Every finding on record at Villa at Willow Place

Based on observations, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. for one (R2) of three residents reviewed. Review of the medical record reflected R2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included generalized anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/26, reflected R2 scored 6 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 4/16/26 at 9:53 am, R2 was observed in her room sleeping. R2 recalled an incident where someone grabbed her legs and squeezed her ankles but could not recall any further details.Review of a Facility Reported Incident revealed a staff to resident physical abuse allegation occurred on 4/2/26 at 2:29 am, was discovered on 4/2/26 at 2:56 PM, and submitted to the Michigan Facility Reported Incident for Long Term Care system on 4/2/26 at 7:57 PM.Review of a Nurses note dated 4/2/26 at 11:40 am revealed writer alerted that resisnt [sic] reported to visitor that she was being held down by a staff member on night shift.Review of an Incident Report dated 4/2/26 at 11:30 am revealed writer alerted that resisnt [sic] reported to visitor that she was being held down by a staff member on night shift.Notified Administrator.Review of a witness statement for R2 dated 4/2/26 stated resident reported CNA F had been pushing on her during care to visitor.In an interview on 4/16/26 at 2:04 PM Licensed Practical Nurse (LPN) E stated she was notified of the physical abuse allegation around 11:30 am-12:00 PM and immediately called the abuse coordinator, Nursing Home Administrator A.On 4/16/26 at 2:23 PM Certified Nursing Assistant (CNA) F stated she has been working at the facility for about a month and that their typical assignment consisted of nine to eighteen residents. CNA F confirmed that she was working during the shift and was the staff member that R2 made the abuse allegation on. CNA F stated that she was unaware of the allegation until she received a call and was told that R2 stated that CNA F beat her.In an interview on 4/16/26 at 2:33 pm, Nursing Home Administrator (NHA) A stated that she learned of the abuse allegation around 11:00 am or 12:00 pm and immediately started the investigation process. NHA A stated she then conducted much of the investigation including conducting interviews before submitting the allegation to the State Agency which she reports was much later into the night. When asked what the guidelines were for reported abuse allegations to the State agency, NHA A stated immediately but up to 24 hours. When asked if other residents that were assigned to CNA F were assessed or interviewed to ensure that they were not potentially affected, NHA A stated that they were not.Per the State Operations Manual Appendix PP regarding investigating abuse allegations, conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents.Review of the facilities Abuse Policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property with an effective date of 11/28/17, Section G: Reporting and Response reflected .the facility will ensure that all allegations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown origin are reported immediately but not later than 2 hours after the allegation is made.Per the same Abuse Policy, under section F. Procedure subpart a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation.examine, assess, and interview the resident and other residents potentially affected.Review of the facilities abuse allegation investigation revealed a lack of evidence that any other residents were interviewed or assessed that night to ensure that they did not experience any physical abuse to ensure no other residents were potentially affected.

Based on observation, interview, and record review the facility failed to ensure a thorough abuse investigation was conducted in one (R2) of three reviewed for abuse. Findings include:Review of the medical record reflected R2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included generalized anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/26, reflected R2 scored 6 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 4/16/26 at 9:53 am, R2 was observed in her room sleeping. R2 recalled an incident where someone grabbed her legs and squeezed her ankles but could not recall any further details.Review of a Facility Reported Incident revealed a staff to resident physical abuse allegation occurred on 4/2/26 at 2:29 am, was discovered on 4/2/26 at 2:56 PM, and submitted to the Michigan Facility Reported Incident for Long Term Care system on 4/2/26 at 7:57 PM.Review of a Nurses note dated 4/2/26 at 11:40 am revealed writer alerted that resisnt [sic] reported to visitor that she was being held down by a staff member on night shift.Review of an Incident Report dated 4/2/26 at 11:30 am revealed writer alerted that resisnt [sic] reported to visitor that she was being held down by a staff member on night shift.Notified Administrator.Review of a witness statement for R2 dated 4/2/26 stated resident reported CNA F had been pushing on her during care to visitor.In an interview on 4/16/26 at 2:04 PM Licensed Practical Nurse (LPN) E stated she was notified of the physical abuse allegation around 11:30 am-12:00 PM and immediately called the abuse coordinator, Nursing Home Administrator A.On 4/16/26 at 2:23 PM Certified Nursing Assistant (CNA) F stated she has been working at the facility for about a month and that their typical assignment consisted of nine to eighteen residents. CNA F confirmed that she was working during the shift and was the staff member that R2 made the abuse allegation on. CNA F stated that she was unaware of the allegation until she received a call and was told that R2 stated that CNA F beat her.In an interview on 4/16/26 at 2:33 pm, Nursing Home Administrator (NHA) A stated that she learned of the abuse allegation around 11:00 am or 12:00 pm and immediately started the investigation process. NHA A stated she then conducted much of the investigation including conducting interviews before submitting the allegation to the State Agency which she reports was much later into the night. When asked what the guidelines were for reported abuse allegations to the State agency, NHA A stated immediately but up to 24 hours. When asked if other residents that were assigned to CNA F were assessed or interviewed to ensure that they were not potentially affected, NHA A stated that they were not.Per the State Operations Manual Appendix PP regarding investigating abuse allegations, conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents.Review of the facilities Abuse Policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property with an effective date of 11/28/17, Section G: Reporting and Response reflected .the facility will ensure that all allegations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown origin are reported immediately but not later than 2 hours after the allegation is made.Per the same Abuse Policy, under section F. Procedure subpart a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation.examine, assess, and interview the resident and other residents potentially affected.Review of the facilities abuse allegation investigation revealed a lack of evidence that any other residents were interviewed or assessed that night to ensure that they did not experience any physical abuse to ensure no other residents were potentially affected.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 87 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:During an observation and interview during the initial kitchen tour on 2/10/2026 at 9:28 AM, Food Service Director (FSD) F reported had been in role for about four months. Entered walk-in freezer with FSD F and observed several areas of ice damns that appeared to be coming from unit on ceiling directly over several open and closed cardboard boxes of frozen food items including individual ice creams. Several ice cream containers had solid ice directly on packaging, ceiling had frozen condensation covering large area and solid area of ice located on floor just inside door. FSD F reported freezer had history of issues and maintenance staff monitor routinely. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.During an interview on 2/13/2026 at 10:35 AM, Maintenance Director (MD) BB reported long history of ice buildup in kitchen walk-in freezer with about monthly ice buildup removal. MD BB reported at time of ownership change maintenance was completed on unit in freezer with improvements but continued ice damn buildups with possible cause that staff move curtains. During an observation and interview on 2/13/2026 at 11:15 AM, entered kitchen walk-in freezer with FSD F and observed continued ice buildup on individual ice cream containers (with thin paper top layer) and several boxes with frozen ice buildup located under freezer unit. FSD F reported notified maintenance after surveyor visit on 2/10/26 and some ice buildup removed. During an interview on 2/13/2026 11:20 AM, MD BB reported walk in freezer had been repaired 10/2025 prior to new company purchase.

Based on observation, interview and record review, the facility failed to ensure timely completion of Quarterly Minimum Data Set (MDS) assessments for four (R8, R29, R34, R82) of 25 reviewed for MDS. Findings include: R8: Review of the medical record reflected R8 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and contracture of the right hand. The Quarterly MDS, with an Assessment Reference Date (ARD) of 10/7/25, reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) was not conducted due to R8 being coded as rarely/never understood. R8 was coded for upper extremity impairments on both sides (both arms) and for being dependent upon staff for activities of daily living (ADLs). The Quarterly MDS was completed on 10/23/25. On 02/10/2026 at 12:22 PM, R8 was observed seated in a Broda chair, in the dining room, receiving staff assistance to consume lunch. As of 02/11/2026 at 1:49 PM, R8's Quarterly MDS, with an ARD of 1/6/26, was In Progress (not completed). R29: Review of the medical record reflected R29 admitted to the facility on [DATE], with diagnoses that included dysarthria (speech disorder) following cerebral infarction (stroke). The Quarterly MDS, with an ARD of 12/24/25, was completed on 1/27/26. In an interview on 02/11/2026 at 2:15 PM, MDS Coordinator J reported being about one month behind on MDS assessments. MDS Coordinator J reported a Quarterly MDS was to be completed within 14 days of the ARD. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, .Quarterly Assessment .The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . During an interview on 2/13/2026 at 12:04 PM, MDS Coordinator J reported had been in role for about two years. MDS Coordinator J reported had been behind in completing scheduled MDS assessments for past two months and several were incomplete. MDS Coordinator J reported R34 had a quarterly MDS assessment, dated 12/30/25 that should have been completed within 14 days and verified was not completed until 2/10/26. MDS Coordinator J reported R82 quarterly MDS assessment, dated 1/8/26, should have been completed 1/22/26 and verified was completed until 2/13/26. MDS Coordinator J reported both R34 and R82 MDS assessments were completed late.

Based on observation, interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold and a written reason for the transfer, for two (R1 and R64) of four reviewed for hospitalization. Findings Include:Resident #1(R1)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 1/21/26, reflected R1 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and vascular dementia. The MDS reflected R1 had a BIM (assessment tool) score indicated her ability to make daily decisions was severely impaired, and she was dependent on staff for dressing, mobility, transfers, hygiene, bathing, toileting, and oral hygiene.During a telephone interview on 2/11/26 at 11:49 a.m., R1 Responsible Party reported had concerns that the facility had not contacted her after transferring R1 to hospital.Review of R1 Electronic Medical Record (EMR), dated 1/11/26, reflected R1 was transferred to the hospital. Continued review of the EMR, reflected no evidence that the responsible party was provided written notification of bed hold policy and reason for transfer.Resident #64(R64)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 12/11/25, reflected R64 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, urinary tract infection and spinal stenosis. The MDS reflected R64 had a BIM (assessment tool) score of 4 that indicated her ability to make daily decisions was severely impaired, and she required staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting.During an observation on 2/10/2026 at 10:45 a.m., R64 was observed in bed with two staff at bedside assisting with care. R64 appeared pleasantly confused and did not appear to be oriented.During a telephone interview on 2/11/2026 at 10:54 a.m., R64 responsible party reported R64 was transferred to the hospital prior to Christmas and was not notified by the facility until over 24 hours later.Review of R64 EMR, dated 12/14/25, reflected R64 was transferred to the hospital. Continued review of the EMR reflected no evidence that the responsible party was provided written notification of bed hold policy and reason for transfer.During an interview on 2/13/26 at 12:50 pm, Director of Nursing DON B reported expect staff to complete transfer notice, sbar and Progress Note for transfer to hospital. DON B reported staff send to documents to the hospital with resident, provided to Emergency Medical Staff. DON B reported did recall complaint from R1 responsible party that they were not notified of R1 hospital transfer. DON B reported unit manager had verified it had been documented and reported if it was documented it was done. DON B reported R64 had a Progress Note that family had been notified of hospital transfer. DON B was unable to provide evidence R1 or R64 responsible party was notified and received physical copy of R1 and R64 transfer notice and bed hold.

Based on interview and record review, the facility failed to ensure timely completion of comprehensive significant change Minimum Data Set (MDS) assessments for one (R7) of 25 reviewed. Findings Include: Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 1/2/26, reflected R7 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included spastic quadriplegic cerebral palsy, dystonia(neuromuscular movement disorder), polydipsia(excessive, persistent thirst and consequently high fluid intake), bilateral hand contractures, and depression The MDS reflected R7 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he was dependent on staff for hygiene, bathing, dressing, bed mobility, transfers and eating.Review of R7 Electronic Medical Record on 2/11/26 at 9:22 a.m., reflected R7 had a significant change MDS assessment, dated 1/2/26, that indicated in progress.(incomplete)During an interview on 2/11/26 at 2:25 p.m., MDS Coordinator J reported R7 MDS assessment, dated 1/2/26, should have been completed and within 14 days and was currently late. MDS Coordinator J reported had several late MDS assessments and was currently working on getting them up to date.

Based on observation, interview and record review the facility failed to treat 2 residents (R7, R19) of 18 residents reviewed, with dignity and respect. Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 1/2/26, reflected R7 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included spastic quadriplegic cerebral palsy, dystonia(neuromuscular movement disorder), polydipsia(excessive, persistent thirst and consequently high fluid intake), bilateral hand contractures, and depression The MDS reflected R7 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he was dependent on staff for hygiene, bathing, dressing, bed mobility, transfers and eating. During an observation and interview on 2/10/2026 at 12:00 PM, R7 was observed lying in bed, located against the wall. R7 appeared able to express needs and needed extra time to verbalize. R7 reported staff usually respond to call light if he can reach it and reported was unable to reach call light at the time. Observed R7 soft touch call light on floor between bed and wall out of reach. R7 appeared to have significant contractures to bilateral upper extremities with limited mobility. R7 reported often takes him a long time to verbalize needs to staff and some staff are not patient to listen to R7's needs and makes him frustrated at times. During an observation on 2/10/26 at about 12:40 pm, R7 was laying in bed with staff at bedside assisting with meal. R7 soft touch call light remained on floor between bed and wall, out of reach. R7 call light could be observed on the floor from the hallway door without entering room. During an observation on 2/10/2026 at 3:50 PM, R7 soft touch call light remains on floor out of reach. Observed R7 during lunch meal with staff at bedside assisting with meal and had exited room with call light out of reach. During an observation on 2/11/2026 at 8:41 AM, R7 soft touch call light remains on floor between bed and wall out of reach in same location as evening prior. Observed housekeeping in room at the time. Review of R7 Care Plan, dated 11/30/23, reflected, Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. During an interview on 2/13/2026 at 2:08 PM, Director of Nursing (DON) B reported would expect call light to be in reach for R7 and staff to verify prior to leaving room. DON B verified R7 required one on one assistance with meals with frequent checks and would expect staff to verify call light was in R7 reach prior to leaving the room. R19 Review of the clinical record revealed R19 was admitted into the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), polyneuropathy (numbness/tingling/weakness due to nerve damage), bladder disorder, anxiety and left side hemiplegia (severe or complete paralysis) and hemiparesis (partial muscle weakness). According to the Minimum Data Set (MDS) assessment dated [DATE], R19 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On 2/10/26 at 12:25 PM during an observation and interview, R19 was observed sitting up in a manual wheelchair. R19 reported that the facility had ran out of his size of briefs (medium) and he had to wear size extra-large, which he reported were ill fitting and uncomfortable. In an interview on 2/13/26 at 10:22 AM, Certified Nursing Assistant (CNA) Z reported that the facility had ran out of resident supplies such as briefs and wipes. CNA Z further reported that when the facility ran out of a certain size of briefs residents would need to wear a different size, for example someone who requires a size medium could have needed to wear an extra-large.

Based on interview and record review the facility failed to provide completed Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) for three residents (R41, R45, R86) of three residents reviewed. Findings include:A review of the SNF-ABN's provided by the facility revealed:R41 Beginning on 12/12/25, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care(s) you have been receiving during the Inpatient Skilled Nursing Facility include:Physical Therapy, Daily Skilled Nursing Care, Occupational Therapy, Other-Room and Board.We estimate that these services will cost you $______ per day/item or service.No dollar amount was included on the form to indicate the resident's cost of those items/services. R41 signed the form on 12/11/25.R45 Beginning on 1/12/26, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care(s) you have been receiving during the Inpatient Skilled Nursing Facility include:Physical Therapy, Daily Skilled Nursing Care, Occupational Therapy, Other-Room and Board.We estimate that these services will cost you $______ per day/item or service.No dollar amount was included on the form to indicate the resident's cost of those items/services. R45 signed the form on 1/9/26.R86 Beginning on 1/27/26, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care(s) you have been receiving during the Inpatient Skilled Nursing Facility include:Physical Therapy, Daily Skilled Nursing Care, Occupational Therapy, Other-Room and Board.We estimate that these services will cost you $______ per day/item or service.No dollar amount was included on the form to indicate the resident's cost of those items/services. R86 signed the form on 1/22/26.In an interview on 2/13/26 at 2:37 PM Business Office Manager (BOM) Y explained that her process is to obtain a SNF-ABN after a resident has been cut from Medicare services and after being given a NOMNC (Notice of Medicare Non-Coverage). BOM Y further explained that the form should include the residents name, the date, last covered date and a daily rate if private pay or daily rate based on the resident's secondary insurance. BOM Y did not offer a rationale for why the 3 SNF-ABN's that were reviewed did not have the daily rate filled in but stated that information would be important for the resident to have to make a decision on if they continue services or not.

Based on observation, interview and record review, the facility failed to formulate a Baseline Care Plan which included pertinent care needs for one (R114) of 18 reviewed.Findings include: Review of the medical record reflected R114 admitted to the facility on [DATE], with diagnoses that included ocular laceration of the left eye, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/3/26, was in progress (not completed) as of 2/12/26. On 02/10/2026 at 11:22 AM, R114 was observed lying in bed. On 02/12/2026 at 10:35 AM, R114 was observed being propelled in the hallway, by staff, while seated in their wheelchair. R114's Care Plan reflected a focus area of, Resident requires assist with daily care needs r/t [related to] Date Initiated: 01/29/2026. The Care Plan goal was initiated on 1/29/26. Interventions were not added to the Care Plan until 2/11/26, which included R114 requiring assistance of two people for bathing, bed mobility, toileting and transfers and setup assistance with eating/meals. In an interview on 02/11/2026 at 3:39 PM, Director of Nursing (DON) B reported nurses did initial care planning, then nurse managers and the interdisciplinary team (IDT) reviewed them. According to DON B, MDS consulted in the Care Plan process to make them patient centered. DON B reported it was her expectation that activities of daily living (ADL) Care Plans included bathing/showering level of assistance, oral care, toileting, transfer status, bed mobility and eating.

