks, but not grip socks. He was incontinent of urine in his brief. Resident said he was trying to get to the bathroom. Last time was at midnight, 4 hours prior. He had removed his pants, which were on the other side of the room near the window .Had moved sheets and blankets as well. About an hour later, resident again self-transferred to bathroom . Per the report, Resident #101 did not sustain any injuries, and the new intervention was for .Grippy socks. More frequent toileting . There were no updates noted to the Care Plan Report or Resident Summary after Resident #101's fall on 11/24/18 to reflect these new interventions. Review of the section .Does resident exhibit signs and symptoms of acute confusion ([MEDICAL CONDITION])? revealed .YES . No staff statements were included with the fall investigation. In an interview on 9/18/19 at 11:50 a.m., DON B reported that after a fall occurrs, the charge nurse should talk with the staff to determine what happened, complete assessments, make appropriate notifications to family and the physician, and put an immediate intervention in place in an attempt to prevent additional falls. DON B reported that the Interdisciplinary Team (IDT) reviews the incident reports and ensures that updates to the Care Plan are in place. DON B reported that every fall should have an individualized intervention. Review of a Clinical Notes Report, printed 9/18/19, revealed no Clinical Note related to Resident #101's fall on 11/24/18 at 5:00 a.m. Review of a Clinical Note for Resident #101, dated 11/24/18 at 4:59 p.m., revealed .Continues to self-transfer .Staff performing frequent safety checks . Review of a Clinical Note for Resident #101, dated 11/25/18 at 3:48 a.m., revealed .sleeping on and off. Used urinal around midnight, then found getting ready to get up to bathroom around 0100 (1:00 a.m.) .Has been sleeping thus far, but have been staying outside his room ever-vigilant for him to self-transfer . Review of a Clinical Note for Resident #101, dated 11/25/18 at 10:23 p.m., revealed .Cotinues to self-transfer. Staff making frequent safety checks while resident alone in room . Review of a Clinical Note for Resident #101, dated 11/26/18 at 9:51 p.m., revealed .Resident continues to be confused .More restless today than Friday. Refused medications .Staff attempted to reorient with no success. Resident talked most of the shift about not having access to the basement and continuously inquiring how service work was done on his water heater and furnace if they had no access to the basement. Occasionally having paranoia (sic) thoughts . Review of an Original Summary Fall Event report, dated 11/27/18, revealed Resident #101 was .observed on floor crawling. Per patient he wanted to lie on floor. Observed large bump on right side with small abrasion . on 11/27/18 at 2:30 a.m., with a new intervention for .15 minutes (sic) checks til IDT (Interdisciplinary Team) review . Per the report, Resident #101 was .barefoot . at the time of the fall. The section .Evaluate the contirbuting (sic) factors and the resident description of the fall. What was different this time that may have led to the fall . revealed .(Resident #101) has no safety awareness. Self transfers constantly . No staff statements were included with the fall investigation. In an interview on 9/18/19 at 11:34 a.m., Director of Nursing (DON) B stated that the three Original Summary Fall Event reports provided for Resident #101 were .all that there is . and reported that no other documentation or witness statements were available for the incidents on 11/19/18, 11/24/18, and 11/27/18. In an interview on 9/18/19 at 12:43 p.m., Administrator A reported in regard to fall investigations, the IDT would review the fall and go over the interventions. Administrator A reported that the nurse and any potential witnesses would be interviewed to determine the cause of the fall, the IDT would ensure that all notifications were completed, and stated .we would verify that the interventions were in place visually . Administrator A stated .updates to the care plan were part of our team review . Administrator A stated in regard to the intervention Frequent Checks, .we would tell our staff frequent checks means it's not a specific time but it is frequently .depends on how often that person needs to be checked . Administrator A reported that Frequent Checks were not an intervention that required documentation, and stated .if someone was deemed that they needed 15-minute checks then we would document . Administrator A stated that the intervention More Frequent Toileting .would be at the nurses discretion . and again did not involve a designated time frame. In an interview on 9/18/19 at 2:40 p.m., Licensed Practical Nurse (LPN) Y reported that she provided care for Resident #101 during his stay in (MONTH) of (YEAR). LPN Y reported that one of the reasons for his admission to the facility was his confusion. LPN Y stated .at times it (the confusion) was severe and at times he was lucid .He was very impulsive, but mobility when he admitted was very limited . LPN Y reported that after a fall, a new intervention should be implemented, and documented in the nurses notes, the Care Plan, and the Resident Summary. LPN Y reported that the Resident Summary should contain interventions, safety interventions, and how a resident transfers. LPN Y reported that .grip socks . are a common intervention after a fall and should be documented in the Care Plan and Resident Summary if utilized. LPN Y reported that the intervention Frequent Checks is not commonly used and stated .it's not defined very well .it's at the nurses discretion . LPN Y reported the system previously used for incident reports (at the time of Resident #101's falls in (MONTH) of (YEAR)) did have an area to document statements from staff, however it was not frequently utilized. Review of a Clinical Note for Resident #101, dated 11/27/18 at 7:20 a.m, revealed .Patient observed on floor on hands and knees. When asked what happened patient responded he wanted to stretch out on floor. Refused assistance to get up. Assisted on back. (Nurse) noticed large swelling to Right side of head. Ice applied. Refused orthos, ROM (Range of Motion) Refused head to toe assessment. Requested pillows. Staff monitoring patient. C/o (complained of) pain to right hip Dr (Doctor) notified with orders for Stat Xray, Bilateral rails to bed .Impact mats to both sides of bed. Bed in