Based on observation, interview, and record review the facility failed to inform three residents (#4,#8,#20) of five residents reviewed of the benefits, risks, and alternatives for the prescribing of psychotropic medication. Findings Include: R8: Review of the medical record reflected R8 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and contracture of the right hand. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/7/25, reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) was not conducted due to R8 being coded as rarely/never understood. R8 was coded for upper extremity impairments on both sides (both arms) and for being dependent upon staff for activities of daily living (ADLs). On 02/10/2026 at 12:22 PM, R8 was observed seated in a Broda chair, in the dining room, receiving staff assistance to consume lunch. R8's medical record reflected Physician Orders for 25 milligrams (mg) of Seroquel (antipsychotic medication) twice daily and two mg of Lorazepam (medication to treat anxiety) twice daily. Consents for the use of Seroquel and Lorazepam were not noted in R8's medical record. In an interview on 02/13/2026 at 3:47 PM, Regional Director of Operations (RDO) L reported she did not look for the psychotropic medication consents for R8 personally but reported there were issues with the consent process. R20: Review of the medical record reflected R20 admitted to the facility on [DATE], with diagnoses that included Huntington's Disease, dementia and depression. The Annual MDS, with an ARD of 11/20/25, reflected R20 had short-term and long-term memory impairments and was coded as requiring substantial/maximal assistance to dependence on staff for ADLs. On 02/12/2026 at 2:20 PM, R20 was observed in bed, lying on their left side. R20's knees appeared flexed under their bed linens. R20's medical record included Physician Orders for 15 mg of Mirtazapine (antidepressant medication) at bedtime, one mg of Lorazepam (medication to treat anxiety) daily, two mg of Lorazepam at bedtime and 100 mg of Seroquel (antipsychotic medication) three times daily. Consents for the use of Mirtazapine, Lorazepam and Seroquel were not noted in R20's medical record. In an interview on 02/13/2026 at 12:53 PM, RDO L reported she did not see consents for the use of psychotropic medications in R20's medical record. On 02/13/2026 at 1:23 PM, Social Worker (SW) K confirmed there were no consents for psychotropic medications in R20's medical record. Resident #4 (R4) Review of the medical record demonstrated that R4 was admitted to the facility 02/26/2025 with diagnoses that included end stage renal disease, pain right and left foot, ascites (abnormal buildup of fluid in the abdomen), osteoarthritis (degenerative joint disease) of left knee and bilateral hips, paranoid schizophrenia, chronic constipation, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux, depression, schizoaffective disorder, dependence on dialysis, anemia (low red blood cells), insomnia (difficulty sleeping), cognitive decline, anxiety, gout (buildup of uric acid in joints), hypertension, and atrial fibrillation. Review of R4's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. On 02/10/2026 at 02:13 p.m. during observation and interview R4 was observed lying in bed. When R4 was inquired as to his current mood, he explained that he currently had no concerns. Review of R4's medical record revealed antipsychotic medication orders, written 01/03/2026, Aripiprazole oral tablet 15 MG (milligrams). Give 1 tablet by mouth one time a day for schizoaffective disorder and Olanzapine oral tablet 15mg give 1 tablet by mouth one time a day for paranoid schizophrenia. There were no consents for the above medications in R4's medical record. Review of R4's medical record revealed antidepressant medication orders, written 01/02/2026, Sertraline HCL (hydrochloride) tablet 25 MG (milligrams) give 1 tablet by mouth at bedtime for depression and trazodone HCL oral tablet 100mg give 1 tablet by mouth at bedtime for sleep. There were no consents for the above medications in R4's medical record. In an interview on 02/13/2026 at 12:54 p.m. Regional Director of Operations (RDO) L explained that all residents receiving psychotropic medication required documented consent. RDO L could located consents for R4's psychotropic medication. Review of facility policy entitled Psychotropic Medication Guideline, effective date: 04/27/2027 and last revised: 05/30/2025, revealed 4. Residents who have admitted with or have changes to their psychotropic medication regime will have informed consent obtained. The resident and/or responsible party have the right to accept or decline the initiation of or increase in psychotropic medication.

Based on observation, interview, and record review, the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:During an observation and interview during the initial kitchen tour on 2/10/2026 at 9:28 AM, Food Service Director (FSD) F reported had been in role for about four months. Kitchen tour continued outside and observed four dumpsters labeled with two company names. FSD F reported facility recently changed ownership in November 2025(four months ago) and prior garbage company had not picked up the dumpsters yet. Observed several items outside and around new yellow trash dumpster including full bags of trash. FSD F reported maintenance department responsible for maintaining trash receptacles and reported all trash should be in dumpsters not on ground around them with lids closed.During an interview on 2/13/2026 at 10:35 AM, Maintenance Director (MD) BB reported MD BB reported since ownership changed facility had communicated with prior garbage company but have not removed two full dumpsters yet. MD BB reported when past company had left several items and including large furniture items outside dumpster during the heavy snow and they were working to clean up area.Review of provided communication with prior dumpster company with no follow up or communications noted between 12/3/25 and 2/10/26(survey entrance) related to need to remove prior company dumpsters form facility.

Based on observation, interview and record review, the facility failed to consistently provide palatable food for one resident (R19) of 18 residents reviewed. Findings include:Review of the clinical record revealed R19 was admitted into the facility on [DATE] with diagnoses that included: cerebral infarction (stroke), polyneuropathy (numbness/tingling/weakness due to nerve damage), bladder disorder, anxiety and left side hemiplegia (severe or complete paralysis) and hemiparesis (partial muscle weakness). According to the Minimum Data Set (MDS) assessment dated [DATE], R19 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 2/10/26 at 12:12 PM, R19 was observed sitting at the edge of his bed eating lunch. Lunch consisted of a corn dog, yellow squash and a cold pasta with elbow macaroni. R19 reported that they have been served corndogs twice in the same week, the squash was over cooked (resident was observed having difficultly picking it up with his fork) and that it should have been grilled because is it a vegetable that absorbs a lot of water. R19 reported having dietary/kitchen experience, the food lacks flavor and variety, and he is often not provided with condiments (no salt or pepper observed on resident's tray). R19 further reported that the food is delivered cold sometimes and late on the weekends. On 2/12/2026 at 11:49 AM, R19 was observed sitting at the edge of his bed eating lunch. Meal consisted of cheeseburger with cheese only, coleslaw and juice. R19 reported that the burgers use to be made to order so they could get additional toppings (like onions and tomatoes), he reported that was no longer offered. R19 reported that sometimes the hamburger and grilled cheese will give him diarrhea. No condiments were observed on the resident's tray except salt and pepper. R19 reported that he didn't eat the cole slaw because they were served the same thing with their dinner the night before. Review of the facilities grievance log (August 2025 through January 2026) revealed the following food related concerns:12/26/25 Cold food12/4/25 Paper plates, no desserts

Based on observation, interview and record review, the facility failed to implement interventions to prevent the development and/or worsening of contractures for one (R20) of three reviewed.Findings include: Review of the medical record reflected R20 admitted to the facility on [DATE], with diagnoses that included Huntington's Disease, dementia and depression. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/25, reflected R20 had short-term and long-term memory impairments and was coded as requiring substantial/maximal assistance to dependence on staff for activities of daily living (ADLs). The same MDS reflected R20 did not have any upper or lower extremity impairments that interfered with daily functions or placed them at risk for injury in the prior seven days. On 02/10/2026 at 10:54 AM, R20 was observed seated in a Broda chair, in their room, watching TV. A hoyer lift sling was observed beneath them. Both knees were in a flexed (bent) position. On 02/12/2026 at 11:18 AM, R20 was observed in an activity, seated in a Broda chair, with their eyes closed and their knees in a flexed position. On 02/12/2026 at 2:20 PM, R20 was observed in bed, lying on their left side, and appeared to have their knees in a flexed position, beneath bed linens. R20's medical record reflected a task, with a revision date of 12/17/25, reflecting they were to have active and passive range of motion (ROM) with ADL care. On 2/13/26, there was no documentation to reflect that R20 received ROM within the prior 30 days. R20's Kardex (Certified Nurse Aide/CNA care guide) reflected active and passive ROM was to be provided with ADL care. A Physician's Order, with a revision date of 1/5/26, reflected ROM was to be provided with ADL care. In an interview on 02/12/2026 at 2:03 PM, Licensed Practical Nurse (LPN) M reported the facility started a list of residents with contractures, to begin ROM on. LPN M reported R20 was on the list, and staff were to begin ROM exercises with R20 on 2/17/26. In an interview on 02/12/2026 at 2:23 PM, CNA W reported R20's lower extremities were contracted, and the contractures had worsened in the six months they had worked with him. CNA W reported R20 kept their knees in a flexed position throughout the day. They attempted to stretch R20's extremities when getting him dressed and asked him to stretch his legs out. CNA W denied a ROM program being in place for R20, which included repetition. CNA W reported only stretching of the extremities for dressing and care was performed. In an interview on 02/12/2026 at 3:19 PM, Director of Nursing (DON) B reported R20's arms and legs could not fully extend, and he needed passive ROM. When asked about their expectations for R20's task pertaining to active and passive ROM with ADL care, DON B reported the expectation would be for abduction, adduction and rotation of the extremities. They would also expect assessment and monitoring of R20's tolerance, as well as documentation in the task, and assessment by the Restorative Nurse in a Progress Note. DON B explained that ROM should include two rounds of 15 or 30 repetitions.

Based on observation, interview and record review, the facility failed to 1) follow Physician Orders for vital signs monitoring; and 2) assess and monitor respiratory status with administration of an as needed nebulizer treatment for one (R114) of 18 reviewed.Findings include: Review of the medical record reflected R114 admitted to the facility on [DATE], with diagnoses that included ocular laceration of the left eye, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/3/26, was in progress (not completed) as of 2/12/26. On 02/10/2026 at 11:22 AM, R114 was observed lying in bed and reported since having a pacemaker implant, they used oxygen at night, as needed. R114 reported when notifying staff of shortness of breath, staff would check their oxygen saturation and say it was fine. R114 stated that morning (2/10/26), they became short of breath in the Therapy Gym and were told to return to their room and rest. On 02/11/2026 at 10:09 AM, R114 was observed lying in bed and reported that morning or the night prior, they felt short of breath and requested a breathing treatment, which was not provided to them. The February 2026 Medication Administration Record (MAR) reflected R114's vital signs were to be monitored twice daily and as needed. The order was signed out as being completed twice daily; however, vital signs information was not recorded. As of 2/12/26 at 10:42 AM, the vital signs section of R114's medical record reflected temperature, pulse, respiratory rate and oxygen saturation were recorded a total of four times (1/28/26, 1/30/26, 2/5/26 and 2/9/26). R114's blood pressure was documented a total of 15 times between 1/28/26 and 2/12/26 at 7:37 AM. The February 2026 MAR reflected an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams per 3 milliliters) 0.083% to be inhaled orally, via nebulizer, every six hours as needed, for shortness of breath. The MAR reflected the medication was administered on 2/6/26 at 8:33 PM and documented to be effective. R114's medical record did not reflect documentation of a respiratory assessment before or after administration of the medication. In an interview on 02/12/2026 at 10:49 AM, Licensed Practical Nurse (LPN) H reported if there was an order for monitoring vital signs every shift, the documentation would be on the MAR and in the vital signs tab of the medical record. Regarding assessment for administration of an as needed nebulizer treatment, LPN H reported they could obtain an oxygen saturation level and count the respiratory rate, then document in the vital signs tab and in a Progress Note for electronic MAR administration. In an interview on 02/12/2026 at 11:24 AM, Director of Nursing (DON) B reported vital signs were documented under the weights/vital signs section of the medical record. DON B reported their expectation for administering an as needed nebulizer treatment would be to obtain vital signs and assess lung sounds and oxygen saturation before and after administration of treatment.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for three residents (#4,#43,#64) of 18 reviewed. Findings Included: Resident #4 (R4) Review of the medical record demonstrated that R4 was admitted to the facility 02/26/2025 with diagnoses that included end stage renal disease, pain right and left foot, ascites (abnormal build up of fluid in the abdomen), osteoarthritis (degenerative joint disease) of left knee and bilateral hips, paranoid schizophrenia, chronic constipation, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux, depression, schizoaffective disorder, dependence on dialysis, anemia (low red blood cells), insomnia (difficulty sleeping), cognitive decline, anxiety, gout (build up of uric acid in joints), hypertension, and atrial fibrillation. Review of R4's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. On 02/10/2026 at 02:13 p.m. during observation and interview R4 was observed lying in bed. R4 explained that he received dialysis, outside of the facility, 3 times per week. Review of R4's medical record revealed physician orders, dialysis pick up T(Tuesday)/TH(Thursday)/Sat(Saturday). one time per day every Tue, Thu (Thursday), Sat for dialysis. The above listed physician order was written 01/02/2026. Review of R4's medical record revealed a care plan problem that stated, I have renal insufficiency r/t(related to) ESRD (End Stage Renal Disease). R4's also revealed a care plan intervention that stated, Encourage me to go for the scheduled dialysis appointments. Resident Received dialysis on ______, _______, &_______. Resident leaves at ______ & returns at _______. Is transported by ________. The above care plan problem and intervention was initiated 05/31/2025. In an interview on 02/11/2026 at 03:38 p.m. Director of Nursing (DON) B explained that admission plans of care are initiated by the admitting Nursing staff when the resident is admitted to the facility. DON B explained that Nurse Managers then update the initial plans of care. DON B explained that the interdisciplinary team updates the complete plan of care as needed. DON B confirmed that R4 did not have a care plan intervention that was initiated on 05/31/2025. DON B could not explain why R4's dialysis care plan intervention remained blank, as of this date. R43: Review of the medical record reflected R43 admitted to the facility on [DATE], with diagnoses that included lumbar spinal stenosis. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/2/25, reflected R43 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 02/11/2026 at 10:39 AM, R43 was observed lying in bed. R43's Care Plan, with a focus area of, I have an ADL Self Care Performance Deficit r/t [related to] impaired mobility was initiated on 8/26/25. An intervention dated 8/26/25 reflected R43 wore glasses to aid their vision and to ensure they were clean and applied in the morning. An intervention dated 9/3/25 reflected to ensure the resident's feet were properly positioned on the footrest. An intervention dated 1/16/26 reflected R43 was non-compliant with ADL care and was educated on the risks versus benefits. The ADL Care Plan did not include any further interventions for R43's ADL care. In an interview on 02/11/2026 at 3:39 PM, Director of Nursing (DON) B reported nurses did initial care planning, then nurse managers and the interdisciplinary team (IDT) reviewed them. According to DON B, MDS consulted in the Care Plan process to make them patient centered. DON B reported it was her expectation that ADL Care Plans included bathing/showering level of assistance, oral care, toileting, transfer status, bed mobility and eating. DON B acknowledged R43's Care Plan was not comprehensive. Resident #64(R64) Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 12/11/25, reflected R64 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, urinary tract infection and spinal stenosis. The MDS reflected R64 had a BIM (assessment tool) score of 4 that indicated her ability to make daily decisions was severely impaired, and she required staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting. During an observation on 2/10/2026 at 10:45 a.m., R64 was observed in bed with two staff at bedside assisting with care. R64 appeared pleasantly confused and did not appear to be oriented. R64 had foley catheter in place with no catheter secure observed. During an interview on 2/10/2026 at 2:42 PM, Unit Manager (UM) AA reported R64 has had foley catheter since December. Review of R64 Care Plans, dated 2/10/26, reflected, FOLEY: Resident requires use of an indwelling catheter r/t Bladder Dysfunction. Continued review of R64 care plan reflected no evidence R64 catheter care had been added to care plan prior to 2/10/26. During an interview on 2/13/2026 at 10:18 AM, UM AA reported started UM role 1/12/26. UM AA reported R64 was discharged from the hospital on [DATE] with foley catheter. UM AA reported would expect R64's care plan to reflect foley catheter in place and appropriate interventions added timely and verified was not added until 2/10/26.

Based on observation, interview and record review, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for three (R50, R59 and R114) of 25 reviewed.Findings include:R114: Review of the medical record reflected R114 admitted to the facility on [DATE], with diagnoses that included ocular laceration of the left eye, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The admission MDS, with an Assessment Reference Date (ARD) of 2/3/26, was in progress (not completed) as of 2/12/26 at 9:29 AM. On 02/10/2026 at 11:22 AM, R114 was observed lying in bed. In an interview on 02/11/2026 at 2:15 PM, MDS Coordinator J reported being about one month behind on MDS assessments. They reported an admission MDS was to be completed within 14 days of admission, with the date of admission being day one. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2025, .The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . The MDS completion date (item Z0500B) must be no later than day 14 . During an interview on 2/13/2026 at 12:04 PM, MDS Coordinator J reported had been in role for about two years. MDS Coordinator J reported had been behind in completing scheduled MDS assessments for past two months and several were incomplete. MDS Coordinator J reported had been no leave then holiday was busy and had not been able to catch up. MDS Coordinator J reported R50 had an annual comprehensive MDS assessment dated , 1/9/26, that should have been completed by 1/23/26 and verified was currently incomplete. MDS Coordinator J reported R59 had an annual comprehensive MDS assessment dated , 12/29/25, that should have been completed by 1/12/26 that currently incomplete.

Based on observation, interview and record review, the facility failed to ensure accurate documentation for one (Resident #64) of 18 reviewed for accurate medical records. Resident #64(R64)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 12/11/25, reflected R64 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dementia, urinary tract infection and spinal stenosis. The MDS reflected R64 had a BIM (assessment tool) score of 4 that indicated her ability to make daily decisions was severely impaired, and she required staff assistance with dressing, mobility, transfers, hygiene, bathing, and toileting.During an observation on 2/10/2026 at 10:45 a.m., R64 was observed in bed with two staff at bedside assisting with care. R64 appeared pleasantly confused and did not appear to be oriented. This surveyor overheard Licensed Practical Nurse (LPN) CC talking to R64 about plan to change wound dressing. Observed wound supplies at bedside. LPN CC turned R64 side to side in bed and pulled brief down slightly in back and reported that wound must have healed because was unable to locate and exited R64 room with wound supplies. Review of R64 Medication Administration Record(MAR), dated 2/7/26 through 2/10/26, reflected physician order that included, Medihoney Wound/Burn Dressing Gel (Wound Dressings) Apply to coccyx topically every day shift for Wound Care Cleanse with Soap and H2O or wound cleanser. Apply thin layer to wound bed. Cover with Foam dressing-D/C Date-02/10/2026 1744[6:44pm]. Continued review of MAR reflected that LPN CC had signed wound care as completed as evidence by initials. Review of R64 Progress Notes with no linked notes related to MAR.Review of R64 Wound Care Specialists consult note, dated 2/9/26, reflected R64 had a facility acquire unstageable pressure wound to coccyx area that measured 2.3cm length x 7.5cm width. (one day prior).During an interview on 2/10/2026 at 2:40 PM, LPN CC reported when this surveyor had observed R64 care that morning about 10:45 a.m. LPN CC did not complete wound care because she was unable to located wound. LPN CC reported treatment order must have been an old orders and should have been removed from MAR because R64 no longer had a wound.During a telephone interview on 2/11/2026 at 10:52 AM, R64 responsible party reported had concerns that R64 pressure wound had not been improving. During an interview on 2/12/2026 at 9:20 AM Registered Nurse(RN) I reported R64 wound treatment had been completed on night shift at 3:15 am.During an interview on 2/12/2026 at 9:25 AM, Wound Nurse Q reported resident treatmentst are usually scheduled on night shift because resident get in bed at night and staff get residents up in mornings. Wound Nurse Q reported R64 wound was unstageable to coccyx and started on 1/28/26. Wound Nurse Q reported if Physician ordered treatment was not completed would expect staff to document that and not document that treatment was completed. Wound Nurse Q reported R64 definitely had wound on 2/10/26 when LPN CC reported no wound and documented treatment as completed.During an interview on 2/12/2026 at 9:52 AM, Director of Nursing (DON) B reported started employment at facility on 1/12/26. DON B reported would expect nurse staff to follow physician orders for medication and treatment orders. DON B reported would expect if treatment not completed that staff document treatment as not completed. DON B reported would not expect staff to document treatment completed if not done and reported that would be falsification of medical records.