low position when patient in bed . Review of a Clinical Note for Resident #101, dated 11/27/18 at 10:10 a.m., revealed .STAT x-rays obtained of bilateral hips. Results revealed fracture involving proximal right femur with displacement .will send to (Hospital Name) ER (emergency room ) for further evaluation . Review of a Radiology Report for Resident #101, dated 11/27/18 at 8:40 a.m., revealed .There is a fracture involving proximal right femur with displacement. The age of the fracture is recent .Proximal right femur fracture . Review of the hospital records for Resident #101, dated 11/27/18, revealed .Patient is an [AGE] year-old male who presents to the emergency department for evaluation after a fall. He was at rehab and they were able to perform an x-ray of his hip there that showed a right femur fracture .He also has significant bruising of his right hand as well as his right middle toe .His x-ray show a displaced right femoral neck fracture as well as a displaced and angulated [MEDICAL CONDITION] radius and ulna distally . Resident #104 Review of a Face Sheet revealed Resident #104 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 5/24/19, revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated severe cognitive impairment. The MDS assessment revealed Resident #104 had hallucinations, delusions, verbal behaviors, and a history of wandering, and required extensive assistance with transfers and bed mobility. Review of a facility investigation summary for a Fracture of Unknown Origin for Resident #104, dated 8/23/19, revealed .On 8/19/2019 - X-ray of the right kee was ordered due to patient's complaint of pain and manifestation of swelling on that area .Results: Distal femoral perioprosthetic fracture with malalignment. Conclusion: Acute Femoral Fracture. Cause of this injury is unknown. Immediate investigation was initiated .Patient was sent to the hospital on [DATE] for further evaluation and treatment .There were no known fall/s or Incidents reported by staffs (sic) interviewed that may have contributed to this identified injury .Patient is known to wheel self around, using both feet/legs to mobilize the wheelchair. Also, patient gets self up, sitting on edge of bed with both feet planted on the floor .Conclusion: At this time, the facility is not able to determine the exact cause of the injury. The facility could only state that the injury could have occurred between (MONTH) 18 and (MONTH) 19; and that the injury could have been a result of a combination of patient's poor bone quality, [MEDICAL CONDITION] and patient's self-propelling status using her legs/feet and complication from previous knee arthroplasty . Review of a Care Plan Report for Resident #104, effective 8/24/18, revealed the problem .Potential for injury associated with falls. Resident with preference to sit in chair at edge of bed in bent over/hunched position . with interventions which included .Impact mat at bedside . effective 10/27/18, and .Anticipate resident to possibly roll on to bedside mat R/T (related to) preferred posture and desire to always have feet on floor while lying in bed . effective 11/12/18. Review of a Resident Summary for Resident #104, printed 9/17/19, revealed .Mat on floor next to bed while in bed. Tends to roll out of bed onto mat related to posture preference while in bed to maintain feet on floor . Review of a Clinical Note for Resident #104, dated 8/17/19 at 10:11 p.m., revealed .Resident crying at the beginning of this shift off and on. Resident ate a little dinner in the dining room, however, kept wheeling herself out asking when she is going to go home. Resident took her scheduled medications this evening. Resident calm for a brief while afterwards. At 2209 (10:09 p.m.) resident is awake and crying calling for her mother, and making other delusional statements. Resident is loud while other residents are trying to sleep and staff is unable to redirect . Review of a Clinical Note for Resident #104, dated 8/17/19 at 10:54 p.m., revealed .at 2250 (10:50 p.m.) resident is in bed being loud crying calling out for (Name) and making other delusional statements. Staff attempted to give support, redirection which is not effective . In an interview on 9/18/19 at 11:21 a.m., CNA LL reported that she worked Saturday 8/17/19 from 2:30 p.m. to 10:30 p.m. and Sunday 8/18/19 from 8:00 a.m. to 10:30 p.m., and stated .(I) worked with her (Resident #104) that entire weekend prior to her complaints of pain. She was not complaining of any pain (on Saturday 8/17/19). She seemed to be fine. When I came in Sunday morning, I was told in report it (right knee) was swollen and painful. She stayed up on Sunday until about noon. She did complain of pain so I carefully put her in the bed. She slept the rest of the day . CNA LL reported she was unsure what happened between 8/17/19 at 10:30 p.m. to the time she returned to work on Sunday 8/18/19 at 8:00 a.m., and stated .she was in bed when I left at 10:30 p.m. and was up in her chair at 8:00 a.m. on Sunday . CNA LL reported Sunday was the first time Resident #104 complained of right knee pain. CNA LL reported that Resident #104 was not able to verbalize what happened, as .she suffers from dementia . In an interview on 9/18/19 at 1:12 p.m., Registered Nurse (RN) F reported she worked third shift on Saturday night 8/17/19 from 10:30 p.m. to 6:30 a.m. RN F reported that Resident #104 did complain of pain in her right knee. RN F reported she provided Resident #104 with ordered medications for pain. RN F reported that she was notified prior to her shift that there had been a recent change to Resident #104's medications, and stated .I thought her inability to sleep was the change in medications . RN F stated .other than the pain, she didn't have any differences with the leg .She would cry out at times. She would tell me it hurts, but could not rate the pain . RN F reported that when she asked her co-workers about Resident #104's complaints of pain, she was told that is .just how she was . RN F reported that Resident #104 had a fall mat beside her bed, and that at one point on Saturday night she (RN F) observed Resident #104 sitting on the mat beside her bed. RN F stated .I was told it was care planned in and you don't have to do neuro's and vitals. She did slide out of bed onto the mat beside the bed once that night and we assisted her back into bed . Review of the Clinical Notes for Resident for 8/17/19 and 8/18/19 revealed