Based on observation, interview, and record review, the facility failed to administer oral chemotherapy medication as ordered for one (Resident #200) of three reviewed. This citation pertains to intake 2582143.Review of the clinical record revealed R200 was admitted into the facility on 4/23/25 with diagnoses that included: aphasia following cerebral infarction (impaired ability to understand or produce speech following a stroke), malignant neoplasm of upper third of esophagus (throat cancer) and vascular dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R200 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 9/22/25 at 9:59 AM, during an interview with family member (FM) E, when asked to clarify which medication R200 was allegedly not being provided, they reported it was an oral chemotherapy medication and that when family had taken R200 to his oncologist appointment the oncologist could tell that he was not receiving the medication. FM E reported that the medication was not administered for approximately one month and R200's oncologist had not ordered for it to be stopped.Review of R200's Discharge Summary (from the hospital that R200 was at prior to admitting to the facility) documented in part capecitabine 500mg tablet, Take 2 tablets (1,500 mg total) by mouth 2 (two) times a day, Take on Days 1-14, followed by 7 days off, of every 21-day cycle.Review of R200's physician's orders for oral chemotherapy revealed:4/24/25-5/8/25 Capecitabine Oral Tablet 500mg, Give 3 tablet enterally two times a day for Esophageal cancer stage IV for 14 days, 1500mg given enterally. Do not crush, Handle with gloves, Disperse in water for 15 minutes prior to5/9/25-7/4/25 Capecitabine Oral Tablet 500mg, Give 3 tablet enterally two times a day for Esophageal cancer stage IV for 14 days, 1500 mg given enterally. Do not crush, Handle with gloves. Disperse in water for 15 minutes prior to enteral administration, 14 days on; 7 days off, then restart on 5/15/258/5/25-9/30/25 Capecitabine Oral Tablet 500mg, Give 3 tablet via PEG-Tube two times a day for Esophageal cancer for 14 days, dissolve in warm water. Use gloves. DO NOT CRUSH. Give 14 days then 7 days off and then repeat cycle.This review revealed that there was not an active order for R200's oral chemotherapy from 7/5/25 to 8/4/25.A review of R200's Medication Administration Record revealed:July 2025 Capecitabine 1500mg was documented as administered twice a day on the 1st through the 3rd and once on July 4th (no additional doses were documented in July)August 2025 Capecitabine 1500mg was documented as administered twice a day on the 5th through the 18th (medication resumed 7 days later on 8/26/25)This review revealed that the Capecitabine (R200's oral chemotherapy medication) was not administered for a 30-day timespan (spanning from the evening of July 4th through August 4th). Review of a progress note from Nurse Practitioner (NP) C dated 6/10/25 documented in part Principal diagnosis of Esophageal cancer. Pt (patient) is strictly NPO (nothing by mouth) with a peg tube in place.External specialists during regulatory period: Oncology specialist; no new order or papers seen.Medications:.Capecitabine Oral Tablet 500mg Give 3 tablets via PEG-Tube two times a day for Esophageal cancer for 14 days, dissolve in warm water prior to administration.Examined notes from oncology as no noted orders or papers came with pt to appointment. Pt was examined at appointment with no concerns.Follow up appointments with oncology an infusion were added to orders. Pt to continue with capecitabine tablet per peg tube twice daily per orders.Review of progress note from Licensed Practicing Nurse, LPN D, dated 8/4/25 documented in part Resident back from his appointment and continue with his chemo medicine as per NP from hospital- 14 days on and 7 days off and repeat the cycle and continue. On 9/15/25 at 2:44 PM, a request was made for any medication error reports for R200 and 2:51PM ADON reported they did not have any medication error reports for R200. The facility was asked to provide any documentation from R200's oncologist. The only notes that were provided were dated 8/21/25 and 8/25/25. No consult notes prior to the timeframe that R200 did not receive his oral chemotherapy medication were provided. No documentation found to support the medication should have been stopped. On 9/15/25 at 3:17 PM, during an interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON), when asked what the facilities process is to review for any medication changes when a resident goes to an outside appointment, DON reported that paper work (consult report) is sent back to the facility with the resident or whomever accompanied the resident to the appointment. It is the responsibility of the receiving nurse to review for any medication changes. When asked why there was a 30-day period where the resident did not receive his oral chemotherapy medication, DON reported that the resident had went out to the hospital. It was determined by ADON and DON that a hospitalization did not occur around the time the medication was not given. ADON reported that the NP that had written the order that ended in July had been terminated from the facility and no further explanation of why the medication was stopped was provided.

This citation pertains to intakes MI00149170, MI00149191, MI00149342 and MI00150300. Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to meet resident needs timely for four (Resident #2, #3, #8 and #9) of seven reviewed. Findings include: Resident #2 (R2) Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, unspecified urinary incontinence and overactive bladder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/12/25, reflected R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was always incontinent of bowel and bladder. On 3/10/25 at 11:18 AM, R2 was observed in bed. R2 reported being incontinent of bowel and bladder, requiring staff to check and change them for incontinence purposes. R2 reported there have been occasions when they were left soiled in urine and feces for extended periods of time. R2 reported the facility was understaffed on all shifts, and they experienced long call light response times. Resident #3 (R3) Review of the medical record reflected R3 admitted to the facility on [DATE], with diagnoses of COPD and dementia. The Quarterly MDS, with an ARD of 12/4/24, reflected R3 scored 15 out of 15 (cognitively intact) on the BIMS. On 3/10/25 at 12:58 PM, R3 reported using their call light at night and often having to wait more than 15 minutes for staff to respond. Resident #8 (R8) Review of the medical record reflected R8 admitted to the facility on [DATE] and readmitted [DATE]. The Quarterly MDS, with an ARD of 12/6/24, reflected R8 scored nine out of 15 (moderate cognitive impairment) on the BIMS, was frequently incontinent of bladder and always incontinent of bowel. On 3/11/25 at 1:58 PM, R8 was observed in bed. R8 reported call light response sometimes took up to two hours around 1:00 PM. R8 reported that two to three times per week, they waited two hours to be cleaned after episodes of bowel and bladder incontinence. R8 stated that morning, around 9:00 AM, their call light was on for about one hour while they were waiting to be cleaned. According to R8, most extended call light response times were on day shift. Resident #9 (R9) Review of the medical record reflected R9 admitted to the facility on [DATE]. The Admission MDS, with an ARD of 2/25/25, reflected R9 scored eight out of 15 (moderate cognitive impairment) on the BIMS, was frequently incontinent of bladder and always incontinent of bowel. On 3/11/25 at 2:29 PM, R9 was observed in their room. R9 stated that morning, their call light was on for about four hours, and they were waiting for assistance to transfer out of bed via hoyer lift. R9 reported they were checked and changed due to incontinence. At the time of the interview, R9 reported they were wet with urine and soiled with feces, but they had not notified the staff. R9 reported staff were not regularly checking with them to see if they needed to be changed and waited for the resident to call. In an interview on 3/10/25 at 2:04 PM, Certified Nurse Aide (CNA) F reported CNAs were assigned 14 to 15 residents each on day shift, making it difficult to complete resident care. CNA F reported they were assigned 14 residents that day, with 10 to 12 of them requiring check and change for incontinence. CNA F reported they were supposed to check and change incontinent residents every two hours, however, they may have only been able to check and change residents once or twice in an eight hour shift. In an interview on 3/11/25 at 2:08 PM, CNA H reported having 14 residents on their assignment. Three of those residents required total assistance from staff to consume meals, according to CNA H. They reported they also had many residents that transferred via hoyer lift (mechanical lift), which required assistance of two people. CNA H reported they were able to check and change their incontinent residents two times in an eight hour shift. They reported there were residents that were soaking their beds from to incontinence due to staff not being able to change them often enough. In a phone interview on 3/11/25 at 3:57 PM, CNA J reported being assigned to 14 residents on day shift, with many requiring total assistance with care. CNA J reported there were approximately two days per week when they were only able to check and change incontinent residents one time in an eight hour shift. In an interview on 3/11/25 at 3:02 PM, Director of Nursing (DON) B reported the facility did not have the ability to run reports of call light response times. There were no concerns with call light response time that DON B was aware of. DON B reported check and change of incontinent residents should have been performed every two hours. They were not aware of any concerns pertaining to residents being left wet and/or soiled or their bedding being saturated.

Based on observations, interviews, and record reviews the facility failed to clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 12/09/24 at 09:25 A.M., A comprehensive tour of the food service was conducted with Dietary Manager H and Registered Dietician I. The following items were noted: Walk-In Freezer: The automatic door closer assembly was observed weak, allowing the door to not close completely. Registered Dietician I indicated she would contact maintenance for necessary repairs as soon as possible. The Victory one-door reach-in cooler door gasket was observed (worn, torn, missing). Dietary Manager H indicated she would contact maintenance for necessary repairs as soon as possible. Two fry pans (one 18-inch and one 14-inch) were observed (etched, scored, particulate). Dietary Manager H stated: I will just throw the pans away. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. Dry Storage Room: 2 of 2 overhead light assembly lens covers were observed with (8) dead insect carcasses resting upon the interior plastic lens cover surface. Food Production Kitchen: The overhead light assembly lens covers were observed with dead insect carcasses resting upon the interior plastic lens cover surface. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. Walk-In Freezer: The refrigeration unit was observed with ice [NAME] protruding from the Freon supply lines and unit cabinet. Dietary Manager H indicated she would contact maintenance for necessary repairs as soon as possible. The South Bend convection oven interior and exterior surfaces were observed heavily soiled with accumulated and encrusted food residue. The Vulcan stove/oven exterior was observed soiled with accumulated and encrusted food residue. The Legion tilt kettle exterior was observed soiled with accumulated and encrusted food residue. The Juice Machine was observed heavily soiled with accumulated and encrusted food residue. The interior surfaces were also observed soiled with accumulated and encrusted food residue. The (backsplash, undersplash, drip tray) were further observed soiled with accumulated and encrusted food residue. The Univex stand mixer was observed soiled with accumulated and encrusted food residue. Note: Dietary Manager H indicated she would have dietary staff thoroughly clean and sanitize the soiled food service equipment as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The drywall surface was observed (etched, scored, moist, particulate), adjacent to the Evolution steamer. The wall/floor vinyl coving strip was also observed loose-to-mount. The damaged wall/floor vinyl coving strip measured approximately 4-inches-wide by 36-inches-long. Dietary Manager H indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. Sub-Acute Nutrition Room: The Amana refrigerator interior door gasket was observed soiled with accumulated and encrusted food residue. The Amana refrigerator freezing compartment door gasket was also observed soiled with accumulated and encrusted food residue. Long-Term Care Nutrition Room: The Whirlpool refrigerator and freezing compartments were observed with accumulated and encrusted food residue. The door gaskets were also observed soiled with accumulated and encrusted food residue. Note: Dietary Manager H indicated she would have dietary staff thoroughly clean and sanitize the soiled food service equipment as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/11/24 at 04:15 P.M., Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 01/2024 revealed under Policy: Equipment and utensils will be properly cleaned and sanitized to prevent contamination. Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 01/2024 further revealed under Purpose: Safe food handling and minimize the risk of cross-contamination. On 12/11/24 at 04:30 P.M., Record review of the Policy/Procedure entitled: Food Safety Requirements dated 01/2021 revealed under Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, and served in accordance with professional standards for food service safety. 45135

Based on observation, interview and record review, the facility failed to accurately stage and regularly assess pressure ulcers for one (Resident #57) of four reviewed for pressure ulcers, resulting in the inaccurate staging of pressure ulcers and the ineffective treatment and unrecognized worsening of wounds. Findings include: Review of the medical record reflected R57 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, with an Assessment Reference Date (ARD) 9/20/22, reflected R57 scored two out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R57 required extensive to total assistance of one person for activities of daily living. The Admission MDS, with an ARD of 6/20/22, reflected one stage 2 pressure ulcer (partial-thickness skin loss, presenting as shallow ulcer) that was present on admission, one stage 3 pressure ulcer that was present on admission and one unstageable pressure injury presenting as a deep tissue injury (intact skin with non-blanchable deep red, maroon or purple discoloration) that was present on admission. The 6/10/22 Admission Assessment reflected pressure ulcers of the coccyx and right hip. The assessment did not reflect any descriptive wound information or wound characteristics. During an interview on 10/19/22 at 2:51 PM, Licensed Practical Nurse/Unit Manager (LPN) G reported the Admission Skin Assessment should have included the type of wound, the location, if infection was present, if the doctor had been notified, the treatment and the normal assessment. That assessment should have included measurements, wound characteristics and staging. Floor nurses did skin assessments, and if there were any issues, she (LPN G) went down to see them and get started. That usually occurred within 24 hours. LPN G stated the admitting nurse probably did not stage the wounds and did not know how. The first assessment of R57's wounds was documented on 6/13/22. The assessment reflected a stage 3 pressure ulcer to the coccyx, measuring 3.0 centimeters (cm) x 2.2 cm x 0.3 cm with 100% granulation tissue (pink to red tissue that fills a wound bed as it starts to heal). A stage 2 right trochanter (hip) pressure ulcer measured 1.7 cm x 1.6 cm x 0.1 cm with 90% slough (yellow, tan, gray, green or brown non-viable tissue). According to the Wound Assessment, a stage 2 pressure ulcer was classified as partial thickness loss of dermis, presenting as a shallow open ulcer, with a red/pink wound bed, without slough. R57's 6/20/22 Wound Assessment reflected the right trochanter wound was a stage 2 with 100% eschar in the wound bed. According to the Wound Assessment, an unstageable wound was full-thickness tissue loss with the base of the ulcer covered by slough and/or eschar. During the interview with LPN G on 10/19/22 at 2:51 PM, she reported a stage 1 pressure ulcer was red and non-blanchable. A stage 2 was any kind of opening with granulation tissue. A stage 3 was full tissue loss, and a stage 4 was to the bone and cartilage. If there was any eschar and slough and a depth could not be determined, the pressure ulcer was unstageable, if you could not see the wound bed. A suspected deep tissue injury was usually darkening of the skin, and there was no wound bed. When queried about the staging of the right trochanter pressure ulcer for 6/13/22, LPN G stated it was not a stage 2, and she may have been going by what Hospice put in. Regarding the staging of the right trochanter pressure ulcer on 6/20/22, LPN G reported she probably didn't change the staging. On 10/17/22 at 11:44 AM, R57 was observed lying in bed, with a Hospice staff member providing care. A dressing was observed to R57's right hip and was dated 10/14. R57's October 2022 Treatment Administration Record (TAR) reflected the dressing to the right hip was to be changed every other day and was scheduled for odd numbered days of the month. The treatment was signed out as being performed on 10/15/22. R57's Wound Assessments were reviewed and reflected the following dates: 6/13/22, 6/20/22, 6/27/22, 7/5/22 (8 days between assessments), 7/11/22, 7/20/22 (9 days between assessments), 8/15/22 (26 days between assessments), 8/22/22, 8/29/22, 9/12/22 (14 days between assessments), 9/19/22, 9/26/22 and 10/17/22 (21 days between assessments). During an interview with LPN G on 10/19/22 at 2:51 PM, when queried on the absence of Wound Assessments between 7/20/22 to 8/15/22, she stated it was probably because when they did the monthly rounds, they did not put the wound assessment in. When asked if there would be wound documentation anywhere else between that time, LPN G stated it could have been in the Hospice Notes. Regarding the lack of Wound Assessments between 8/27/22 and 9/12/22, LPN G acknowledged her Wound Assessment was not in the medical record. When queried on the absence of Wound Assessments between 9/26/22 and 10/17/22, LPN G stated what she had was there and what she had done. Since they were doing monthly rounds, they probably didn't do the wound documentation, according to LPN G. During the interview on 10/19/22 at 2:51 PM, LPN G reported she had been doing the facility's wounds for about two and a half to three months. LPN G reported Hospice was very involved in R57's wounds, and a wound Nurse Practitioner (NP) saw R57 monthly. The frequency of wound assessments was weekly, and they were documented under the Assessments tab of the Electronic Medical Record, according to LPN G. When queried if wound assessments would be in another location, LPN G stated it would be in the Orders and on the Care Plan, and the wound NP documented in the Progress Notes. The assessment included the type of wound, if it was stageable or unstageable, pressure or non-pressure, the location, any pain, drainage, odor, measurements, appearance of surrounding tissue and determining if the treatment was effective or if it needed to be updated. R57's medical record did not reflect documentation of comprehensive wound assessments in the Hospice Notes for the time periods that were absent on the Wound Assessments. Review of R57's Wound Assessment for 9/26/22 reflected a stage 4 coccyx pressure ulcer, a stage 4 right trochanter pressure ulcer; multiple, scattered suspected deep tissue injuries to the both legs, a resolved stage one pressure ulcer to the right ischium, a stage one pressure ulcer to the right iliac crest, an unstageable pressure ulcer to the left knee and a suspected deep tissue injury to the left trochanter. The next Wound Assessment was dated 10/17/22 and reflected suspected deep tissue injury to the left toes, an unstageable pressure ulcer to the left lateral (outside aspect) knee, a suspected deep tissue injury to the left heel, a stage 4 pressure ulcer to the coccyx, a stage 4 pressure ulcer to the right trochanter, a stage one pressure ulcer to the left lateral foot, a stage one pressure ulcer to the right first toe, a stage one pressure ulcer to the right fifth toe and stage one pressure ulcer of the right lateral foot. A left trochanter pressure ulcer was not documented on the 10/17/22 assessment. R57's October 2022 TAR reflected an order with a start date of 7/13/22 and a discontinue date of 10/18/22 for applying border foam to the stage one pressure injury (intact skin with non-blanchable redness) on the left trochanter every three days. An order with a start date of 10/26/22 reflected to cleanse the left posterior (back) hip/gluteal fold hip wound with wound cleanser, then apply [MEDICATION(S)] gel onto the wound bed and cover with border foam every other day and as needed. On 10/25/22 at 10:23 AM, LPN G was observed performing wound care on two pressure ulcers for R57, with Graduate Nurse (GN) H assisting with resident positioning. R57 was turned to her right side, and a left hip wound was observed to be open to air. The wound bed was covered with eschar (dead or devitalized tissue). LPN G performed hand hygiene with soap and water for less than 10 seconds. She stated they performed hand hygiene for 15 to 30 seconds to the ABC song. She then stated hand hygiene was to be performed for 30 seconds to one minute. LPN G put on (donned) gloves, sprayed wound cleanser on 4 x 4 gauze, then cleansed the left hip wound. She then sprayed skin prep around the edges of the wound. [MEDICATION(S)] was applied to a comfort border foam that was applied to the left hip. No hand hygiene was observed between cleansing the left hip wound and applying the new dressing. LPN G removed (doffed) her gloves and washed her hands with soap and water for less than 20 seconds before donning new gloves. The coccyx dressing, dated 10/24/22, was removed. LPN G described the coccyx wound as having slough and exposed bone. LPN G doffed her gloves and performed hand hygiene for 20 seconds in the bathroom. She donned new gloves and applied wound cleanser to the wound bed. LPN G removed her gloves, and without performing hand hygiene, donned new gloves. Skin prep was sprayed around the edges of the wound. LPN G then applied [MEDICATION(S)] to the new comfort border foam dressing that was applied to the wound. The October 2022 TAR reflected an order with a start date of 10/26/22 to cleanse the coccyx wound with wound cleanser, apply [MEDICATION(S)] gel onto the wound bed and cover with border foam every other day and as needed. During an interview regarding wound care on 10/25/22 at 11:23 AM, LPN G reported the facility had skin prep pads, in addition to the spray. She used the skin prep spray on R57 because there was less touching, which caused R57 pain. When queried on how she ensured she was not spraying skin prep inside the wound, LPN G stated that was why she made sure she went around the circumference of the wound. She reported she tilted to bottle to go around the wound. When asked if [MEDICATION(S)] was to be applied to the entire wound bed, LPN G stated it was, and that was how the order was written. When queried on how she ensured the [MEDICATION(S)] covered the entire wound bed (when only applying it to the center of the comfort border foam), LPN G stated she used a lot of [MEDICATION(S)] and watched as she applied the dressing, going from the bottom up.

This Citation Pertains To: MI 138 Based on observation, interview and record review the facility failed to 1. Implement interventions and safety measures for one resident (#2) whom was identified as being at risk for elopement of 6 residents reviewed for elopement. #2. Failed to initiate the facility's elopement protocol, failed to immediately respond to door alarm, failed to activate intercom announcement. Resulting in immediate jeopardy when Resident #2 eloped from the facility unbeknownst to staff and was found 1 hour and 11 minutes later, 0.9 miles away, which required hospital treatment, resulting in the potential for all 10 residents that have been identified to be an elopement risk, at risk for harm, injury, and or death. Findings Include: According to the clinical record Resident #2 (R2) was an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review revealed R2 scored a 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) completed on 12/23/2020. Review of R2's Nurses notes dated 12/19/2020 reflected R2 left the Covid-19 unit where she was supposed to have been for quarantine, telling the Nurse she had to get out of here. Licensed Practical Nurse (LPN) I completed an elopement risk assessment on 12/19/2020, R2 scored 12 on the elopement risk assessment which determined R2 was at risk for elopement. LPN I did not report this information to the family, the physician or the interdisciplinary team. No wander guard or any other safety measures were implemented at that time, when resident was determined to be at elopement risk. On 2/25/2021 at 3:10 PM LPN I was interviewed via phone and reported she had completed the elopement risk assessment for R2 on 12/19/2020. When queried what safety measures or interventions were implemented for R2 based on the result of the elopement risk assessment completed on 12/29/2020, LPN I stated she was a new Nurse and didn't know she needed to notify the physician or family nor was she aware she was to implement safety measures. LPN I further stated she was written up by management over the incident and would now notify the Physician, family , document the incident and include it in the 24 hour report and notify management of the findings and get a physician order for [REDACTED]. On 02/25/21 at 2:35 pm, during a telephone interview with Certified Nursing Assistant (CNA )C reported she was working the sub acute unit on 12/23/20 but was not assigned to R2. CNA C reported the units had heavy duty plastic type barrier doors added due to housing Covid-19 residents. CNA C reported the unit also had double doors that were kept shut. CNA C stated she could not hear any alarms while on the hallway. CNA C reported on 12/23/2020 at 5:40am, she came off her assigned hall way to go and take a break, and heard an alarm sounding. CNA C stated no one was around except for Housekeeper D who was doing something at the sink. I asked her if she did anything about the alarm, or told someone and she said no. CNA C stated she shut the alarm off and noticed the double doors entrance/exit were opened, CNA C stated the double doors are always closed and locked. CNA C stated she went outside looked around and could see as far as the main road (approximately .25 mile) and did not see anyone. CNA C stated she went back to the her assigned hallway , informed Registered Nurse G that she believed an elopement occurred, based on the alarm sounding and the double doors that were locked were now open. CNA C stated RN G told her to let another nurse know because she was passing medications. CNA C stated she then went over to the long term care side of the building and informed another nurse. CNA C stated it (the elopement) was not announced. On 02/25/2021 at 11:10 am during an interview with Housekeeper D she reported she starts her shift at 6:00 am, but always arrives at the facility between 5:30 am and 5:45 am. Housekeeper D reported on 12/23/20 she arrived at the facility at 5:30am and upon entering the sub acute care unit at 5:30 am, she heard an alarm sounding. Housekeeper D stated I didn't even know what it meant, I wasn't even punched in, I was fixing my cart. Housekeeper D reported she was not aware an elopement had occurred until she overheard staff talking about it approximately 10 minutes later. When queried if she responded to the alarm or notified other staff an alarm was sounding , Housekeeper D stated No. When queried why she didn't respond to the alarm or notified someone that the alarm had sounded Housekeeper D stated I don't know. Housekeeper D reported nobody had asked her to assist in a search for R2 and that there was no overhead announcement that a resident was missing and reiterated the only reason she knew a resident was missing was because she overheard other staff members talking about it. When queried if she looked for R2, Housekeeper D stated she looked out a window but didn't see anyone. On 02/25/2021 at 12:32 PM during a phone interview with Registered Nurse G she reported she was a new nurse and had been employed at the facility for one month when R2 eloped. RN G stated CNA C informed her on 12/23/20 at approximately 5:30am that an alarm was sounding and the doors leading to the outside that were normally locked were not only unlocked but open. RN G stated she thought it may have been one of her residents, she went to check her resident , saw that she was in bed and , therefore continued to pass her morning medications and instructed CNA C to let another nurse know of her suspicion of elopement. RN G stated nobody announced anything overhead and she really was not sure what to do, so she continued to pass medication. On 03/01/2021 at 8:20am phone interview with CNA E whom was assigned to R2 on 12/23/2020 and CNA E reported staff had to keep redirecting R2 she always had her bags packed CNA E reported she last saw R2 about 5:15 am , stated she did not hear the alarm and there was no overhead announcement related to an elopement. CNA E stated she was not aware that there was a potential elopement on 12/23/20 until 6:00am. On 02/25/2021 at 12:15 pm during an phone interview with Licensed Practical Nurse (LPN) F she reported she was the nurse assigned to R2 on 12/23/20. LPN F stated she administered R2 her medication at 5:15 am, and did notice her wheelchair had a bag full of clothes on it. LPN F stated she did not think or view the bag packed of R2's clothes packed and sitting on the wheelchair as a warning sign. LPN F described that day as typical, it was the Covid-19 Unit and the double doors are kept shut and a plastic barrier outside the hallway. LPN F reported that Registered Nurse (RN) G Poked her head thru the barrier that was set up for Covid-19 and asked if I was missing someone, that was between 6:00 and 6:05 am LPN F stated she did a head count at that time and realized R2 had eloped, there was no overhead announcement of a potential elopement and she had no idea there was a problem until RN G asked her if she was missing a resident. LPN F stated a code was never called. When queried if the facility elopement policy and procedure entailed an overhead announcement to be made, LPN F stated yes and she thought the code was Teddy Bear. LPN F acknowledged that after she completed a head count and confirmed R2 was missing, she did not make any announcement. LPN F further stated CNA C was yelling at her for the delay in announcing the elopement, because she had told RN G that she heard the alarm and saw the exterior doors open and reported it to her Nurse, RN G 20 minutes prior. Review of the facility reported incident dated 01/05/2021 reflected R2 had eloped from the facility on 12/23/2020 with the alarm heard sounding at 5:40am. The County Sheriff was notified at 6:12am and the Sheriffs staff had located R2 at 6:51 am .9 miles away. The temperature was 35 degrees Fahrenheit. R2 was taken to the emergency department where she received treatment for [REDACTED]. Hospital record indicated R2 complained of knee pain and being cold, along with a history of cognitive impairment. On 03/02/2021 at 12:45pm, during an interview with Administrator A he was offered no explanation for the lack of implementation of safety measure that resulted in R2's elopement on 12/23/2020. No explanation was offered for how staff responded to the sounding alarm. Record review of the facility policy and procedure titled Resident Elopement revealed on page #2 under, Wander/Elopement Alarm Activation, #1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm .; c. If no resident is found to be exiting the facility, the employee should Page overhead Code Green. This policy had a last revision date of August 2012. Review of another facility policy and procedure titled, Elopement Management revealed on page #1, under Practice Guidelines, #3. Upon admission or readmission, if the resident is identified to be at risk for elopement, interventions are developed and implemented in accordance with the care plan . This policy had a last revision date of July 2017. On 3/1/2021, at 8:57 AM, the Administrator was notified of the Immediate Jeopardy that was identified on 3/1/2021, that began on 12/23/2020, when R2 elopement on 12/23/20 at 5:40 AM, and the facility failed to initiate their elopement protocol, which resulted in a delayed search for R2, who was ultimately found by the Police Department one hour and 11 minutes later 0.9 miles away from the facility. On 3/ the survey team verified the facility implemented the following corrective action to remove the Immediate Jeopardy: 1). Beginning 12/23/2020 Elopement risk assessments for all residents were reviewed and updated accordingly. 2). Beginning 12/23/2020 residents identified at risk have current assessment, Wanderguard bracelets and care plans were updated to reflect the current assessments. 3). Beginning 12/23/2020 The Wanderguard bracelets for the like residents were checked for placement and function. 4). Beginning 3/1/2021 all staff have been re-educated on: a). Facility elopement policy and procedure. b). Immediately announcing overhead paging of code green. c). Staff are to drop everything, respond to alarm. Conduct a head count. d). Once determined that resident is missing, contact DON, Administrator. e). Conduct a thorough search of the building and premises. f). Admin or DON will notify police, physician, legal guardians/responsible parties, state. g). Provide search teams, extensive search of surrounding area. h). Upon admission/readmission, quarterly and if a wandering incidence occurs residents will be assessed for elopement risk. k). Residents identified will have interventions implemented in accordance with care plan. 5). Beginning 12/23/2020 all doors were checked for proper closure and locking by Maintenance supervisor or designee. 6). Beginning 12/23/2020 elopement drills were conducted. 7). Beginning 12/23/2020 elopement risk binders which contain pictures and detailed descriptions of all residents listed as elopement risks are at every unit and the front desk. 8). Beginning 12/23/2020 Social Services will update binders with changes to elopement risk assessments. 9). Beginning 12/23/2020 nursing staff is checking for proper, function, placement and expiration of all Wanderguards every shift and recording findings on the resident's medication administration record. 10). Beginning 12/23/2020 the maintenance supervisor or designee will be responsible for auditing all doors for proper closure and locking daily. 11). Beginning 12/23/2020 any identified concerns will be addressed immediately and corrective action taken. 12). Beginning 12/24/2020 the DON or Designee is responsible for completion of an audit of the MAR for placement and function of Wanderguards weekly times 4 weeks. The maintenance supervisor or designee in conjunction with nursing will conduct elopement drills at different times and shifts times 4 weeks. The results of these audits will be reviewed by the QAPI committee until further directed. If the threshold of 95% is not achieved an action plan will be developed to ensure compliance. Although the Immediate Jeopardy was removed on 3/1/2021, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the state agency.