no information related to Resident #104 being observed beside her bed on the floor, and no documention of assessments for injury. In an interview on 9/18/19 at 11:12 a.m., LPN OO reported she worked Saturday 8/17/19 and Sunday 8/18/19 from 6:30 a.m. to 2:30 p.m. each day. LPN OO reported that on Sunday morning, the night shift nurse notified her at shift change that Resident #104 had complaints of right knee pain during the night and was provided with pain medication. LPN OO reported that Resident #104 never complained of pain on her shift, and stated it .was a very quiet Sunday morning . LPN OO reported that there were no falls or incidents that she was aware of that could have resulted in Resident #104's right knee pain/injury. In an interview on 9/18/19 at 2:57 p.m., RN Z reported that she worked second shift on Saturday 8/17/19 and Sunday 8/18/19 from 2:30 p.m. to 10:30 p.m. RN Z stated Resident #104 .was complaining of knee pain which she does, it wasn't out of the ordinary for her .she took her scheduled medications . RN Z reported that she was not aware of any falls or incidents that weekend which could have resulted in Resident #104's fracture and complaints of knee pain. RN Z stated Resident #104 .put her legs on the side of her bed .would get off the bed onto the floor mat every once and awhile .staff would help her back into bed . RN Z reported that she would not complete incident reports when this occurred. RN Z reported she was unsure if the resident was found on the floor mat beside her bed on 8/17/19 or 8/18/19. Review of a Clinical Note for Resident #104, dated 8/18/19 at 10:57 p.m., revealed .Resident sleeping the beginning of this shift. Resident woke up at 1800 (6:00 p.m.) crying and yelling for her mother. Resident c/o (complained) that her left knee hurts. Biofreeze applied with no relief. Resident took her scheduled evening medications. Resident eventually calmed down and fell asleep . In an interview on 9/18/19 at 9:45 a.m., Licensed Practical Nurse (LPN) CC reported that she worked third shift from 8/18/19 at 10:30 p.m. to 8/19/19 at 6:30 a.m. LPN CC reported that she was notified by second shift of 8/18/19 that Resident #104 had complaints of knee pain, however Resident #104 slept through the night on her shift. LPN CC stated that when Resident #104 woke up on 8/19/19 that .was when the pain became an issue . LPN CC reported CNA NN went in to provide incontinence care on 8/19/19 at 6:30 a.m. and Resident #104 was .complaining of pain and wouldn't let anyone touch her . LPN CC reported that Resident #104 has impaired cognition and was not able to recall what happened to her knee. In an interview on 9/18/19 at 9:32 a.m., Certified Nursing Assistant (CNA) NN reported that when she arrived for her shift on 8/18/19 (10:30 p.m. to 6:30 a.m. shift), she went to check on Resident #104 and noticed that her right foot and right knee were swollen, and notified the nurse. CNA NN reported that Resident #104 frequently sleeps with her feet and lower legs off the side of the bed. CNA NN stated that Resident #104 .slept most of the night .When I checked on her she was okay . CNA NN reported that Resident #104 was incontinent in the morning (8/19/19), and when she went to assist the resident with a brief and bedding change .she was yelping in excruciating pain. She was literally screaming. I told the nurse it needed to be looked at . CNA NN reported that she worked third shift the night prior and stated .she was ouchin' but not like the pain the next day . In an interview on 9/17/19 at 3:59 p.m., Registered Nurse (RN) P reported that she observed signs/symptoms and vocalization of pain from Resident #104 at the beginning of her shift, on 8/19/19 at approximately 6:30 a.m. RN P reported Resident #104 was in pain .immediately upon rising . and noted visible swelling of Resident #104's right knee. RN P reported Resident #104 often complains of pain in her legs and back, and has two prosthetic knees. RN P reported she administered ordered medications, however, Resident #104 was still calling out and crying, and .it seemed like more pain than usual . RN P reported the Physician assessed the resident on 8/19/19 and an X-ray was ordered. Review of a Clinical Note for Resident #104, dated 8/19/19 at 2:40 p.m., revealed .New orders received and noted for increase in [MEDICATION NAME] PRN (as needed) order to 25 mg BID (twice a day), labs draw and x-ray to right knee .Elder c/o (complained of) right knee pain throughout the shift .Tearfulness and agitation noted for duration of shift with brief periods of calm . Review of a Clinical Note for Resident #104, dated 8/19/19 at 6:54 p.m., revealed .Orders received to send elder to (Hospital Name) ER (emergency room ) r/t (related to) fracture of right distal femur as shown in today's x-ray .At approximately 6:15 p.m., elder was transferred to (Hospital Name) ER . In an interview on 9/18/19 at 3:45 p.m., Clinical Care Coordinator (CCC) [NAME] reported that Resident #104 frequently complained of pain in her knees, and had a history of [REDACTED].#104 had a fall mat beside of her bed, due to her tendency to slide out of bed onto the floor. CCC [NAME] reported that staff would complete an incident report when this occurred. CCC [NAME] reported staff would consider that type of incident a fall when unwitnessed, with assessments completed to identify any possible injuries, and stated .unless you saw her (Resident #104) you would have no idea . what actually occurred. CCC [NAME] reported Resident #104 preferred to sleep with both feet on the floor when in bed. CCC [NAME] reported she participated in the investigation into Resident #104's fracture, noted on 8/19/19, and reported none of the staff interviewed indicated Resident #104 had been on the floor at any point on 8/17/19 or 8/18/19. In an interview on 9/18/19 at 3:55 p.m., Director of Nursing (DON) B reported that if a resident is found on the floor, and staff is unsure how they got there, it would be considered a fall and an incident report should be completed. Review of Resident #104's incident/accident reports for the past 3 months revealed a report was completed by facility staff on 7/16/19 for a skin tear, and on 8/19/19 for an injury of unknown origin. No incident/accident reports for falls were noted in the past 3 months for Resident #104 including no documentation that RN F observed Resident #104 on the floor during her shift on 8/17/19-8/18/19.

Based on observation, interview, and record review, the facility failed to prevent the formation of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #4), from a total of 24 sampled residents, resulting in Resident #4 developing 4 facility acquired pressure ulcers, worsening of one of the pressure ulcers, and the potential for continued worsening of all 4 pressure ulcers due to potential contamination. Findings include: Review of Residents #4's MDS/Minimum Data Set, dated dated [DATE], revealed she was admitted to the facility on [DATE], scored 7 out of 16 on the Brief Interview for Mental Status, (indicating she had severe cognitive impairment), and [DIAGNOSES REDACTED]. Review of Pressure Ulcer records revealed Resident #4 developed 2 Stage II (A. 2 cm x 1.5 cm x < 0.1 cm and 2 cm x 2 cm x <0.5 cm) pressure ulcers on her right buttocks on 2/19/16, and then developed a Stage II (2.0 cm x 0.5 cm x 0.1 cm) due to shearing on her coccyx 24 days later (on 3/14/16), and then 2 days later (on 3/16/16), she developed a Stage II (1.0 cm x 0.5 cm x not recorded) on her left buttocks. According to the Pressure Ulcer records, the 2 ulcers on the right buttock were almost resolved (0.1 x 0.1 x <0.1) when last measured on 3/16/16, while the coccyx ulcer increased to 2.1 x 1.9 x 0.1 as of 3/22/16; the ulcer on the left buttocks had not been re-measured since originally recorded on 3/16/16. In an interview, on 3/21/16 at 3:00 PM, Dietitian C reported Resident #4 had lost weight due to a decline in oral intake while on antibiotics from an infected hip incision and a recent decline in mental status, but reported Resident #4's laboratory values, dated 3/07/16, were fine. According to Dietary Clinical Notes, dated 3/11/16, NAR (Nutrition AT Risk) held today w (with) CCC's (Unit Managers) present. Skin status: 2-Stage 2/s pressure ulcers to Rt Buttocks - noted as healing per nursing. Receives [MEDICATION NAME] (antibiotic) (started 3/7/16 x 6 weeks) for VRE ([MEDICATION NAME]/antibiotic Resistant [MEDICATION NAME]/bacteria) infection to Rt (right) hip prosthesis (surgical hip incision infection) .Significant unplanned weight loss of 5.4% x 30 days .Receives Ensure Plus TID (3 times a day) - pt (patient) accepts well .Maintain current nutrition plan of care d/t (due to) stabilization of weight 159-161 # (pounds) since 2/29/16. On 3/22/16 at approximately 1:00 PM, Resident #4 was observed sitting upright in a wheelchair in her room and no braces were observed on her legs. In an interview, on 3/23/16 at 8:30 AM, Unit Manager/Licensed Practical Nurse G reported the pressure ulcers Resident #4 developed on 2/19/16 were unavoidable because Resident #4 was admitted to the facility from the hospital (1/08/16) with moisture associated skin damage caused during her hospitalization for hip surgery, and she was then wearing a hip abduction brace, had lethargy and fatigue, and was incontinent of bowel and bladder. When asked how wearing a hip abduction brace, lethargy, fatigue and being incontinent of bowel and bladder caused the pressure ulcers, Unit Manager G had no response. On 3/23/16 at 10:00 AM, this Surveyor observed Unit Manager G, assisted by Nurse Aide H', perform a dressing change to Resident #4's buttocks/coccyx area. Upon entering the room, a Chux (large paper pad lined with plastic) was observed in Resident #4's recliner chair. When asked about it, Nurse Aide H said Maybe, they put her in her recliner last night without a brief on. Without the assistance of Nurse Aide H, Unit Manager G pulled on the draw sheet under Resident #4 to roll her from her back to her left side; Resident #4 was not wearing an abduction brace. Unit Manager G pulled off a large dressing with scant amounts of serosanguinous fluid in 3 areas on the dressing, and 4 Stage II pink pressure ulcers were observed; the surrounding area around the ulcers was pale, firm, without signs and symptoms of bogginess or deep tissue injury. There was a large formed BM (bowel movement) in Resident #4's brief/anus area, and Nurse Aide H removed the BM and cleaned the area, wiping towards and nearly touched the uncovered/exposed pressure ulcers on the left buttocks and coccyx. Then, wearing the same gloves she was wearing upon first entering the room, Unit Manager G began pointing out and touching the edges of the pressure ulcers while discussing the healthy, surrounding tissue. Unit Manager G opened a sterile water tube and squirted the water on 4 x 4 gauze sitting directly on Resident #4's tray table, she then daubed the pressure ulcers with the moist gauze, opened a tube of [MEDICATION NAME] ointment, squirted the cream onto her gloved finger, and touched each of the pressure ulcers with it. Unit Manager G then grabbed the tray table to move it, then put her gloved hand into her pocked, then asked Nurse Aide H if she had a pen, which Nurse Aide H took from her pocket and gave to Unit Manager G. Unit Manager G then used the pen to write the date on the outside of the foam dressing, put the pen on the tray table, then applied the dressing that covered all 4 ulcers. When that was completed, Unit Manager G opened a white cream tube of [MEDICATION NAME] and smeared the cream on Resident #4's mons pubis and anus. While holding Resident #4 over to apply the ointment, Unit Manager G was touching Resident #4's hip incision with the contaminated, gloved hand. Unit Manager G then removed her gloves, put the caps on the ointments, repositioned Resident #4 with Nurse Aide H with the draw sheet, touched Resident #4's pillow and blanket, and grabbed Resident #4's water and coffee cups and offered Resident #4 a drink. At no time, did Unit Manager G was her hands or change gloves during these actions. Unit Manager G handed the pen to Nurse Aide H who, in turn, placed it in her pocket. According to the facility's education guide entitled Pressure Ulcer Prevention Interventions, (not dated), .Use a lift sheet or device to reduce friction and sheer during repositioning . The guide did not describe how to properly use of a draw sheet to reduce shearing/friction (2 persons lifting on opposite sides or rolling gently without pulling) rather than contributing to it by using it improperly (pulling/yanking on a draw sheet - creates friction/shearing). The facility did not have a Policy and Procedure on Pressure Ulcer Prevention. According to the facility's One-On-One In-Service - Treatment Administration, (dated 1/31/08) used as Post-Test, .2. Wash you hands or use hand sanitizer. Set up barrier; 3. Prepare supplies .4.place equipment on barrier (no supplies on bare table) 6. Assist resident to a comfortable position and place barrier under site if needed. Place over bed table with equipment where it is comfortable for you. 7. Wash hands or use hand sanitizer. Don gloves; 8. Remove old dressing .9 .Remove gloves and wash hands or use hand sanitizer. Put clean gloves on; 10. Cleanse site as ordered .11. Remove gloves (Use alcohol wipes to cleanse reusable equipment if used); 12 .wash hands or use hand sanitizer . Another document provided to Surveyor for review in lieu of a Policy and Procedure was entitled Lippincott Procedures - Quick Lists for: Foam dressing application, (not dated, but printed 3/23/16). According to the Quick List, .Prepare the cleaning solution; Open the supplies; Perform hand hygiene, and put on necessary personal protective equipment .Irrigate the wound with appropriate solution using a syringe; also clean the surrounding skin; Remove and discard your soiled gloves; Perform hand hygiene, and then put on a new pair of clean or sterile gloves .Applying the dressing .Apply a topical agent if prescribed; Lay the foam dressing over the wound Perform hand hygiene . According to another document provided to Surveyor for review was entitled Lippincott Procedures - Pressure ulcer prevention, (not dated, but printed 3/23/16), .Most pressure ulcers develop over bony prominences, where friction and shearing force combine with pressure to break down skin and underlying tissues . ( )