This citation pertains to MI 041 This citation has two Deficient Practice Statements (DPS A and DPS B). DPS A Based on observation, interview and record review, the facility failed to establish and implement proper infection prevention and control policies and procedures to prevent development and transmission of Coronavirus Disease 2019 (COVID-19), resulting in Immediate Jeopardy when the facility failed to properly clean and disinfect resident rooms and equipment placing all 67 residents and staff at risk for contracting COVID-19. Findings include: Review of the facility's undated Resident COVID-19 results spreadsheet revealed a total of 44 residents tested positive for COVID-19. In an interview on 5/20/20 at 10:02 AM, Director of Nursing (DON) B reported that 42 of the 44 positive residents were transferred to a sister facility or the hospital and two remained in the facility. According to the facility's Resident COVID-19 results revealed the first positive resident test was on 4/4/20 and the most recent positive test was on 5/12/20. In an interview on 5/21/20 at 10:51 AM, when asked about the positive residents who were transferred out of the facility, Director of Nursing (DON) B stated as soon as they were positive, they went to the hospital if hypoxic. If no other symptoms, we had to send them to another facility, one of our facilities that actually had a COVID unit. They remain there .and then sent back to us. We monitor them still. DON B reported the residents who tested positive for COVID-19 and who have returned to the facility were recovering. Review of the facility's Interim Recommendations for Routine & Terminal COVID-19 Isolation Room/Unit Cleaning, revealed It is important that for each infectious disease and EPA approved solution's use, preparation, and dwell time, also referred to as contact time, can be found on a combination of the Safety Data Sheet (SDS) and the manufacturer's label .Current evidence suggests that the new coronavirus may remain viable for hours to days on surfaces made from a variety of materials. Disinfection is a best practice measure for prevention of COVID-19 and other [MEDICAL CONDITION] respiratory illnesses .EPA-registered disinfectants must be used .Be sure to follow the manufacturer's recommended dwell time. Dwell time-also referred to contact time-is how long a chemical needs to be in contact with the surface in order to effectively sanitize or disinfect. Review of the Coronavirus (COVID-19) Frequently Asked Questions for (housekeeping contract company name) Field Managers, revealed There is no disinfectant that will have a COVID-19 kill claim on its label. (Housekeeping contract company name) purchases and utilizes chemical disinfectants that have demonstrated effectiveness [MEDICAL CONDITION] similar to COVID-19 when used in accordance with the manufacturer directions on hard, non-porous surfaces . According to CMS (Centers for Medicare and Medicaid) Covid-19 focused survey protocol, Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare setting (effective against the organism identified if known) at least daily and when visibly soiled. Review of the CDC's Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 revealed, Disinfectants used at a facility should be EPA-registered, hospital-grade disinfectants with an emerging [MEDICAL CONDITION] pathogens claim against [DIAGNOSES REDACTED]-CoV-2. List N on the EPA website lists products that meet EPA's criteria for use against [DIAGNOSES REDACTED]-CoV-2 (https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2) .All EPA-registered, hospital-grade disinfectants have a contact time which is required to kill or inactivate pathogens. Environmental surfaces must remain wet with the product for the entire contact time duration to work appropriately. Contact times range from 30 seconds to 10 minutes. Keeping a surface wet for 10 minutes is seldom accomplished with a single application. It is important for facilities to know that their product is appropriate (List N as above) and is being used for the entire contact time. Also, it is helpful for the facility to assign responsibility for cleaning and disinfection of specific surfaces and equipment (who cleans what). According to the EPA's website (https://www.epa.gov/coronavirus/disinfectant-use-and-coronavirus-covid-19), How does EPA know that the products on List N work on [DIAGNOSES REDACTED]-CoV-2? While surface disinfectant products on List N have not been tested specifically against [DIAGNOSES REDACTED]-CoV-2, the cause of COVID-19, EPA expects them to kill [MEDICAL CONDITION] because they: Demonstrate efficacy (e.g. effectiveness) against a harder-to-[MEDICAL CONDITION]; or Demonstrate efficacy against another type of human coronavirus similar to [DIAGNOSES REDACTED]-CoV-2. All surface disinfectants on List N can be used to [MEDICAL CONDITION] on surfaces such as counters and doorknobs. Because [DIAGNOSES REDACTED]-CoV-2 is a new virus, this pathogen is not readily available for use in commercial laboratory testing to see if a certain disinfectant product is effective at killing [MEDICAL CONDITION]. EPA reviews and registers antimicrobial pesticides, which include disinfectants for use on pathogens like [DIAGNOSES REDACTED]-CoV-2, the novel human coronavirus that causes COVID-19 .In early March, EPA released its initial List N: Disinfectants for Use Against [DIAGNOSES REDACTED]-CoV-2 (List N). This list continues to be updated on a weekly basis. It is searchable and sortable, comes with helpful tips on how to use disinfectants properly, and features frequently asked questions to ensure correct product usage. As with any EPA-registered product, carefully read the label and only use the product as described in its directions . According the EPA's Frequently Asked Questions page (https://www.epa.gov/coronavirus/frequent-questions-related-coronavirus-covid-19), What does the column Follow the disinfection directions and preparation for the following virus mean? Why [MEDICAL CONDITION] other than the human coronavirus listed in that column? This column shows the harder-to-[MEDICAL CONDITION] than the human coronavirus. Products qualify for the emerging [MEDICAL CONDITION] pathogen claim by showing that it works against the listed harder-to-[MEDICAL CONDITION]. Therefore, if the contact time for this harder-to-[MEDICAL CONDITION] is followed, EPA expects the product to be effective against [DIAGNOSES REDACTED]-CoV-2 on surfaces. You can also find this information on the product label. In a telephone interview on 5/20/20 at 2:30 PM, Housekeeper M reported she usually worked the 100 and 200 hallways which were the hallways dedicated to COVID positive residents and residents on quarantine/isolation. When asked if anything was done differently since COVID-19, Housekeeper M reported the facility was now using AIR X. When asked how that product was used, Housekeeper M reported AIR X was supposed to be sprayed in the rooms before the housekeeper goes into that room and then let sit for a while before wiping it down. When asked how long the product was to sit, Housekeeper M stated I usually let it sit for 6 minutes, but I'm not sure if that's long enough or too long. Housekeeper M reported AIR X was only to be used in rooms of residents who were positive for COVID-19 or on quarantine. When asked about any education received, Housekeeper M stated I think it was just a verbal from our boss saying everything. In a telephone interview on 5/20/20 at 3:07 PM, Housekeeper N reported he has worked on all hallways in the facility. When asked about the cleaning procedures for COVID-19, Housekeeper N reported he used a Quat (HB Quat) disinfectant for high touch surfaces and resident rooms. When asked about AIR X, Housekeeper N reported that was the product used for high touch areas. When asked how the AIR X was used, Housekeeper N stated just spray it on high touch areas and wipe it down with a clean rag. When asked if the product needed to sit or remain wet for a certain amount of time, Housekeeper N stated No, I just wipe it down quickly after spraying it on. In a telephone interview on 5/20/20 at 3:58 PM, Housekeeper O reported she worked all hallways in the facility, including the 100 and 200 hall approximately once a week. When asked if anything was done differently related to COVID-19, Housekeeper O stated Not really. We use more AIR X over on the 100 and 200 halls. We don't use it much on (300 and 400 hallways). We use the Quat (HB Quat) and all that stuff. When asked how the AIR X was used, Housekeeper O stated I spray everything down in the room and come back and wipe everything down. It's at least three to five minutes before I wipe it down. When asked how the AIR X was different from the Quat solution, Housekeeper O stated I think it's just timing and how fast it works. When asked what the contact time was for the Quat, Housekeeper O stated I use them about the same amount of time. I think there is about a one-minute difference. I use them both the same. In a telephone interview on 5/21/20 at 1:00 PM, when asked how cleaning/disinfecting procedures have changed since COVID-19, Housekeeper Q reported the facility now used AIR X 75 disinfectant spray for high touch areas and positive COVID-19 resident rooms. Housekeeper Q reported HB Quat was used as a substitute for the AIR X 75. When asked how AIR X 75 was used, Housekeeper Q stated You spray it and then it sits for two to three minutes and then you wipe it down. When asked about the contact time for HB Quat, Housekeeper Q reported the HB Quat did not have to sit before wiping down and stated, You can spray it and then wipe it down. When asked if there was any specific education related to AIR X 75, since it was a new product to the facility, Housekeeper Q stated No. In a telephone interview on 5/21/20 at 9:06 AM, when asked about changes since COVID-19, Environmental Services Supervisor (ESS) P reported the facility was performing disinfection of high touch surfaces twice daily. When asked about staff education, ESS P reported education included dwell/contact times for chemicals. ESS P reported the facility was using some new chemicals, such as AIR X 75 and 3M HB Quat. ESS P reported both the products have a high dwell time of 5 to 10 minutes. ESS P stated have to soak everything and let it sit and then wipe it down which is different than normal routine. When asked about the two different products, ESS P reported the facility had multiple chemicals because of the supply chain but preferred to use the AIR X 75. ESS P reported the 3M HB Quat was used if the AIR X 75 was not available. ESS P reported AIR X 75 was only being used on the isolation wing and for high touch points in the entire building. When asked about the dwell/contact time for AIR X 75 and 3M HB Quat, ESS P reported he believed it was 10 minutes. ESS P reported the facility began using AIR X 75 right around the end of March when this whole situation started. ESS P reported the facility also had Micro Dot Bleach wipes that have a five-minute dwell time, but the wipes were hard to get and were used fast. Observation of the package insert and review of AIRx 75's label revealed EPA registration number 1839-83- . Further review of the label revealed, Virucidal Activity - This product kills on hard, non-porous inanimate surfaces when allowed to remain wet for 10 minute contact time against: [MEDICAL CONDITION] Virus (HAV), Canine Parvovirus, [MEDICATION NAME] Type 1 . Review of EPA's List N information (retrieved on 5/20/20) revealed that this product was added to List N on 3/3/20. It further stated, Products with Emerging [MEDICAL CONDITION] Pathogens AND Human Coronavirus claims for use against [DIAGNOSES REDACTED]-CoV-2 .Follow the disinfection directions and preparation for the following virus: Canine Parvovirus .Contact time in minutes: 10. Observation of a photograph of 3M HB Quat's label revealed EPA registration number -5- . Review of EPA's List N information (retrieved on 5/20/20) revealed that this product was added to List N on 3/13/20. It further stated Products with Emerging [MEDICAL CONDITION] Pathogens AND Human [MEDICAL CONDITION] claims for use against [DIAGNOSES REDACTED]-CoV-2 .Follow the disinfection directions and preparation for the following virus: Human Coronavirus. Contact time in minutes: 10. On 5/20/2020 at 4:20 PM, during a phone interview with Certified Nursing Assistant (CNA) G, reported working at the facility for approximately 3 months, and was assigned on the 200 hall, where two residents that tested positive for Covid 19 reside. When queried how resident equipment was cleaned and sanitized, (lifts, blood pressure cuffs etc ) CNA G reported all resident equipment was cleaned with wipes. CNA G was uncertain of the name or brand of the wipes and was not aware of any guidelines that the product had a contact/dwell time for disinfecting. You just wipe in down. On 5/20/2020 at 6:40 PM during a phone interview with CNA H, it was reported that her assignment was on the 200 hall working the afternoon shift. When queried how resident equipment was cleaned, sanitized and disinfected CNA H reported she wiped down equipment with hand sanitizer. A muffled voice was heard in the background, CNA H then stated Not hand sanitizer I meant spectrum wipes. (Review of the photograph of the spectrum wipes container, reflected spectrum wipes were hand sanitizer wipes.) CNA H then changed her answer to Cavi wipes (Environmental Protection Agency registration number -13), CNA H then changed her answer to Clorox bleach wipes. CNA H stated she was not aware there was contact or dwell time to disinfect or sanitize equipment. On 5/21/2020 at 12:45 during a telephone interview with CNA I it was stated she worked the 200 hall on the day shift. CNA I reported that the facility had not provided education on cleaning or disinfecting resident equipment. CNA I stated all staff were aware that resident equipment was supposed to wipe it down after its used. When queried what product resident equipment was wiped down with CNA I was not sure but thought it was pretty intense. When queried about the contact time with the product in used had CNA I reported a 2 minute contact time was standard. CNA I further stated she will help the housekeepers and will occasionally clean and disinfect the facility shower rooms, including the shower chair, bench and hand rails. CNA I reported for shower rooms she used something in a spray bottle but was not sure of the name. When queried about the contact time for the spray cleaner she used for the shower rooms, she stated It's a 2 minute contact time too. During a phone interview on 5/21/2020 at 9:32 AM, Registered Nurse (RN) K reported that they used alcohol wipes to disinfect resident equipment, such as vital signs carts. RN K also reported using alcohol wipes to disinfect goggles. RN K reported the contact time (dwell time) for the alcohol wipes was maybe one minute or two minutes, but if the item was bloody, they would wash it. Review of facility Alcohol Prep Pad label did not reflect and EPA registration number. [MEDICATION NAME] alcohol and water were listed as the ingredients on the product label. According to EPA List N, [MEDICATION NAME] alcohol had a contact time of five minutes. During a phone interview on 5/21/2020 at 12:46 PM, Licensed Practical Nurse (LPN) L reported using (Brand Name) wipes (EPA registration number -13) to clean equipment, such as the medication cart, bladder scanner and glucometers. When asked what the contact time/dwell time was for the product, LPN L reported they had not received any type of input on that. Observation of a photograph of the (Brand Name) wipes, revealed an EPA registration number of -13. According to EPA List N, the contact time for the product with EPA registration number -13 was three minutes. During a telephone conversation on 5/21/20 at 2:33 PM, NHA A was made aware of the Immediate Jeopardy that began and was idenfied on 5/21/2020. On 5/27/20, it was verified that the facility implemented the following to remove the Immediate Jeopardy as of 5/21/2020: On 5/21/20 the facility completed a review of the cleaning products. On 5/21/20 the facility also reviewed current cleaning processes and procedures related to disinfecting resident rooms and equipment and appropriate contact times associated with their use. On 5/21/20 Licensed Nursing Staff and Resident Care Specialists identified in the interview process were re-educated on use of Cavi wipes for resident equipment with a contact time of (3) three minutes. On 5/21/20 all Housekeeping Staff were educated on the appropriate contact time for HB Quat and AIR X 75 and to reapply these disinfectants should they dry prior to the contact time being reached. On 5/21/20 all staff have also been educated on not using alcohol wipes, Spectrum Wipes and hand sanitizer to disinfect resident equipment. On 5/21/20 the facility initiated re-education and training of remaining staff members prior to next scheduled shift. The training includes review of current cleaning products being used to disinfect resident rooms and resident equipment as well as the contact times associated with product use of AIR X 75 which includes a contact time of (10) ten minutes, HB Quat which includes a contact time of (10) ten minutes to disinfect high touch contact surface areas which includes resident rooms. In an telephone interview on 5/27/20 at 10:55 AM, Housekeeper Q reported the education she received last month was that the AIR X 75 had a contact time of 3 minutes, but that has now changed to 10 minutes with the new education received on 5/21/20. In a telephone interview on 5/27/20 at 10:59 AM, Housekeeper O reported before the most recent education on 5/21/20, she was using a 5 minute contact time for AIR X 75, but with the re-education, the contact time was now 10 minutes. During a phone interview on 5/27/2020 at 9:15 AM, LPN L reported that they received education Thursday or Friday of the prior week. LPN L reported being educated that housekeeping had a special cleaning fluid for cleaning big equipment that had to stay for ten minutes. LPN L reported receiving a paper that reflected sanitizer wipes and contact time as well as (Brand Name) Wipes (EPA registration number -13) and a contact time of three minutes. LPN L reported being told that people were using sanitizer wipes to clean and were not aware they were not supposed to use those on equipment like blood pressure cuffs, glucometer and lifts. On 5/27/20 the State Agency completed verification that the Immediate Jeopardy was removed on 5/21/20. However, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that all staff had not been confirmed to have been educated and sustained compliance had not yet been verified by the State Agency. DPS B) Based on observation, interview and record review, the facility failed to maintain evidence of complete and thorough staff screening for Coronavirus Disease 2019 (COVID-19), resulting in unidentified staff illness and increased potential for staff to resident transmission of COVID-19. Findings include: At approximately 9:25 AM on 5/20/2020, a screening table was observed, occupied by a nurse, in the lobby area of the facility's main entrance. A questionnaire was provided by the facility, and the surveyor's temperature was taken orally by the facility nurse. A screening log for staff was also present on the table. Review of the EMPLOYEE AND ESSENTIAL HEALTHCARE PERSONNEL SCREENING LOG for April 2020 reflected the following columns: -Date -Shift -Employee/Essential Healthcare Personnel Name -Do you have any of the following symptoms: Fever, Cough, Shortness of breath, Sore Throat? (YES/NO) *If Yes, indicate symptom(s) -Temperature Check Results (Fever is > (greater than) 100.4 (degrees) F (Fahrenheit)) -Have you taken any fever-reducing medications containing Tylenol ([MEDICATION NAME]) [MEDICATION NAME] ([MEDICATION NAME]) or cold/sinus mediations within the past 24 hours? Yes/No -Have you, or anyone you have had contact with, traveled internationally within the past 14 days to Europe, UK, Ireland and/or Level 3 countries with sustained community transmission? (YES/NO) *If Yes, indicate area -In the past 14 days, have you had any contact with any person with known Coronavirus COVID-19 or who may be under evaluation for exposure to Coronavirus COVID-19 or a person who is ill with respiratory illness? (YES/NO) -In the past 14 days, have you worked in or entered a facility with suspected or confirmed COVID-19 infection? (Yes/No) -If you answered Yes to column 5, did you wear appropriate PPE? (Yes/No) -In the past 14 days, have you taken trips on cruise ships or participated in other settings where crowds are confined to a common area? (YES/NO) *If yes, where? -Is there evidence of Coronavirus COVID-19 or possible exposure? (YES/NO) *If Yes, notify Infection Preventionist for further action. -Instructional Handout Reviewed/Provided -Nurse's Name Completing Screen--Utilize clinical judgment and the CDC's Persons Under Investigation criteria to determine .*If the employee/ essential HCP indicates fever-reducing medication was used, conduct further evaluation for potential fever and possible work restriction Further review of the April 2020 EMPLOYEE AND ESSENTIAL HEALTHCARE PERSONNEL SCREENING LOG reflected the following, which is not an all-inclusive list: 4/2/2020: Two staff members left the column for symptom reporting blank/unanswered. 4/3/2020: One staff member left the column for symptom reporting blank/unanswered. 4/5/2020: One staff member did not have a temperature recorded. 4/6/2020: One staff member answered, Yes to having symptoms but did not specify the symptoms. One staff member left the column for symptom reporting blank/unanswered. 4/9/2020: One employee left the column for symptom reporting blank/unanswered. 4/10/2020: Three employees left the column for symptom reporting blank/unanswered, and one employee used that column for temperature recording. 4/11/2020: One employee left the column for symptom reporting blank/unanswered. 4/12/2020: One employee answered the symptoms question with a response of Fever. The same staff member answered, Yes to, Have you taken any fever-reducing medications containing Tylenol ([MEDICATION NAME]) [MEDICATION NAME] ([MEDICATION NAME]) or cold/sinus mediations within the past 24 hours? Yes/No. Their temperature recording was not legible. 4/13/2020: One employee left the column for symptom reporting blank/unanswered. 4/14/2020: One employee recorded responses in columns for symptom reporting, temperature and instructional handout provided/reviewed. All other columns were blank/unanswered for that employee. 4/16/2020: One employee recorded, Yes in the column for symptom reporting but did not specify their symptoms. Four employees left the column for symptom reporting blank/unanswered. 4/17/2020: Four employees left the column for symptom reporting blank/unanswered. One employee only completed the columns for symptom reporting and temperature recording. Five employees answered yes or y to having symptoms but did not specify their symptoms. 4/18/2020: Four employees left the column for symptom reporting blank/unanswered. 4/19/2020: Two employees left the column for symptom reporting blank/unanswered. 4/20/2020: One employee only recorded their temperature. Three employees left the column for symptom reporting blank/unanswered. One employee recorded y to having symptoms but did not specify their symptoms. 4/21/2020: Five employees left the column for symptom reporting blank/unanswered. 4/22/2020: One employee did not enter a response for any screening questions or temperature recording. Two employees answered yes to symptoms but did not specify their symptoms. One employee left the column for symptom reporting blank/unanswered. 4/23/2020: Two employees left the column for symptom reporting blank/unanswered. 4/24/2020: Three employees responded yes to having symptoms but did not specify their symptoms. Four employees left the column for symptom reporting blank/unanswered. The log continued to reflect incomplete employee screening for 4/25/2020 through 4/30/2020. The May 2020 EMPLOYEE AND ESSENTIAL HEALTHCARE PERSONNEL SCREENING LOG reflected the following, which is not an all-inclusive list: 5/1/2020: Two employees left the column for symptom reporting blank/unanswered. 5/2/2020: One employee left the column for symptom reporting blank/unanswered. 5/3/2020: Two employees left the column for symptom reporting blank/unanswered. 5/4/2020: Four employees left the column for symptom reporting blank/unanswered. 5/5/2020: Six employees left the column for symptom reporting blank/unanswered. One additional employee only recorded their temperature. 5/6/2020: Two employees left the column for symptom reporting blank/unanswered. One additional employee only recorded their temperature. Two undated entries on the log for 5/6/2020 and 5/7/2020 did not have a name or temperature recorded 5/8/2020: Two employees only had their temperature recorded. On 5/8/2020, the log changed to reflect a fever was a temperature >100.0 degrees Fahrenheit 5/12/2020: One employee only had their temperature recorded. 5/14/2020: One employee did not have responses for any screening questions or a temperature recording. Two undated entries on the log dated 5/17/2020 only had temperature recordings. The log also reflected incomplete employee screening on 5/19/2020 and 5/20/2020. Review of the CDC's Preparing for COVID-19 in Nursing Homes, reflected Evaluate and Manage Healthcare Personnel .Screen all HCP (Healthcare Personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 .Fever is either measured temperature >100.0 F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed or taking certain medications (e.g., NSAIDs) .HCP who work in multiple locations may pose higher risk and should be encouraged to tell facilities if they have had exposure to other facilities with recognized COVID-19 cases. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html) According to the CDC, People with COVID-19 have had a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: -fever or chills -cough -shortness of breath or difficulty breathing -fatigue -muscle or body aches -headache -new loss of taste or smell -sore throat -congestion or runny nose -nausea or vomiting -diarrhea (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) During a phone interview on 5/27/2020 at 12:11 PM, Director of Nursing (DON) B and Infection Control Nurse (IC) D, reported that during the employee screening process, a nurse was signing off on a series of questions and that they did check. They reported staff was being screened for any respiratory issues and fever. If there were abnormal findings, the nursing manager, Infection Control Nurse and possibly the DON were notified. When asked if it was documented on the screening tool if a nurse manager was notified, they reported that each screening tool was signed off by a Registered Nurse (RN), the DON, IC D or a nurse manager. They signed off that the nurse doing the screening knew what to call a manager for, if that nurse was concerned about anything. They reported the nurse doing the screening was signing off after each person was screened. During the same interview DON B and IC D, were asked what the expectation of staff was when completing the screening form. They reported that the nurse took the temperature, and staff wrote the temperature in with the nurse there. It was reported by DON B and IC D that if staff had any symptoms, they were expected to put those symptoms down (on the screening form). When asked if it was the expectation that the staff filled out all columns on the screening form, they responded that either the staff filled them out or the nurse asked the question and filled them out.

Based on observation, interview and record review, the facility failed to provide a safe environment and prevent a serious injury in 1 (Resident #1) of 3 residents reviewed for supervision and safety, resulting in a finger laceration requiring emergency care involving 10 sutures. Findings include: On [DATE], at 11:00 AM, a review of Resident #1's electronic medical record revealed an admission on [DATE] with a readmission on [DATE] with the following [DIAGNOSES REDACTED]. Resident #1 required extensive assistance with Activities of Daily Living (ADL's) and had severely impaired cognition. Resident expired on [DATE] in the facility. A review of Resident #1's care plan revealed, Focus . I have an ADL self-care performance deficit r/t (related to) Activity intolerance, confusion, dementia . Interventions . I have a knitted item in my closet at the top that I like holding. Ensure that I have this, it allow me to keep my hands busy . date initiated [DATE]. A review of Resident #1's Emergency/Urgent Care . [DATE] 10:35 . Ext: dry blood noted on hand; difficult to pry hand open, but upon opening, revealed degloving type injury at base of the right finger over the palmar surface. No obvious arterial injury noted . tendon visible. macerated appearing. Description/repair . Laceration 3 cm (centimeter) in length. Hand: Right, palmer. Shape: irregular . Skin closure: #10 sutures. Interrupted technique. One ,[DATE] deep [MEDICATION NAME]: Nine superficial ,[DATE] Nylon. Complexity; 2 layers . total time 45 minutes. On [DATE], at 1:00 PM, a record review of the facility Incident/Accident Report dated [DATE] . Time of incident/accident 0530 AM revealed Resident #1 had open area to third digit of R (right) Hand . non-verbal resident d/t (do to) diagnosed Dementia and Alzheimer's. A handwritten statement by Nurse C revealed the following, The CNA (certified nursing aide) immediately grabbed my attention to assess (the residents) right hand. He had blood over his hand and had blood on his gown. After I was to get his fingers to open up, was able to see his 3rd digit opened up with what appears to have missing skin and tissue. A second hand written statement by Nurse D revealed, Upon assessment I noted a quarter size opening on the interior third digit and the base of the finger with skin layers and tissue removed and bone visual through opening . I reassessed scene and noted blood on the far left side of the bedside table across the top of it and on the rear of it at the top. The 5 Day dated [DATE] revealed There was no blood noted on the bed frame or call light. However, blood was discovered on the far left side of the bedside table and on the rear of the bedside in the area of the adjustment control handle. Inspection of the bedside table revealed that there was a sharp edge noted where the blood was discovered . This particular bedside (table) was one the older tables in the building. It was removed and discarded. On [DATE], at 4:30 PM, The Administrator A was asked for the preventive maintenance logs for medical equipment and the Administrator A responded, We don't have one for that. The Administrator A was asked to provide manufactures recommendations on maintenance of the bedside tables used in the facility. On [DATE], at 9:30 AM, The Director of Nursing (DON) B was asked to provide the facility accident policy and a medical equipment maintenance policy. The DON B provided the Fall Management policy but no other policy and the DON B stated, That's all I have. The DON B was asked to provide all the emergency/hospital records for Resident #1's visit to theER on [DATE] and for a copy of Resident #1's incident report from that day. On [DATE], at 11:40 AM, The DON B once again was asked to provide the incident report for Resident #1 and the DON B offered an incomplete report. The DON was asked for the missing 3rd page of the incident report and the DON B at that time printed off the SBAR report that was missing and provided it. The DON B provided the Discharge Summary for Resident # 1's visit to the hospital on [DATE] and did not offer the entire visit summary. The DON B was questioned again for the entire ER visit summary and the DON B then provided the Emergency/Urgent Care hospital report. During this interview, the DON B stated that Resident #1 was a grabber. (the resident) would grab and hold onto things. On [DATE], 1:00 PM, along with the Administrator A, a record review of Maxwell(NAME)Overbed Table assembly & operating instructions revealed, Inspect the product for damage before each use. The Administrator A responded we do ambassadors check from floor to ceiling. If something is broke, they get rid of it. It was an older bedside table. The Administrator A was asked to explain what the Family Dining room was used for (this was a small private room in the hall near the rehab unit.) The Administrator A stated anybody can use it whenever. Yes. It's kept open and available. The Administrator A was asked why the carpet had a 1 and ½ inch raised area approximately 5 inches wide running along the entire room and would he think that was a trip hazard and the Administrator A stated, We are replacing that next week. The Administrator A was also asked why the window frame was manipulated and had 7 areas of sharp/rough areas exposed for anybody to touch and possible cut themselves on and the Administrator A stated, Maintenance will fix the window jam today. On [DATE], at 2:00 PM, a review of the facility policy Fall Management revision date: (MONTH) (YEAR) revealed, Policy the facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .

This citation pertains to intakes: MI 198, and MI 361 Based on interviews and record reviews, the facility failed to ensure two of two residents (#202, #212) reviewed for medication administration, from a total sample of 12, received their medications as prescribed by the Physician, resulting in resident #202 receiving insulin and other medications that was not prescribed for her on one occurrence, and resident #212 not receiving her insulin for 31 days, ultimately requiring hospitalization for uncontrollable high blood sugars and behavior changes. Findings include: Resident #202: According to the medical record review, conducted on 8/15/16, R#202 was re-admitted to the facility on [DATE] with multiple diagnoses that include [MEDICAL CONDITION] and [MEDICAL CONDITION]. There was no [DIAGNOSES REDACTED]. R#202's cognition score was 15/15. A review of the Medication Administration Record [REDACTED]., [MEDICATION NAME] 25 mg ER, and [MEDICATION NAME] aerosol puffer 5 mcg at 11:00 p.m. A review of the nursing notes and physician progress notes [REDACTED]. During an observation and interview with R#202 on 8/15/16 at 9:40 a.m., and again at 11:30 a.m., the resident did not voice any complaints regarding staffing or medication administrations. R#202 could not recall if she received an insulin injection, and did not recall any unusual side effects after receiving medications. During an interview with the Administration on 8/15/16 at noon, she said that she was aware that R#202 had accidently received her roommates medications on 7/29/16, during the p.m. shift, but could not elaborate further. The Administrator said the former DON (Director of Nursing) was suppose to investigate the incident and write up the nurse who made the medication error. However, the DON had recently quit and took all the paperwork regarding that incident with her, and no information is available at this time. During an interview with the current DON on 8/16/16 at 4:30 p.m., he said was aware that R#202 had accidently received her roommate's medication on 7/29/16, p.m. shift, which included insulin and an antihypertensive drug. The medication error was made by License Practical Nurse (LPN 'G'). The current DON could not provide any additional information because the file/paperwork regarding the incident could not be found. The current DON said he went through all the former DON's paperwork, investigations, and files, and could not locate the incident report. During an interview with LPN 'G' on 8/16/16 at 5:00 p.m., she said that on 7/29/16 at approximately 9:00 p.m., only one resident was in the room, and only one set of medications was in the cart for that room. LPN 'G' said that she gave R#202 her roommates medications by accident because, R#202 was a new admit that evening and her medications had not arrived from the pharmacy. R#202's roommate was out of the room, and she confused the two residents, mistaking R#202 for her roommate. LPN 'G' said that she did not check or ask the resident to identify herself, nor did she check the resident's wristband to confirm identification. LPN 'G' said that later on in the evening when she was reviewed R#202's admission orders [REDACTED]. LPN 'G' said that she immediately assessed R#202 and checked her blood sugar, which was normal. She said she wrote a note to the former ADON, and put it in her (ADON) mailbox. LPN 'G' said she continued to monitor the resident's blood sugar, but did not document it because she was not sure of the protocol. LPN 'G' could not recall if she called the physician or the family. On 8/16/16 at 5:15 p.m., LPN 'G' provided a copy of the note she gave to the former Assistant DON dated 7/29/16, which read as follows: 'R#202 was accidently given her roommates medications on 7/29/16; [MEDICATION NAME] 10 mg, Atorvastin 40 mg., [MEDICATION NAME] 10 mg., [MEDICATION NAME] 400 mg., Insulin [MEDICATION NAME] 10 units SQ., [MEDICATION NAME] 100 mg., [MEDICATION NAME] 8 mg., [MEDICATION NAME] 20 mg, Suboxon 2 - 0.5 mg., and [MEDICATION NAME] 12.5 mg.' Resident #212: According to the medical record, reviewed on 8/15/16, R#212 admitted to the facility on [DATE] with multiple diagnoses that included kidney disease and insulin-dependent diabetes. A review of the hospital's transfer orders revealed multiple medication prescriptions that included [MEDICATION NAME] 70/30 Insulin 25 units SQ twice a day. A review of the resident's MARs from 5/29/16 through 7/4/16 indicated no insulin had ever been prescribed or administered to R#212. According to the nursing notes written by Registered Nurse (RN) 'H', dated 7/4/16 at 11:54 a.m., the resident's daughter came in and asked about the resident's blood sugar levels and insulin injections. A review of the resident's medication record revealed no prescription or administration of insulin. However, the hospital transfer orders revealed insulin orders, but they were not found on the facility's orders. R#212's blood sugar was checked and indicated 'HI', no number registered. The Physician was notified and insulin was prescribed as follows; [MEDICATION NAME] R 25 units SQ now, and [MEDICATION NAME] 70/30 25 units SQ twice a day. During an interview on 8/15/16 at 2:10 p.m., RN 'H' said that on 7/4/16 around noon it was discovered that R#212's insulin prescription had never been ordered by the facility's admitting Physician. The resident's transfer orders from the hospital had prescribed the insulin, but it was never ordered at the facility's physician. R#212 had been without insulin or blood sugar monitoring for over a month. RN 'H' said when she checked the resident's blood sugar on 7/4/16, it was so high that the accucheck (blood sugar monitoring device) could not even give a number. The accucheck would only read 'HI'. RN 'H' said that the resident's blood sugar continued to read in the 500's for the next couple days. (Normal blood sugar range is: 70 - 140). After several days R#212 had to be transferred out to the hospital because the blood sugar could not be controlled in the facility, and she was exhibiting aggression and behaviors that were not normal for her. A review of the resident's MAR for 7/2016 revealed the following blood sugar readings: 7/4/16 at 4:30 p.m. = 567, at 9:00 p.m. = 542. Readings on 7/5/16, 7/6/16 were left blank. Blood sugar readings for 7/7/16 at 7:00 a.m. = 504, and at 11:30 a.m. = 600. Blood sugar readings for 7/8/16 was blank. According to the physician's progress notes dated 7/9/16, the resident was transferred to the hospital for severe high blood sugars and behavior changes. According to the hospital records dated 7/9/16, R#212 was admitted to the hospital for severely high blood sugars, over 700, and aggressive behaviors. The hospital physician's notes reads as follows;' she (R#212) was not placed on insulin while at the Long term care facility, she (R#212) was suppose to receive [MEDICATION NAME] Insulin 70/30 25 units SQ twice a day. During an interview with the current DON and Administrator on 8/15/16 at noon, they said they were aware that R#212 had not received her insulin prescription for over 30 days in June of 2016. The Administrator said they realized they were 'out of compliance' at that time, and had completed some training and auditing to educate staff. However, there was no documentation to support that all licensed staff was educated, or that medication administration audits were conducted with regards to the 'past non-compliance' of medication errors. ( )

This citation pertains to intake #MI 450. Based on interview and record review the facility failed to implement adequate, appropriate and timely interventions for prevention and treatment of [REDACTED].#501) of three resident's reviewed for pressure sores from a total sample of four resulting in the development and/or worsening of a pressure sore. Findings include: On 7/15/16 upon review of a complaint filed on behalf of Resident #501, the complainant indicated that Resident #501 was not turned and repositioned every (q) 2 hours as ordered by the physician. On 7/18/16 at 10:00 a.m., record review revealed that Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident cognition was intact and required extensive, one person assistance with bed mobility. The Admission Nursing Assessment dated 6/10/16 documented that Resident #501 had an unstageable pressure sore (Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) on the sacrum (area above the buttocks). A Nursing Alteration in Skin Integrity Care Plan dated 6/10/16 had only two preventative interventions, Turn and Reposition q 2 hours. Encourage oral intake at meals. The Braden Scale for Predicting Pressure Sore Risk dated 6/13/16 documented Resident #501's risk score at 15 =(a score of 15-18 patient At risk). A weekly Skin-Head to Toe Skin Check dated 6/13/16 documented that Resident #501's Sacrum wound had Eschar (tan, brown or black dead tissue). Review of the Skin Integrity Care Plan revealed no new interventions to prevent the worsening of the Sacral pressure sore. The physician's orders [REDACTED]. The Nutritional Data Collection assessment dated [DATE] documented that #Resident #501 has had a gradual weight loss and decrease oral intake. A weekly Skin-Head to Toe Skin Check dated 6/20/16 documented that Resident #501's Right Buttock (Sacrum) had a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Review of the Skin Integrity Care Plan revealed no new interventions to prevent the worsening of the Sacral pressure sore. A wound care note dated 6/20/16 documented, The Sacral wound was thoroughly cleansed .No discharge. No drainage. Just a foul odor associated with the putrefying (to rot or decay) eschar .It measures 11 centimeters (cm) x 9 cm . Review of the Skin Integrity Care Plan revealed no new interventions to prevent the worsening of the Sacral pressure sore. A physician's progress note dated 6/27/16 documented, He has a sacrum wound, which is fairly severe. We need to make sure that he is being turned frequently . The Treatment Administration Record (TAR) for Resident #501 for the months of June and July 2016 were reviewed. The review revealed an entry Turn and Reposition q 2 hours every shift. The entry was to be signed out by the nursing staff as being completed each shift. The TAR revealed 37 out of 62 shifts were not signed out as task (turn and reposition q 2 hours) being completed. On 7/18/16 at 11:45 a.m., the Director of Nursing (DON) was interviewed regarding the pressure sore and interventions for Resident #501. The DON said that the nurses have been told not to stage pressure sores. The DON said she was not aware why a loss air loss mattress or any other interventions were put into place to prevent the worsening of the pressure sore. The TAR's for June and July 2016 were reviewed with the DON at this time. The DON was asked how she could ensure (by looking at the TARS) that Resident #501 was turned and repositioned every 2 hours to which she responded, I have always told the nurses, if it's not documented, it's not done. On 7/18/16 at 12:35 p.m., the Unit Manager/Wound Care Nurse (Nurse A) was interviewed via the phone. Nurse A, who indicated that he was familiar with Resident #501, was asked why no new pressure relieving interventions were implemented to prevent the worsening of Resident #501's sacral pressure sore. Nurse A stated, We had talked about putting a pressure relieving mattress into place, but he was at risk for falls, so we didn't. Review of the document titled Fall Risk dated 6/13/16 documented a fall risk score for Resident #501 as 5 Fall Risk Category-Low Risk. On 7/18/16 at 3:10 p.m., review of the facility's policy titled, Skin Management dated August 2012 documented, .The nurse will assure Treatments, Interventions Care Plans, and the appropriate skin documentation's records are initiated in a timely manor according to practice guidelines. ( )

Based on observation, interview, and record review, the facility failed to prevent mistreatment and neglect of one sampled resident (#611) out of 19 sampled residents reviewed for abuse, resulting in emotional harm, mental anguish and lack of appropriate care and services. Findings include: On 5/1/16 at 11:45 AM, during the initial tour of the facility, resident #611 revealed that the facility staff has been verbally abusive towards her. Resident #611 stated I have [MEDICAL CONDITION] and has left side paralysis, I require set up for meals, and needs assistance with my care. When I request for morning wash up my aides will tell me every morning that they don't have time in the morning, you require too much help, nobody wants to work with you because you make too much demands, we don't like you, you are too picky. My aides will set my meal trays very far from my reach, will refuse to cut my food, making it difficult for me to reach my food tray and they will come in and pick up my meal even when I inform them that it was not accessible and that I have not eaten. Resident #611 indicated that she has reported to the nurse's, unit manager, and social worker all the verbal torture my aides verbalize towards me. Resident #611 further stated the way they talk to me makes me feel so bad and sorry for myself and I will not ask for help again, I will stay here and that's it. On 5/1/16 at 1:25 PM, during an interview with Resident #611's sister at the facility, she stated I want to tell you that the facility staff are very unprofessional. The first day my sister was admitted at this facility, she was left unattended all day from morning until late evening when her son came to the facility to ask why facility will not acknowledge his mothers presence at the facility. My sister requires set up for her meals but they always place her meals out of reach and will not cut food to small pieces for easy chewing. My sister likes to wash her hands before and after meals and none of the staff here will do that for her. The staff didn't care to set up the styrophone cup with a handle so that she can use the cup to drink. The Residents sister reported you see, one of the aides told my sister that she is too picky and that is why nobody likes her. The Residents sister indicated that on 4/27/16 during breakfast time, that she reported an incident to the nurse when my sister requested staff set her food up and was told you can set it up yourself and my sister turned the light on for another assistant, fell asleep and woke up with her food gone. On 5/2/16 at 1:30 PM, during an interview with Resident #611 she stated the aide that worked with me today (CNA #A) told me that nobody wants to work with me, she had an attitude, refused to dry me up during care and left me very wet. Resident #611 further stated When I asked the aide to wash up my face with my toilet soap that I have used for years, she told me we are not allowed and when I pleaded with her, she told me nobody wants to work with you because you are always making demands and using your call light. At the time of the interview resident #611 was observed in tears and very distressed and she stated I give up I am not going to ask them anymore. On 5/2/16 at 1:35 PM, during an interview with nurse '#Y' on the 100 unit taking care of Resident #611, she revealed when asked where the certified nursing assistant CNA '#A' that took care of Resident #611 was, she replied to be honest with you I don't know where she is. At about 1: 40 PM, nurse '#Y', indicated that the CNA '#A' went out for lunch and will be back at 2PM. On 5/2/16 at 1:58 PM, in an interview with the facility administrator, she revealed I have verified all your concerns regarding my staff treatment of [REDACTED]. Resident #611 told me herself. CNA '#A' was prescheduled to leave at 1:30 PM today. During an interview on 5/2/16 at 2:15 PM with Resident # 612 roommate to Resident #611, she stated This facility has gone down, I am a retired nurse, the aides here are very uncaring, with bad attitudes. They tell her she requires too much care. One day it was over 50 minutes with her light on, and they wouldn't come to help her. When I got here the social worker was giving my roommate a bed bath because there was no staff help at the facility on that day. On 5/2/16 at 4:20 AM, during an interview with the unit manager on the 100 unit, he indicated that on 4/27/16 while making rounds with the wound Doctor between breakfast and lunch that resident #611 stated that the staff are always rushing her daily care with specific preferences relating to her [MEDICAL CONDITION] disease condition, she is very particular about her washing up. The male unit manager stated I had a verbal 1:1 education with CNA #A. My perception was that it was a feasible moment to reinforce that she should take her time when performing care and not rush the resident when performing care to decrease the residents anxiety. During an interview on 5/2/16 at 4:30 PM, with the social service director (SWD), she indicated that on 4/22/16, that when she entered Resident #611's room, that she observed her call light was tied and put at the back of her bed and resident was unable to reach her light. The resident reported concerns regarding CNA #A and this CNA #A was gone for the day and wasn't here when it was reported. I filled out the concerns form and gave the concerns directly to the Director of Nurse's DON that day. My part is to talk to the resident, which I did and submitted the concern form to the DON on that same day. The (SWD) when queried if she went back to see the resident for follow up, stated I think I went back likely on Sunday the 24th. When asked about the documentation stated I did not document anything. On 5/2/16 at 4:45 PM, review of the concern form dated 4/22/16 from social work department documented Resident reported the resident care specialist (RCS) CNA#A that was assigned to her on 4/22/16 dayshift told her she was picky and that she does not like working with her. RCS left resident in her motorized wheelchair in a position where resident was unable to reach her control to wheelchair, she was no where near her call light, bedside table or water. Resident #611 reported she told RCS she needed to be repositioned so she could reach control of wheelchair and asked to move her bedside table so she could access it however the RCS did not. This writer, PT-Wanda and OT- Heather found resident. On 5/2/16 at 4:55 PM, review of the concern form-Action revealed that the DON failed to address the reported concern allegation of Resident #611 reported and sent to her on 4/22/16. The DON on 5/2/16, 10 days after the concern incident,documented spoke with RCS , stated she does not remember Intend to teach RCS re: attitude (perceived or otherwise) Respectful to all residents and attend to their needs as resident desires . This concern form action was not followed up with the Administrator and per administrator's interview on 5/2/16 at 5:02 PM, she indicated that she not made aware of the incident. Review of the staffing schedule dated 5/2/16 by the Unit male nurse manager on the 100 unit, revealed that the RCS CNA #A worked with the Resident #611 on 4/18/16, 4/21, 4/22, 4/25, 4/26, 4/27, 4/29, and 5/22/16. The Facility Resident Admission Record printed on 5/2/16 revealed that resident #611 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set resident Assessment , dated 4/22/16, revealed that resident #611 was cognitively intact having scored 15 of 15 on the Brief Interview for Mental status screening tool. Resident #611 requires extensive assistance and two plus persons physical assistance for bed mobility, transfer and personal hygiene. The residents comprehensive assessment CAA indicated that resident #611 requires staff assistance with activities of daily living ADL's, was a [MEDICAL CONDITION] with spastic (MS), has pain, complications of immobility, pressure ulcers, contractures, incontinence and depression. Review of the hospital discharge summary dated 4/5/16, revealed Resident #611 had a history of [REDACTED]. On 5/2/16 at 5:15 PM review of the plan of care initiated 4/19/16, revealed that Resident # 611 was dependent on staff for ADLS and mobility related to spastic [MEDICAL CONDITION] secondary to (MS) and [MEDICAL CONDITION]. Requires single handled sip cup for cold liquids and scooped edged plate for all meals to ease feeding tasks initiated 4/22/16. On 5/2/16 at 6:09 PM, review of the facility abuse policy revised June 2013, revealed that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, . Any observations or allegations of abuse, neglect . must be immediately reported to the Administrator and / or Director of Nursing , screen, identify, prevent, investigate, protect, and report abuse . At the survey exit, any additional information related to this citation was requested from staff and none was provided by time of exit. ( )