Based on observation, interview and record review, the facility failed to prevent pressure ulcers for 1 of 4 residents reviewed for pressure ulcers (Resident #14) out of a total sample of 24 resulting in an unstageable pressure ulcer to the left heel and stage II pressure ulcer to the left ankle for Resident #14. Findings include: Resident #14 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #14 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #14 had severe cognitive impairment and required staff assistance with all activities of daily living. According to the facility policy/procedure for care plans dated 4/4/14 reflected, A comprehensive care plan guides the resident's care from admission to discharge .A care plan is an individualized, written action plan for the resident's care, treatment, and services that's based on nursing assessments, reassessments, diagnostic tests results, and the resident's individual goals .The multidisciplinary team then collaborates with the patient and reviews and revises the plan of care .the care plan for each resident must include: goals, interventions that describe the services you'll employ to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, evaluation of the fulfillment of goals as planned .Write the care plan clearly and concisely so that other members of the health care team can understand it. Record the resident's progress (or lack of progress) toward meeting set goals. Record Review of the Pressure Ulcer/Non-Pressure Ulcer Healing Record dated 1/10/15 reflected that Resident #14 was admitted to the facility on [DATE] with an unstageable pressure ulcer (to the left heel) defined on the record as, full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed. The record further reflected no measurement and was documented as, closed & fragile. The healing record dated 1/16/15 reflected the following open area to the left heel, 1.4 cm x 1.7 cm x .02 cm open area, wound re-opened/scab off, full thickness loss, shallow, maceration surrounding unable to visualize full wound bed The yes box was checked which indicated that a care plan was initiated but did not indicate a date that is was initiated. On 1/26/14 the Surveyor requested a copy of Resident #14's current care plans and all incident/accident occurrence reports from the Director of Nursing (DON). The care plans were reviewed and did not contain a care plan for the unstageable pressure ulcer to the left heel and stated that Resident #14 did not have any accident/incident occurrence reports. Review of the Pressure Ulcer/Non-Pressure Ulcer Healing Record dated 1/26/15 revealed that in addition to the unstageble pressure ulcer on the left heel, Resident #14 developed a Stage II pressure ulcer to the left ankle. The record reflects, Stage II: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. The left ankle wound measured .04 cm x .07 cm <.01 cm and was documented as a partial thickness loss with the appearance of an abrasion and open. In an interview and record review on 1/29/15 at 1:10 PM, the DON and Clinical Care Coordinator, Registered Nurse (CCC RN) Q confirmed through record review and review of the electronic medical record that there was not an active care plan for the new/reopened unstageable pressure ulcer (of the left heel) from 1/10/15 (date the wound was discovered) through 1/26/15. The CCC RN Q stated that she had difficulty reactivating the previous care plan but created a new care plan that was dated 1/27/15 (one day after this surveyor asked for the current care plans, 7 days after the pressure ulcer to the left heel reopened and one day after the left ankle pressure ulcer developed.) The CCC RN Q stated that on 1/28/15 (two days after the stage II pressure ulcer was discovered to the left ankle) she initiated an Accident/Incident Unplanned Occurrence report for the pressure ulcer and stated it was not known what caused the open area over the left ankle. During an observation of care for Resident #14 on 1/29/15 at 8:55 AM with CNA P in his room, CNA P rolled Resident #14 side to side and washed and dried his peri area and buttock. When Resident #14 was rolled side to side the bed sheet and pad beneath was noted to have a large yellow area. CNA P was observed to remove his gloves and stated that he was done with Resident #14's care. When asked if CNA P noticed the large yellow area on the bed sheet and pad beneath Resident #14 he stated, No. After it was brought to CNA P's attention by the Surveyor, CNA P obtained clean bed sheet and pad and together with Licensed Practical Nurse (LPN) R changed Resident #14 bed lines. When asked about the large yellow area on the bed linen, LPN R stated, The catheter must have leaked (urine) .it was wet. After CNA P and LPN R changed the sheets they did not rewash Resident #14's skin where he came into contact with the wet, urine soaked bed sheet. Having moist/wet skin has the potential to exacerbate skin breakdown. (# )

This citation contains multiple deficient practice statements (A and B). Deficient Practice A: Based on interview and record review, the facility failed to use the assistance of two staff members for a transfer, for 1 of 7 (#8) sampled residents reviewed for falls and 1 of 6 sampled residents (#8) observed for transfers out of a total of 24 sampled residents, resulting in a fall and fracture. Findings Include: Resident #8 according to the January 2015 monthly physician order, was a ninety-two year old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status score of 3 out of a possible 15, which reflected severe cognitive impairment. Resident #8's fall care plan created 4/10/13 and updated 12/14/13 reflected Resident #8 was at risk for falls related to weakness, decreased mobility, Parkinson's disease, vision deficit, forgetfulness, dementia and increased risk for falls with medications to treat bipolar, dementia, Parkinson's [DIAGNOSES REDACTED] . The portion of the fall care plan updated again on 3/26/14 reflected Resident #8 needed total assistance of two nursing staff with gait belt or EZ lift for transfers. The unplanned occurrence report dated 9/13/14 reflected Resident #8 was observed sitting on her buttocks with her legs outstretched on the impact mat. CENA (certified educated nursing assistant) placed gait belt around resident's waist to assist resident to the restroom Resident stood started to walk before CENA could place FWW (four wheeled walker) in front of her. Resident's knees buckled causing her to fall backward onto her buttocks. ROM (range of motion) - neuro checks . Resident #8 c/o (complained of) back pain - norco had been administered prior to occurrence. Upon follow up resident pain was a 3 out of 10 using Wong baker faces scale. 0 visible injuries at this time . The physician's statement on this same unplanned occurrence report reflected above noted - pt. being seen and evaluated for back pain. Licensed practical nurse B transferred Resident #8 on 9/13/14 completed a written statement. LPN B's written statement dated 9/13/14 reflected the following On 9-13-14, at approximately 5:30 a.m. (LPN B) walked into (Resident #8's) room to provide morning care . (LPN B) assisted (Resident #8) into a sitting position at the edge of her bed, and placed a gait belt around her waist. (LPN B explained to (Resident #8) that she was going to assist her to sit in her wheelchair (the wheelchair was at an angle on (Resident #8's) right side.) After (LPN B) assisted (Resident #8) to stand, (Resident #8) then attempted to walk using the wheelchair as an assistive device. (LPN B) asked (Resident #8) if she would like to walk to the bathroom. (Resident #8) replied, 'yes'. (LPN B) reached for the walker still holding on to (Resident #8) with a gait belt. (Resident #8's) legs buckled causing her to fall butt first onto floor onto impact mat. The Proof of Internal Investigation Report dated 10/1/14 reflected Resident (#8) fell on to her buttocks on impact mat resulting in compression fracture. Conclusions from the investigation were Mild compression fracture r/t (related to) witnessed fall on 9/13/14. Resident (#8) with increased pain which prompted additional follow-up. NP (nurse practitioner) was present and assessed resident. He initially felt it was a muscle sprain, but continued pain warranted additional x-ray and MRI which showed fracture . On 1/28/15 at 3:10 PM LPN B was interviewed, she explained that at the time of Resident #8's transfer she was a contingent nurse aide and had not worked with her in 5 weeks. LPN B further explained that she was not aware Resident #8 was a 2 person transfer, because the last time she worked with Resident #8 she transferred her alone, and Resident #8 was able to use her 4 wheeled walker. LPN B was asked were the Resident Care guides available to nurse aides. LPN B replied yes the resident care guides were in the Kiosk, but she had not checked and didn't know Resident #8's transfer status had changed. However, Resident #8's fall care plan had not changed and transferring with 2 people assisting had been in effect since 12/14/13. The Interventional Radiology Reports dated 9/29/14 reflected the reason for the exam was L1 compression fracture. The findings were Lumbar Vertebroplasty. This same report also reflected that Resident #8 had a history of [REDACTED]. This same report reflected The patient tolerated procedure well without evidence for complication. The incident report dated 9/13/14 reflected Resident #8 had a fall that day (9/13/14) and the date on the Interventional Radiology Report was dated 9/29/14 which reflected resident #8 went at least 12 days with increased back pain before the fracture was discovered and the vertebroplasty treatment of [REDACTED]. On 1/28/15 at 3:10 PM, during an interview, LPN B stated Resident #8 was able to ambulate with a walker. The Incident report dated 9/13/14 indicated Resident #8 got up and walked while LPN B's hand was still on the gait belt. The significant change Minimum Data Set (MDS) assessment date 10/8/14 reflected Resident #8 was totally dependent for transfers and ambulation. The Quarterly MDS dated [DATE] reflected Resident #8 needed extensive assistance for transfers and was totally dependent for ambulation. Thus, Resident #8 went from extensive assistance for ambulation to total dependence for ambulation. ( ) Deficient Practice B: Based on observation, interview and record review the facility failed to identify a potential safety hazard and develop and educate staff regarding a process for safe serving temperatures after re-heating food and liquids in the microwave for 132 out of 132 residents currently residing in the facility resulting in the potential for resident burns. Findings Include: On 1/27/14 at 12:15 p.m. on the 600 unit dining room, CNA (Certified Nurse Aide) H was observed to place a frozen cup of ice cream in the microwave. On 1/27/15 at 12:30 p.m. an interview with Resident #26 stated the food is sometimes cold when it gets to my room but the aides will warm it up in the microwave for me. On 1/27/14 at 12:45 p.m. an interview with CNA H was asked about the microwave use and stated .we reheat food in the microwave if the food comes from the kitchen and a resident wants it hotter .I don't check the temperature of the food before giving back to the resident . CNA G who was also in the dining room at the same time stated . I check the temperature when reheating food or liquid by holding my hand over the food to see how much heat is radiating off the food . An interview with the Dietary Manager D on 1/28/15 at 11:00 a.m., when asked what the process was for reheating of food by CNA's once the food left the kitchen and on the unit. Dietary Manager D stated if the food needs to be reheated after it gets to the unit it should be discarded and a new tray ordered from the kitchen. Dietary Manager Ddidn't think they (the microwaves) were used for reheating of resident food, but that she would expect the temperature of the food or liquid be tested before serving to residents. According to the HACCP ( Hazard Analysis and Critical Control Point) Food Safety Recipe Guidelines, undated, that was provided by Dietary Manager D under Reheating: Food reheated in the microwave must reach an internal temperature of at least 190 degrees. Dietary Manger D stated that this was the process and procedure that the facility used as a guide for reheating food in a microwave. On 1/28/15 at 9:00 a.m. the DON (Director of Nursing) confirmed that there was not a process in place to ensure safe reheating of food using the microwave.

This citation contains multiple deficient practice statements (A and B). A. Based on interview and record review, the facility failed to protect one (Resident #24) from physical, psychological and verbal abuse and neglect in 1 of 14 residents reviewed for abuse, from a total of 25 sampled residents and 4 extended sample residents, resulting in Resident #24 being placed in immediate jeopardy to her health and safety on 12/28/13 when Resident #24 was forced to be washed up and denied care she needed. Resident #24 remains fearful of Certified Nurse Assistant (CNA) "H" to the current date. These deficient practices placed all residents in the care of CNA "H" at risk for serious harm, injury, and/or death. The facility was placed in Immediate Jeopardy as a result of the facility's failure to protect Resident #24 from physical, verbal and psychological abuse from CNA "H" (held Resident #24 down, twisted Resident #24's shoulder, forced Resident #24 to accept care that she did not want, denied Resident #24 care), on 12/28/13, at 9:30 AM. The facility failed to investigate an allegation of abuse/neglect and protect Resident #24 from further physical, verbal and psychological abuse. CNA "H" is currently working in the facility and has been assigned to work with Resident #24 since the incident on 12/28/13. CNA "H" is considered a full time employee and is assigned to Resident #24's hall on a routine basis. On 01/17/2014 at 9:30 AM Resident #24 stated she remains fearful of CNA "H". On 1/21/14 at 2:55 PM the Nursing Home Administrator (NHA) was notified of Immediate Jeopardy that began on 12/28/13, and identified on 1/17/14 at 4:00 PM, due to the facility's failure to protect Resident #24 from abuse and the potential for all residents in the care of CNA "H" at risk for abuse. A request for a written plan of removal was requested at that time. On 1/22/14 3:00 PM, the Immediate Jeopardy was removed when the surveyors verified the following: -On 1/21/14 the local police department was notified of the allegation of physical abuse. -On 1/17/14 at 6:17 PM the State Agency was notified of the allegation of physical abuse. -On 1/17/14 at 4:20 PM staff members CNA "H" and Licensed Practical Nurse (LPN) "J" were suspended from work pending further investigation. -On 1/21/14 the facility completed the investigation and submitted it's findings to the State Agency. -On 1/21/14 the facility terminated the employment of staff members CNA "H" and LPN "J". -On 1/21/14 the facility interviewed all interviewable residents residing on the (name of the hall) that CNA "H" was assigned to determine if any other residents have been affected. -On 1/21/14 the facility's Regional Clinical Manager provided education on reporting abuse to the State Agency per facility policy/procedure to the NHA, Director of Nursing (DON), management staff and the interdisciplinary team. -On 1/21/14 the facility began educating all current staff members on reporting abuse. No staff members will be allowed to work past 1/21/14 without receiving abuse education. -On 1/22/14 resident concerns, grievances, allegations of abuse that were reported to the DON and NHA will be reviewed with the Regional Director of Operations to assure all allegations are reported per regulation and policy. -On 1/22/14 the facility will report trends to the MDQI (quality assurance committee) for review and recommendations until further recommendation of the committee. Although the Immediate Jeopardy was removed on 1/22/14 the facility remained out of compliance with a scope of isolated and severity of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" due to all staff had not received the inservice education for abuse and reporting and sustained compliance had not been verified by the State Agency. Findings include: Resident #24 Review of the Face Sheet, run date 01/17/2014, revealed Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #24's Brief Interview for Mental Status (BIMS), dated 12/24/2013 and authored by Social Services Director "K", reflected a score of 15/15 indicating that Resident #24 was cognitively intact. Review of Resident #24's Minimum Data Set (MDS), dated [DATE], reflected Resident #24 required extensive staff assistance with transferring (movement between surfaces including to or from bed, chair, wheelchair, etc.), movement between locations in her room and with bathing. The MDS also reflected that Resident #24 was not steady, only able to stabilize with staff assistance when moving from seated to standing position and for surface-to-surface transfers. Review of Physical Therapy Plan of Care dated 12/11/2013, reflected that Resident #24 required "maximum assistance" for rolling in bed and "total assistance/dependent" for transfers from bed to chair and chair to bed. During an interview with Resident #24 on 1-17-14 at 9:15 AM, Resident #24 was alert and oriented to person, place and time. Resident #24 stated that the morning of 12-28-13, while in the bathroom CNA "H" wanted to wash but she (Resident #24) did not want to wash at that time, however CNA "H" twisted Resident #24's shoulder, held here down and started to wash her face, disregarding Resident #24's refusal. Resident #24 stated she bent forward and guarded her face so CNA"H" could not wash her face as she continued to scream, "get me out of here!" Resident #24 said she continued to scream and CNA "H" finally stopped. Resident #24 said CNA "H" refused to provide her any further assistance; she requested help from CNA "H" to transfer back to the bed. Resident #24 stated that CNA "H" refused to assist her back to bed so Resident #24 stated, "I transferred myself back to bed." Resident #24 said the next time CNA "H" was assigned to care for Resident #24, Resident #24 said she told CNA "H" that she "hoped it would not be a repeat of the last time" and CNA "H" said, "It is entirely up to you." Resident #24 remains fearful of CNA "H". Resident #24 stated she had told LPN "J" about the incident that occurred with CNA "H" on 12-28-13. During a telephone interview with LPN "J", on 1/17/14 at 1:15 PM, LPN "J" said Resident #24 told LPN "J" that CNA "H" was trying to wash her face and Resident #24 told CNA "H" that she did not want to be washed while sitting on the toilet and CNA "H" continued to forcefully wash Resident #24's face, so Resident #24 yelled out again and then demonstrated to LPN "J" how she leaned forward and guarded her face while CNA "H" continued to attempt to wash her face. LPN "J" stated that Resident #24 told her that CNA "H" refused to assist her with transferring from the toilet to the wheel chair and then from the wheel chair to the bed. LPN "J" stated that she was in the next room during the time of the incident on 12/28/13, and she heard Resident #24 yell out (twice from the bathroom) "get me out of here." LPN "J" stated that she asked CNA "H" what happened in the bathroom and CNA "H" stated that Resident #24 had refused care and she did not assist Resident #24 with the transfers because, "she can do it herself." LPN "J" stated that Resident #24 requires the assistance of staff to safely transfer. LPN "J" stated that she removed CNA "H" from caring for Resident #24 at Resident #24's daughter "Q's" request on 12-28-13. The Surveyor asked LPN "J" if LPN "J" would define this incident as abuse or neglect and LPN "J" said "neglect" and she "should have reported it to the (NHA), but I tried to handle it myself." In a telephone interview on 1/17/14 at 11:00 AM, Resident #24's daughter "Q" stated that she was present on 12/28/13 when Resident #24 informed LPN "J" of the incident that she experienced in the bathroom with CNA "H" on the morning of 12/28/2013. Resident #24's daughter "Q" stated that she heard Resident #24 tell LPN "J" that CNA "H" wet a wash cloth and forcefully washed Resident #24's face. Resident #24 stated she struggled to get CNA "H" to stop and CNA "H" twisted Resident #24's shoulder during the incident and refused to assist Resident #24 to safely transfer from the toilet back into the wheel chair then back into the bed. Resident #24's daughter "Q" stated that Resident #24 told LPN "J" that she repeatedly yelled for help during the incident. In an interview, on 1/17/14 at 11:40 AM, CNA "H" asked about the above incident in the bathroom with Resident #24 on 12/28/13. CNA "H" stated that Resident #24 refused AM care. CNA "H" stated that she received a final written warning from the facility for the incident on 12/28/13 because, "I didn't report to the nurse what had happened and I didn't create a positive atmosphere." CNA "H" stated that she had two prior written councilings prior to this one, "I know on paper it looks really bad." Review of an e-mail sent by the DON, dated 12-30-13 at 3:09 PM revealed the DON was aware that another one