This citation has three deficient practices. Deficient Practice #1. Based on interview and record review the facility failed to provide pain medication in a timely manner for one sampled resident (#507) of 10 residents reviewed for pain, from a total sample of 19, resulting in the resident experiencing severe pain, crying, anxiety and frustration. Findings include: On [DATE] at 9:20 a.m., during the initial tour of the sub acute unit, observation was made of resident #507 laying in bed with a sheet partially covering the midsection. Resident #507's legs were extending out from under the sheet and bilateral surgical incision sites were noted on the tops of both knees. When interviewed regarding the care being provided by the facility, resident #507 stated, "They had a really rough time getting my pain under control without not being able to secure my pain medication. With my other medical conditions, experiencing pain just makes them worsen." The resident said that the nurse on the midnight shift on Saturday (the first night of admission into the facility) did not give the as needed pain (PRN) medication for "several hours" causing the resident to experience "severe pain and anxiety." On [DATE] at 11:00 a.m., record review revealed that resident #507 was admitted into the facility on [DATE] at approximately 4:15 p.m. with [DIAGNOSES REDACTED]. Resident #507's Admission Nursing assessment dated [DATE] indicated the resident's cognition was intact and required the assistance of two persons for transfers. The Admission Pain Evaluation dated [DATE], rated the residents pain as a "7" out of "10" (10 indicating the worst pain), "Pain primarily associated with bilateral Total Knee Replacements." Review of the Interim Plan of care for "Pain", dated [DATE] documented the following interventions; "Observe for signs/symptoms of verbal and non-verbal indicator of pain at each medication pass, and periodically. Provide medication as ordered and document effective results of medication administration. Notify Medical Doctor of unrelieved pain..." On [DATE] at 11:30 a.m., review of the signed admission physician orders [REDACTED]. The orders also documented the three following orders for [MEDICATION NAME] which could be administered as needed by the nursing staff: [MEDICATION NAME] 5 mg one tablet every 4 hours PRN for break through pain. [MEDICATION NAME] 5 mg two tablets every 4 hours PRN for mild/moderate pain. [MEDICATION NAME] 5 mg three tablets every 4 hours PRN for moderate/severe pain. On [DATE] at 11:45 a.m., review of a nurse's note dated [DATE] revealed that at 7:45 p.m., resident #507 received the routine dose of [MEDICATION NAME] 10 mg, and a PRN dose of [MEDICATION NAME] 5 mg. There was no documentation of these administered doses on the [DATE] Medication Administration Records (MAR). On [DATE] at 9:50 a.m., the Midnight Nurse, staff "S" was interviewed via the telephone regarding the pain medication administration for resident #507. Nurse "S" said that her shift started at 11:00 p.m. Nurse "S" stated "Because (resident #507) was just admitted into the facility earlier that day, we had no meds (medications) for her." The nurse said that the facility had a system where back up medications can be obtained. Nurse "S" stated she evaluated the resident some time during the early part of her shift and the resident "appeared in distress, had facial wincing, the voice was quivering, and described the pain as a 10 out of 10." The nurse said she attempted to obtain the pain medication from the back up system and discovered she did not have access to the back up system. Nurse "S" said she took care of some other patients and went over to the "long-term" unit to see if any of her fell ow nurses on duty had access to the back up system. Nurse "S" said the first nurse she asked, also did not have access to the back up system and had to go find a third nurse, who eventually did have access to the pain medication. Nurse "S" stated, "This is my greatest frustration is access to the back up system. I feel helpless and frustrated. (Resident #507) waited longer than she needed to for the pain medication." On [DATE] at 10:00 a.m., review of the document titled (Back Up System) Activity Report, dated [DATE] documented that resident #507's [MEDICATION NAME] was signed out at 2:38 a.m. and signed out on the MAR indicated [REDACTED]. On [DATE] at 10:40 a.m., during an interview with assigned Certified Nurse Assistant (CNA), CNA "T", she said that she responded to the resident's call light on [DATE] around 11:45 p.m. CNA "T" said the resident was requesting pain medication and ice packs for the knees. The CNA stated, "I could tell the resident was in severe pain. The resident's voice was shaking and was crying and frustrated. I reported it to the nurse." On [DATE] at 11:45 a.m., record review revealed a nurses note written by Staff Nurse "U" dated [DATE] at 8:00 a.m., documenting "Resident is alert and oriented x 4 and able to voice all wants and needs. As soon as writer approached resident, resident 'burst into tears and is sorry for being emotional, but I had a terrible night last night. I'm in so much pain.'...Resident said she had a really rough time getting pain under control without not being able to receive pain meds last night. Resident became very tearful and anxious." At 11:50 a.m., Nurse "U" was interviewed regarding the incident with resident #507 and stated "I got in report from the midnight nurse that the resident was in a lot of pain and that the pain medications took a long time to get to the resident. I went in to see the resident right away. You could tell the resident was is severe pain because of the clenching of the teeth, and describing the pain as a 10 out of 10." On [DATE] at 12:10 p.m., the Director of Nursing (DON) was queried regarding the facility's policy on pain management. The DON said that this was an isolated incident and that the previous Unit Manager only gave some staff nurses "temporary access" to the back up system, which had expired. She indicated that that the Unit Manger no longer works for the facility and that all nurses will have access to the back up system upon hire. On [DATE] at 9:50 a.m., review of the facility's policy titled "Pain Management" with a revision dated of ,[DATE], documented; "The facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to impaired quality of life. The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause(s); determine the type and severity of the pain; and develop a Care Plan for pain managment...The Licensed Nurse will implement a Medication Administration Record [REDACTED] At that same time the facility's policy titled "Emergency Medication Supplies" dated [DATE], documented "...once facility staff receives the completed written authorization release from the Pharmacy, Facility staff may access the medically necessary controlled substance from the Facility's Emergency Medication Supply." ( ) Deficient practice #2: Based on observation, interview, and record review, the facility failed to administer the prescribed dosage of Aspirin (for the heart) for one (#18) supplemental sampled residents, resulting in the potential for compromise in cardiac status. Findings include: On [DATE] at 9:40 AM, Nurse 'I' was observed preparing medications for resident #18. The nurse poured "one" 81 milligram (mg) Aspirin tablet into a medication cup and administered it to the resident. At 10:20 AM, resident #81's clinical record was reviewed and the medications were reconciled with the Staff Development Director. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was prescribed Aspirin 81 mg, "give four tablets" daily. At 10:25 AM, as the error was being discussed with the Staff Development Director, Nurse 'I' approached, overheard the conversation, and asked, "What did I do?" She looked at the Aspirin order and said, "I gave him (the resident) one" then re-read the order and said, "I should have given four." On [DATE] at 2 PM, per review of the facility's "General Dose Preparation and Medication Administration" policy dated [DATE]: "Facility staff should verify that the medication name and dose are correct...." ( ) Deficient practice #3. Based on observation, interview and record review, the facility failed to maintain documented evidence that care and services were provided by hospice nurse aides for two (#512 and #516) of three sampled Residents reviewed for hospice care services from a total of 19, resulting in lack of written communication regarding hospice care, and the potential for unmet resident care needs. Findings include: On [DATE] at 12:25 p.m., record review revealed that resident #512 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted into Hospice Services on [DATE]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the Resident's cognition was severely impaired and required total assistance from staff for all activities of daily living. On [DATE] at 12:40 p.m., record review revealed documents titled "Care Coordination Note" from the hospice Chaplain, the hospice Social Worker, and the hospice Nurse. The "Care Coordination Note" included issues address at the visit, interventions provided and plan for the resident. There was a handwritten note in the front of the chart that documented; "Hospice Aide will be here Wednesdays at 10 a.m., and Fridays around 3:30 p.m." There was no "Care Coordination Note" from the hospice Certified Nurse Assistant (CNA). On [DATE] at 11:20 a.m., the Nurse Case Manager for Hospice, Nurse "Y" was queried regarding the communication between the Hospice provider and the facility. Nurse "Y" stated, "the Certified Nurse Assistant (CNA) fill out the skin audit form and specifies what they found, and gives a verbal report to the nurse on any concerns found. That is the way the facility wants us to do it." On [DATE] at 11:45 a.m., the document titled "Resident Skin Audit" sheet, dated 2014 with "Hospice" written across the top was blank. At this same time the Unit Manger Nurse "V" was queried about the communication with the hospice CNA's. Nurse "V" said the hospice CNA comes in the facility once or twice a week and verbally communicates any abnormal findings to the assigned staff nurse. On [DATE] at 12:30 p.m., Social Worker "E" provided progress notes (which she obtained via fax from the Hospice agency) documenting the Hospice CNA's visits dated [DATE], [DATE], [DATE], [DATE] and [DATE]. The progress notes dated [DATE] and [DATE] documented "Reddened Buttocks". The progress note from [DATE] documented "patient denies pain when asked, but makes facial grimacing when repositioned." On [DATE] at 1:30 p.m., the facility's document titled "Nursing Daily Skilled Summary" with corresponding dates with the hospice CNA visits, did not address the reddened buttocks. There was a note on [DATE] that addressed the residents pain, two days after the facial grimacing was noted by the hospice CNA. On [DATE] at 2:00 p.m., Resident #516 was interviewed regarding her stay at the facility and stated, "Things are good except I have a fever today and I ache all over." On [DATE] at 2:10 p.m., Resident #516's medical record was reviewed and revealed that the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was under hospice care. The Minimum Data Set Assessment, dated [DATE], revealed that the Resident's cognition was moderately impaired and required extensive assistance with most activities of daily living. On [DATE] at 1:50 p.m., Nurse "M" was queried regarding hospice services and how the hospice nursing assistants communicate with the facility and document care provided during visits. Nurse "M" stated, "When they come in the introduce themselves as a hospice aide. They provide the care then follow up with the nurse and certified nursing assistant (CNA) that the care is complete." When queried as to if there was documentation for the care Resident #516 received from the hospice CNA's, Nurse "M" stated, "Not with that hospice. The other hospice provides documentation and you have to sign off on it." On [DATE] at 1:55 p.m., the Director of Nursing (DON) was queried as to how hospice CNA's communicate with the facility and how that information is relayed to other shifts for Resident #516. The DON stated, "Communication would have to be verbal from shift to shift to shift. There is no documentation from the CNA's from that hospice group." On [DATE] at 2:00 p.m., review of the facility's policy titled "Referrals to Outside Agencies", dated [DATE], documented; "progress notes, prescriptions from the service provider are to be placed in the resident's clinical record...Recommendations for approaches or interventions should be communicated to the direct care staff." (,[DATE])