of Resident's #24 daughter, daughter "I" had made an allegation of abuse/neglect. During an interview on 1-17-14 at 12:30 PM, the NHA said she was not aware of the allegation of abuse until 1-2-14 when she was alerted by the DON. When the NHA was asked what she did to protect Resident #24, she said that CNA "H" was given written counseling for customer service. The NHA said no Unplanned Occurrence Report (Incident/Accident Report) was completed and CNA "H" was not suspended. NHA said she did not interview Resident #24 and completed her investigation after interviewing CNA "H". NHA said there was no need for further investigation. Review of the facility policy and procedure "Abuse Prevention/Prohibition Program" dated 6/1/07 lasted revised on 4/2012, revealed "All complaints of abuse/neglect (suspected or alleged) will be reported immediately to the Administrator and the Director of Nursing. All complaints of abuse/neglect (suspected or alleged) will be investigated immediately. Allegation that has no credibility whatsoever should have clear documentation as to the reason the Administrator chose not to conduct an investigation." (# ) B. Based on interview and record review, the facility failed to protect an additional 2 of 11 residents reviewed from abuse (Residents #4 and #19), from a total of 25 sampled residents, resulting in verbal abuse and the potential for continued abuse for Residents #4 and #19. Findings include: Resident #4 Review of Resident #24's Brief Interview for Mental Status (BIMS), dated 9/20/13, revealed she scored 8/15 indicating she had moderate cognitive impairment. In an interview, on 1/16/14 at 9:30 AM, laundry aide (LA) "T" reported, "I heard an aide (CNA "HH") verbally abusing (Resident #4) last summer. Obviously, they did nothing about it; she continued to work that shift and ever since. (CNA "HH") was yelling at (Resident #4); told her she was selfish, needed to get patience, and didn't care about anybody but herself. I reported it to the nurse. I don't know her name. I reported it, called the DON/Director of Nursing, and she told me to call the Administrator. I did. I filled out a form". LA "T" stated she was not aware of anyone else she could report the incident to and was unable to locate the State agency or Ombudsman phone numbers in the facility. LA "T" reported she was afraid of retaliation from management. In an interview, on 1/16/14 at 9:55 AM, the Administrator was asked about the allegation of abuse that LA "T" reported to her regarding CNA "HH". The Administrator stated she remembered LA "T" calling her. At 12:40 PM, the Administrator reported they "searched high and low" and there was no paperwork regarding the allegation. In an interview with LA "T" and the DON, at 1:41 PM, LA "T" told the DON, "I called you at about 7:00 AM. I did call you and (the Administrator), and I did fill out a report". In a telephone interview, on 1/17/14 at 10:50 AM, CNA "HH" reported there was not suspended and there was no investigation regarding an allegation of abuse, but stated, "There was an issue between me and (LPN "BB"). In September, around 5:00 AM, there was a very tiny lady who was hard to get situated; it took time to make her comfortable. I would have to take care of her alarms". CNA "HH" reported, "(LPN "BB") thought I didn't want to take care of her. ( ) Resident #19 Review of the Brief Interview for Mental Status (BIMS), dated 11/01/13, revealed Resident #19 scored 9/15 indicating she had moderate cognitive impairment. According to a Grievance/Complaint Report, dated 11/08/13 and signed by CCC/Clinical Care Coordinator/Licensed Practical Nurse "V", "(Resident #19's son "JJ") stated that may be the staff member (nurse aide/CNA "H") was having a bad day, but she was rude. She covered my mom's tray and said 'You aren't getting anything else" and started to remove tray. (Son "JJ" stated (Resident #19) would eat some; to leave the tray". According to a Staff Interview Summary, dated 11/02/13, RN "D" documented, "(Receptionist) interviewed...Family members of (Resident #19) (son "JJ" and his wife came up to me stated staff brought lunch trays in. The (CNA) took lid off tray and my mom said she didn't like it and she wasn't going to eat it. The aide slammed the lid down and said you ar not going to get anything else and picked up the tray. The son said leave the tray she will eat the potatoes and stuff and the aide walked out...He said he didn't know who to report this to. I gave him the Administrator and DON's card". According to a Staff Interview Summary, dated 11/02/13, RN "D" documented, "(CNA "W") interviewed...At approx. (approximately) 12:05 PM, I brought (Resident #19) her lunch tray. (CNA "H") followed in...I placed (Resident #19's) tray in front of her and uncovered her plate and (Resident #19) remarked, "Ugg, this crap again', as she pointed to the broccoli...(CNA "H") grabbed the lid and put it back on (Resident #19's) plate and said, 'So you are not going to eat any of this?' (Resident #19) remarked, 'I will eat the mashed potatoes'. (CNA "H" put the tray back down and said, 'Do you really think it is necessary to make a show like this every time we put food in front of you? We left the room." In an interview, on 1/15/14 at 12:00 PM, the Administrator reported she was the Abuse Coordinator for the facility and taught the Abuse Prevention/Prohibition Program policy and procedure at new employees orientation and annually to all staff. When asked why she used a Grievance/Complaint Report form, but did not fill out an Unusual Occurrence Report (Briggs Form FTCC166) when she read the Grievance from Resident #19's son "JJ" , the Administrator stated, "(Son "JJ") made the complaint". When asked how she determined that nurse aide/CNA "H" had not been abusive to Resident #19, the Administrator stated she determined there was no abuse after speaking with CNA "H". When asked if she interviewed Resident #19, she stated she did not because, "I wanted to give (CNA "H") the benefit of the doubt". When asked how she protected Resident #19 from CNA "H" from continued abuse, the Administrator stated, "I gave (CNA "H") a corrective action for customer service". When asked if she were planning on doing a further investigation of the alleged abuse, the Administrator stated, "There will be no change in reporting. I do the reporting". When asked if she thought the allegation was potential abuse, the Administrator stated, "It could be potential abuse but I determined it was a customer service issue". When asked if the facility routinely used the Grievance/Complaint Report without using the Unusual Occurrence Report Briggs Form FTCC166 to record allegations of abuse, the Administrator stated, "Yes". In an interview, on 1/17/14 at 11:40 AM, CNA "H" was asked about the above incident. CNA "H" stated, "In my opinion, I was not out of line or rude to (Resident #19). Visitors were there; I thought they were with the roommate. I was not asked to go home. I got a write up a few days later. I have had 3 complaints. One was an allegation that I held a man down". In a telephone interview, on 1/17/14 at 2:45 PM, CNA "W" was asked if she considered the incident on 11/08/13 abuse, and CNA "W" stated, "I questioned that at the time because I wasn't sure. (CCC/RN "D") said (CNA "H") was just being rude; not abuse as she understood it". ( )