THIS CITATION PERTAINS TO INTAKE NUMBER MI 809. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING IN 1 OF 7 SAMPLED RESIDENTS (RESIDENT #103), SAMPLED FOR QUALITY OF CARE IN ADVANCE DIRECTIVES, FROM A TOTAL OF 12 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #103 WHEN FACILITY STAFF FAILED TO PERFORM CARDIOPULMONARY RESUSCITATION (CPR) ON RESIDENT #103, WHO WAS A FULL CODE, AFTER FINDING HER IN BED, UNRESPONSIVE, WITH NO PULSE AND NO RESPIRATIONS. RESIDENT #103 WAS PRONOUNCED DEAD ON [DATE] AT 5:55 P.M. THIS DEFICIENT PRACTICE PLACED ALL RESIDENTS AT RISK FOR SERIOUS HARM AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #103 ACCORDING TO THE FACE SHEET, DATED [DATE], RESIDENT #103 WAS A [AGE] year OLD FEMALE, WHO LIVED AT THE FACILITY FROM [DATE] UNTIL HER DEATH ON [DATE]. IN AN INTERVIEW ON [DATE] AT 2:00 P.M., THE DIRECTOR OF NURSING (DON) #1 SAID A MINIMUM DATA SET WAS NOT AVAILABLE FOR RESIDENT #103 DUE TO HER SHORT LENGTH OF STAY. REVIEW OF THE physician progress notes [REDACTED]. RESIDENT #103'S ADMISSION [DIAGNOSES REDACTED]. REVIEW OF THE HOSPITAL TRANSFER PAPERS, DATED [DATE], WHICH WAS RESIDENT #103'S DATE OF ADMISSION TO THE FACILITY, REVEALED RESIDENT #103'S DOCUMENTED END-OF-LIFE WISHES WERE "FULL RESUSCITATION (CPR)" IN THE EVENT HER HEART WAS TO STOP OR HER BREATHING WAS TO CEASE. REVIEW OF RESIDENT #103'S FACILITY MEDICAL RECORD REVEALED THERE WAS NO DOCUMENTATION REGARDING AN END-OF LIFE DISCUSSION OR THAT ANY CHANGES WERE MADE WITH RESIDENT #103 REGARDING HER CODE STATUS. IN AN INTERVIEW ON [DATE] AT 2:30 P.M., SOCIAL WORKER (SW) #1 SAID HER DEPARTMENT WAS RESPONSIBLE FOR ADDRESSING THE END-OF-LIFE WISHES WITH RESIDENT #103 UPON ADMISSION TO THE FACILITY. SW #1 REVIEWED RESIDENT #103'S MEDICAL RECORD FOR EVIDENCE THAT RESIDENT #103'S END-OF-LIFE WISHES WERE ADDRESSED BY HER DEPARTMENT. SW #1 REPORTED THAT PRIOR TO RESIDENT #103'S DEATH ON [DATE], SOCIAL SERVICE STAFF DID NOT DISCUSS OR CHANGE END-OF-LIFE CHOICES WITH HER. SW #1 SAID RESIDENT #103 REMAINED A FULL CODE ON [DATE] AT 5:55 A.M., WHEN STAFF FOUND HER UNRESPONSIVE WITHOUT A PULSE OR RESPIRATIONS. IN AN INTERVIEW ON [DATE] AT 10:30 A.M., DON #1 STATED WHEN STAFF FOUND RESIDENT #103 UNRESPONSIVE, WITHOUT A HEART BEAT OR RESPIRATIONS ON [DATE] AT 5:55 A.M., RESIDENT #103 WAS "A FULL CODE". DON #1 STATED THAT, IN ORDER TO MEET RESIDENT #103'S END-OF-LIFE WISHES AND IN ACCORDANCE WITH THE BASIC STANDARDS OF PRACTICE FOR A FULL CODE, FACILITY STAFF SHOULD HAVE INITIATED CPR IMMEDIATELY. ACCORDING TO NURSE'S NOTES, DATED [DATE] AT 6:30 A.M., LICENSED PRACTICAL NURSE (LPN) #1 ASSESSED RESIDENT #103 AT 2:00 A.M. LPN #1 FOUND THE RESIDENT AWAKE, ALERT AND ORIENTED WITH A BLOOD PRESSURE OF ,[DATE] (NORMAL LESS THAN ,[DATE]), A HEART RATE OF 82 (NORMAL ,[DATE]), AND RESPIRATIONS OF 24 (NORMAL). A NURSE'S NOTE REVEALED AT 4:30 A.M. ON [DATE], RESIDENT #103 WAS SEEN BY CERTIFIED NURSING ASSISTANT (CNA) #1, WHO REPORTED NO SIGNS OF DISTRESS WERE PRESENT AND RESIDENT #103 SPOKE CLEARLY WITHOUT COMPLAINTS. REVIEW OF THE NURSE'S NOTE, DATED [DATE] AT 5:55 A.M., REVEALED LPN #1 ENTERED RESIDENT #103'S ROOM ON ROUNDS AND FOUND RESIDENT #103 " ...EXPIRED ...". THIS SURVEYOR ATTEMPTED TO INTERVIEW LPN #1 VIA TELEPHONE ON [DATE], [DATE], AND [DATE]. AS OF THE SURVEY EXIT ON [DATE], THERE HAS BEEN NO RESPONSE FROM LPN #1. IN AN INTERVIEW ON [DATE] AT 11:45 A.M., REGISTERED NURSE (RN) #1 STATED THAT SHE WAS THE CHARGE NURSE ON [DATE] AT APPROXIMATELY 6:00 A.M., WHEN LPN #1 ASKED HER TO LOOK AT RESIDENT #103. RN #1 SAID SHE WENT DIRECTLY TO RESIDENT #103'S ROOM AND FOUND THAT RESIDENT #103 HAD NO DETECTABLE HEARTBEAT OR RESPIRATIONS. RN #1 SAID, DESPITE KNOWING RESIDENT #103 WAS A FULL CODE WHEN SHE WAS ASSESSED ON [DATE] AT 5:55 A.M., FACILITY STAFF DID NOT INITIATE CPR OR EMERGENCY MEDICAL CARE. RN #1 SAID "I PRONOUNCED HER DEAD BECAUSE FACILITY POLICY DOES NOT PERMIT RESUSCITATION IF A RESIDENT'S DEATH IS UNWITNESSED". RN #1 SAID SHE WAS UNAWARE OF HOW LONG RESIDENT #103 WAS WITHOUT A PULSE OR RESPIRATIONS WHEN STAFF FOUND HER AT 5:55 A.M., OR IF RESIDENT #103 COULD HAVE BEEN SUCCESSFULLY REVIVED WITH STAFF INTERVENTION (CPR). A REVIEW OF THE FACILITY'S "DEATH OF A RESIDENT" POLICY, DATED [DATE], REVEALED, "WHEN A RESIDENT IS FOUND TO BE WITHOUT HEARTBEAT OR RESPIRATIONS THE NURSE ON DUTY IDENTIFIES THE CODE STATUS. IF THE RESIDENT IS 'FULL CODE' STATUS, CPR IS STARTED AND EMERGENCY 911 SERVICES ARE ACTIVATED." IN AN INTERVIEW ON [DATE] AT 2:00 P.M., DON #1 STATED BOTH LPN #1 AND RN #1 FAILED TO MEET FACILITY POLICY, NURSING STANDARDS OF PRACTICE, AND RESIDENT #103'S END-OF-LIFE WISHES ON [DATE] AT 5:55 A.M. WHEN THEY FOUND HER WITH NO A PULSE AND NO RESPIRATIONS AND DID NOT INITIATE CPR OR EMERGENCY MEDICAL SERVICES. DON #1 STATED, "I HAVE A LOT OF WORK TO DO AND CHANGING A FORM THAT SUGGESTED DEATHS MUST BE WITNESSED TO INITIATE CPR OR EMERGENCY CARE IS ALREADY BEING ADDRESSED". IN AN INTERVIEW ON [DATE] AT 3:00 P.M., ADMINISTRATOR #1 STATED THE QUALITY ASSURANCE TEAM FOUND A DEFICIENT PRACTICE WHEN STAFF FAILED TO INITIATE CPR AND EMERGENCY MEDICAL CARE TO RESIDENT #103 WHEN SHE WAS FOUND WITH NO PULSE AND NO RESPIRATIONS ON [DATE] AT 5:55 P.M. ON [DATE] AT 4:30 P.M., ADMINISTRATOR #1 WAS NOTIFIED OF AN IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON [DATE] AND BEGAN ON [DATE] AT 5:55 A.M., WHEN FACILITY STAFF FAILED TO PERFORM CARDIOPULMONARY RESUSCITATION (CPR) ON RESIDENT #103, WHO WAS A FULL CODE, AFTER FINDING HER IN BED, UNRESPONSIVE, WITH NO PULSE AND NO RESPIRATIONS. RESIDENT #103 WAS PRONOUNCED DEAD ON [DATE] AT 5:55 P.M. ON [DATE], THIS SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1.) ON ,[DATE], THE FACILITY COMPLETED A 100% CHART REVIEW OF ALL RESIDENTS TO ESTABLISH END-OF-LIFE DECISIONS AND ESTABLISH THE POTENTIAL NUMBER OF RESIDENTS AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. 43 OF 84 RESIDENTS WERE IDENTIFIED AS HAVING A FULL CODE STATUS. 2.) ON [DATE], LICENSED NURSING STAFF VERIFIED THAT ALL MEDICAL RECORDS WERE CLEARLY MARKED TO IDENTIFY A RESIDENT'S CODE STATUS. 3.) BEGINNING ON [DATE], 26 OF 43 LICENSED STAFF WERE EDUCATED ON THE FOLLOWING BY THE STAFF DEVELOPMENT COORDINATOR: A.) LICENSED FIRST RESPONDERS WILL RESUSCITATE THOSE RESIDENTS IDENTIFIED AS A FULL CODE, WHEN FOUND WITHOUT A HEARTBEAT AND/OR RESPIRATIONS. B.) ADDITIONAL STAFF, RESPONDING TO THE CODE, WILL ENSURE THAT EMERGENCY SERVICE PERSONNEL (911) ARE CALLED WHILE RESUSCITATION CONTINUES UNTIL THE RESIDENT IS RESUSCITATED OR EMERGENCY SERVICES PERSONNEL ASSUME THE RESIDENT'S CARE. C.) THE POLICY FOR ADVANCE DIRECTIVES. D.) THE POLICY FOR DEATH OF A RESIDENT. E.) DURING AN EMERGENT SITUATION, WHEN A RESIDENT IS FOUND WITHOUT A HEARTBEAT OR RESPIRATIONS, CPR WILL BE INITIATED BY LICENSED NURSING PERSONNEL. IN AN EMERGENT SITUATION, SUCH AS CHOKING OR A FALL, WHEN A RESIDENT'S ADVANCED DIRECTIVE IS "DO NOT RESUSCITATE", EMERGENCY MEASURES (I.E.: [MEDICATION NAME] MANEUVER) WILL BE PERFORMED. AS OF [DATE], 38 OF 43 LICENSED NURSES EMPLOYED AT THE FACILITY HAVE RECEIVED EDUCATION. THE REMAINING 5 LICENSED STAFF MEMBERS WILL NOT BE PERMITTED TO RETURN TO WORK UNTIL THIS EDUCATION IS RECEIVED. 4.) BEGINNING ON [DATE], UPON ADMISSION, ALL RESIDENTS OR THEIR RESPONSIBLE PARTY WILL BE INTERVIEWED BY THE SOCIAL SERVICE TEAM REGARDING THEIR WISHES FOR RESUSCITATION AND WILL DOCUMENT THEIR WISHES ON THE RESIDENT ACKNOWLEDGEMENT FORM. 5.) BEGINNING ON [DATE], THE PHYSICIAN WILL BE CONTACTED AND AN ORDER RECEIVED FOR THOSE RESIDENTS WHO REQUEST A "DO NOT RESUSCITATE" STATUS. THE ORDER WILL BE DOCUMENTED IN THE MEDICAL RECORD AND ON THE PLAN OF CARE. STAFF WILL ALSO DOCUMENT IN THE MEDICAL RECORD AND PLAN OF CARE THOSE RESIDENTS WHO WISH TO HAVE A FULL CODE STATUS. 6.) ON [DATE], THE QUALITY ASSESSMENT AND ASSURANCE COMMITTEE MET AND THE POLICY FOR THE "DEATH OF A RESIDENT " AND "ADVANCE DIRECTIVES" WERE DEEMED APPROPRIATE BY THE ADMINISTRATOR, DIRECTOR OF NURSING, PHYSICIAN AND ADDITIONAL INTERDISCIPLINARY MANAGERS. THE FORMER ADVANCED DIRECTIVE ELECTION FORM WAS REMOVED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF WIDESPREAD AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THEN MINIMAL HARM, THAT IS NOT IMMEDIATE JEOPARDY, DUE TO ALL STAFF HAD NOT BEEN EDUCATED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO MI 376 BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ASSESS AND PROVIDE ADEQUATE INTERVENTIONS AND SUPERVISION FOR ONE (#503) OF FOUR SAMPLED RESIDENTS AT RISK FOR FALLS FROM A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN RESIDENT #503 SUSTAINING AN INTRACRANIAL HEMORRHAGE FOLLOWING A FALL. FINDINGS INCLUDE: RECORD REVIEW ON [DATE] AT 1:00 P.M., REVEALED THAT RESIDENT #503 WAS AN [AGE] year OLD MALE WHO WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF DOCTOR'S PROGRESS NOTE DATED [DATE] REFLECTED THAT PRIOR TO THE RE-ADMISSION RESIDENT #503 HAD A RECENT LEFT HIP FRACTURE AND HAD ORIF (OPEN REDUCTION INTERNAL FIXATION) AT THE HOSPITAL. THE MDS ASSESSMENT (MINIMUM DATA SET) DATED [DATE] REVEALED THAT RESIDENT #503 REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, WAS ABLE TO EXPRESS IDEAS AND WANTS AND WAS USUALLY UNDERSTOOD, AND THAT THE resident had a history of [REDACTED]. RESIDENT #503 WAS deceased AT THE TIME OF THE UNANNOUNCED SURVEY INVESTIGATION. ACCORDING TO THE CLINICAL RECORD, THE RESIDENT WAS TRANSFERRED TO AN ACUTE CARE FACILITY ON [DATE]. ACCORDING TO THE AMBULANCE TRANSPORT SHEET DATED [DATE] REVEALED, "UPON ARRIVAL TO PATIENT AT 1447, THE FOLLOWING ASSESSMENT WAS COMPLETED. ARRIVE TO FIND [AGE] year OLD MALE PATIENT LYING SUPINE IN BED AT NURSING HOME, WITH A HEMATOMA OVER HIS LEFT EYE AND BRUISING ON HIS FOREHEAD. STAFF STATED THAT PATIENT HAD FALLEN 3 DAYS AGO OUT OF WHEELCHAIR AND SINCE HAD A FAILURE TO THRIVE..." THE HOSPITAL emergency room assessment dated [DATE] DOCUMENTED, "PATIENT HERE FOR (NURSING HOME) status [REDACTED]. PATIENT ARRIVES WITH RACCOON MARKING TO LEFT EYE. STAFF AT NURSING HOME BELIEVES HE HAS BEEN DECLINING SINCE THE FALL. RESIDENT #503 WAS DISORIENTED TO PERSON, TIME AND PLACE. " HOSPITAL TRAUMA PROGRESS NOTES DATED [DATE] DOCUMENTED, "INTRAVENTRICULAR BLEED, ECCHYMOSIS ON LUE, RUE, LEFT EYE, SMALL LACERATION OVER RIGHT EYE. MECHANISM OF INJURY: INTRAVENTRICULAR HEMORRHAGE FOLLOWING A FALL FROM SITTING." REVIEW OF HOSPITAL DISCHARGE SUMMARY [DATE] REVEALED "...HE WAS admitted TO THE TRAUMA SERVICE. NEUROSURGERY WAS CONSULTED, THEY RECOMMENDED NO OPERATIVE INTERVENTION. ..HE WAS discharged TO FACILITY ON [DATE]...CONDITION AT DISCHARGE COGNITIVE STATUS IMPAIRED, RESUSCITATION STATUS DO NOT RESUSCITATE." RESIDENT #503 RETURNED TO THE FACILITY FROM THE HOSPITAL ON [DATE]. ACCORDING TO DOCTOR'S PROGRESS NOTES DATED [DATE], "FAMILY IS MOST INTERESTED IN COMFORT CARE..." THE RESIDENT WAS PUT ON HOSPICE, AND PASSED AWAY ON [DATE] (NINE DAYS AFTER THE FALL). REVIEW OF THE CLINICAL RECORD REVEALED AN INCOMPLETE FALL RISK EVALUATION THAT WAS INITIATED ON [DATE] WITH A TOTAL SCORE OF 14 (A SCORE OF 10 OR ABOVE REPRESENTED A HIGH RISK FOR FALLS). THE EVALUATION WAS INCOMPLETE BECAUSE, ACCORDING TO THE FALL MANAGEMENT POLICY DATED AS REVISED IN FEBRUARY 2010, "FACILITIES WILL TAKE A PROACTIVE APPROACH FOR NEW RESIDENTS AND WILL CONSIDER NEW ADMISSIONS AT RISK FOR FALLS UNTIL THE RESIDENT IS REVIEWED BY THE IDT (INTERDISCIPLINARY TEAM). UPON ADMISSION, THE ADMITTING NURSE WILL COMPLETE THE FALL RISK ASSESSMENT AND THEN WEEKLY FOR 3 ADDITIONAL WEEKS . . . AND IMPLEMENT APPROPRIATE INTERVENTIONS AS IDENTIFIED." THE FALL RISK ASSESSMENT FOR RESIDENT #503 HAD THREE DOCUMENTED ENTRIES: 1) ON [DATE], 2) UNDATED, AND 3) ON [DATE]. EACH ASSESSMENT HAD A TOTAL SCORE OF 14. THE RESIDENT HAD SEVERAL FALLS DURING HIS STAY IN THE FACILITY AND THE FALL RISK EVALUATION WAS NOT UPDATED AFTER EACH FALL. REVIEW OF THE RESIDENT'S PLAN OF CARE FOR "FALLS" REVEALED THE FOLLOWING INTERVENTIONS: ON ADMISSION, THE RESIDENT WAS PLACED ON THE FALLING STAR PROGRAM. ON [DATE], A LOW BED WAS PROVIDED. UNDATED ENTRY, MATS WERE PLACED ON SIDE OF BED, AND BED AND CHAIR ALARMS WERE PLACED. ON [DATE], BILATERAL BOLSTERS WERE PLACED ON BED. FURTHER RECORD REVIEW REVEALED THAT RESIDENT #503 SUSTAINED A NUMBER OF FALLS. FALL #1 OCCURRED ON [DATE]. ACCORDING TO NURSES' NOTES AT 9:15, "PATIENT fell OUT OF BED DISCOVERED BY STAFF ON FLOOR. LUE (LEFT UPPER EXTREMITY) WITH 4 SMALL SKIN TEARS..." ACCORDING TO THE INCIDENT/ACCIDENT (I&A) REPORT DATED [DATE], "DISCOVERED PATIENT PRONE ON FLOOR ON TOP OF BAR OF UPRIGHT BEDSIDE TABLE. PATIENT STATES HE JUST fell OUT OF BED..." THERE WERE NO WITNESSES. THE SUMMARY OF THE INTERDISCIPLINARY TEAM (IDT) POST FALL REVIEW, DATED [DATE], DOCUMENTED, "MATS AT BEDSIDE, ISOLATED INCIDENT, RESIDENT HAS SAFETY MEASURES IN PLACE." FALL #2 OCCURRED ON [DATE]. ACCORDING TO NURSES' NOTES, AT 10:25 P.M., "RESIDENT OBSERVED ON FALL MAT BY RCS (RESIDENT CARE SPECIALIST)...WRITER ASSESSED RESIDENT FOR INJURIES, NO APPARENT INJURIES NOTED..." THERE WAS NO DOCUMENTED EVIDENCE THAT THIS FALL WAS WITNESSED. THE I&A REPORT, DATED [DATE], DOCUMENTED "BED ALARM" AS THE EQUIPMENT INVOLVED AT THE TIME OF THE FALL, BUT THERE WAS NO DOCUMENTATION THAT INDICATED WHETHER OR NOT THE ALARM SOUNDED. THE I&A FURTHER DOCUMENTED THAT A "BED ALARM" WOULD BE IMPLEMENTED AS AN "ACTION." THE IDT POST FALL REVIEW DOCUMENTED, "FALL SAFETY DEVICES IN PLACE AND FUNCTIONING. (RESIDENT) STATES THAT HE WAS REACHING FOR HIS TELEPHONE WHEN HE ROLLED OUT OF BED..." INTERVENTION RECOMMENDATIONS INCLUDED: "BED ALARM." IT WAS UNCLEAR WHY THE RECOMMENDATION WAS FOR A BED ALARM WHEN THE I&A REPORT INDICATED THAT "BED ALARM" WAS THE EQUIPMENT INVOLVED. FALL #3 OCCURRED ON [DATE]. ACCORDING TO NURSES' NOTES, AT 12 P.M., "PER CENA (CERTIFIED NURSE AIDE) REPORT, PATIENT WAS DISCOVERED ON SAFETY MAT BESIDE BED WITHOUT OBSERVABLE INJURY." THE I&A REPORT, DATED [DATE], REVEALED EQUIPMENT INVOLVED WAS A SAFETY MAT. THERE WAS NO MENTION OF AN ALARM. IDT POST FALL REVIEW, DATED [DATE], DOCUMENTED, "CURRENTLY ON LOW BED WITH MATS, UNABLE TO REMEMBER TO ASK FOR ASSISTANCE..." THERE WERE NO WITNESSES WITH THIS INCIDENT. FALL #4 OCCURRED ON [DATE]. ACCORDING TO NURSES' NOTES, ON [DATE], "PATIENT CAME OUT OF HIS WHEELCHAIR IN HIS ROOM AT BEDSIDE WHILE AWAITING TRANSFER TO BED FOR WOUND CARE. HE SUSTAINED A 1.5 CENTIMETER LACERATION TO THE SUPER ORBITAL AREA ON THE OUTER EDGE. WOUND CLEANSED A STERISTRIP WAS APPLIED. NEURO CHECKS COMPLETED . . ." ADDITIONAL NURSES' NOTES ON [DATE] AT 1200 DOCUMENTED, "FALL FROM WHEELCHAIR. LACERATION TO LEFT SIDE OF HEAD ABOVE EYES. WOUND CARE EVALUATED AND TREATMENT PROVIDED..." FURTHER REVIEW REVEALED ADDITIONAL NURSES' NOTES DATED [DATE] AT 10:15 P.M., THAT DOCUMENTED, "RESIDENT ALERT AND ORIENTED TIMES 2, LEFT EYE BLACK AND BLUE. LUMP ON LEFT FOREHEAD DECREASING IN SIZE. NEURO CHECKS DONE... " ACCORDING TO THE I&A REPORT DATED [DATE], "PATIENT WAS UP IN WHEELCHAIR SITTING IN ROOM WAITING FOR WOUND CARE, WHEN (NURSE) LEFT THE ROOM AND CAME BACK; PATIENT WAS FOUND FACE DOWN ON FLOOR." THE INCIDENT AND ACCIDENT REPORT NOTED THAT ALARMS WOULD BE THE PLAN OF ACTION. THE SUMMARY OF IDT POST FALL REVIEW, DATED [DATE], DOCUMENTED, "LACERATION ABOVE LEFT EYE, STERI STRIP IN PLACE, BRUISE APPROXIMATELY THE SIZE OF A QUARTER ONE HOUR POST FALL. ALL SAFETY INTERVENTION IN PLACE AND FUNCTIONING, CONTINUE WITH ALARMS." ON [DATE] AT 4:15 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH NURSE #7 WHO WAS NO LONGER EMPLOYED AT THE FACILITY. NURSE #7 VERIFIED THAT SHE PROVIDED CARE FOR RESIDENT #503 SEVERAL TIMES WHEN SHE WORKED AT THE FACILITY. NURSE #7 STATED, "HE (RESIDENT 503) fell SEVERAL TIMES. I REMEMBER HIM HAVING A BLACK EYE. HE LOOKED TERRIBLE. HE WAS FRAIL. I REMEMBER THAT HE WASN'T ACTING THE SAME AFTER THE LAST FALL. HE WAS DECLINING. HE WAS A QUIET MAN, BUT AFTER THAT FALL HE WAS ACTING DIFFERENT, HE WAS IN PAIN." DURING AN INTERVIEW WITH LPN #13 ON [DATE] AT 9:30 A.M., THE LPN CONFIRMED THAT HE WAS THE NURSE WHO PROVIDED WOUND CARE FOR RESIDENT #503 ON THE DAY OF HIS HEAD INJURY. LPN #13 STATED, "THE RESIDENT WAS IN HIS WHEELCHAIR. HE HAD JUST EATEN LUNCH AND I WAS GETTING READY TO DO HIS WOUND TREATMENT. I ROLLED HIM (IN WHEELCHAIR) INTO HIS ROOM AND I WENT OUT TO GET SUPPLIES FOR HIS WOUND TREATMENT AND DOWN HE WENT, THE RESIDENT fell on THE FLOOR." WHEN THE NURSE WAS ASKED IF HE KNEW THAT THE RESIDENT WAS AT RISK FOR FALLS, LPN #13 SAID, "I DIDN'T EVEN KNOW THAT HE COULD MOVE. HE WASN'T ON ANY FALL PRECAUTIONS AT THE TIME, HE DIDN'T HAVE A LAP BUDDY (RESTRAINT)." AN INTERVIEW WITH THE FACILITY ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON) WAS CONDUCTED ON [DATE] AT 10:00 A.M. THE ADMINISTRATOR VERIFIED THAT SHE DID RECALL THE RESIDENT AND THE INCIDENT. THE ADMINISTRATOR STATED, "I DON'T KNOW IF HE (RESIDENT #503) fell BEFORE HE HAD THE BLEED OR IF HE HAD THE BLEED AFTER HE fell ." NEITHER THE ADMINISTRATOR NOR THE DON WERE ABLE TO EXPLAIN WHY APPROPRIATE INTERVENTIONS TO PREVENT RESIDENT #503 FROM FALLING WERE NOT CONSISTENTLY IN PLACE. ( )

REFER TO INTAKE MI 291. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF 1 (#500) OF 6 SAMPLED RESIDENTS AT RISK FOR ELOPEMENT IN A TOTAL OF 14 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #500 LEFT THE BUILDING UNDETECTED BY FACILITY STAFF AND WAS FOUND IN THE PARKING LOT, PLACING HER IN DANGER OF INJURY FROM FALLS OR BEING STRUCK BY A VEHICLE. FINDINGS INCLUDE: RESIDENT #500, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE ADMISSIONS RECORD. ACCORDING TO A PHYSICIAN'S HISTORY & PHYSICAL (H&P) REPORT, RESIDENT #500 WAS hospitalized PRIOR TO THE 3/2/11 ADMISSION FOR A STROKE AND LEFT SIDED PARALYSIS. THE resident had a history of [REDACTED]. A MENTAL HEALTH SCREENING FOR RESIDENT #500 WAS DONE ON 3/1/11 AT THE HOSPITAL. ACCORDING TO THIS SCREEN, RESIDENT #500 DISPLAYED SOME CONFUSION, HALLUCINATIONS, PARANOID THINKING, AND DIFFICULTY COMMUNICATING. RESIDENT #500 WAS OBSERVED IN HER ROOM AND INTERVIEWED ON 9/9/11 AT 11:30 A.M. THE RESIDENT ANSWERED QUESTIONS IN A VERY QUIET, TIMID VOICE. THE RESIDENT'S ANSWERS WERE DIFFICULT TO HEAR AND WERE NOT ALWAYS APPROPRIATE. THE RESIDENT STATED, "I JUST WANT TO GO HOME." REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A SOCIAL SERVICE NOTE, DATED 3/3/11, DOCUMENTING THAT RESIDENT #500 HAD ATTEMPTED TO EXIT THE BUILDING. AT THAT TIME, A WANDERGUARD BRACELET (CAUSES AN ALARM TO SOUND WHEN THE RESIDENT ATTEMPTS TO LEAVE THE BUILDING THROUGH DOORS EQUIPPED WITH A WANDERGUARD SYSTEM) WAS PLACED ON THE RESIDENT. AN ELOPEMENT RISK REVIEW, COMPLETED ON 3/2/11, HAD A SCORE OF 21 (A TOTAL SCORE OF 12 OR HIGHER IS 'AT RISK' FOR ELOPEMENT). A CARE PLAN FOR ELOPEMENT RISK WAS DEVELOPED ON 3/3/11. A RESIDENT CARE CARDEX, USED BY CERTIFIED NURSING ASSISTANTS, DOCUMENTED THAT THE RESIDENT WORE A WANDERGUARD. IN AN INTERVIEW ON 9/8/11 THE DIRECTOR OF NURSING (DON) SAID RESIDENT #500 HAD ATTEMPTED TO EXIT THE BUILDING ON OTHER OCCASIONS UNSUCCESSFULLY. SOCIAL WORKER #8 WAS INTERVIEWED ON 9/8/11 AT 2 P.M. SHE SAID RESIDENT #500 HAD TALKED ABOUT GOING HOME SINCE ADMISSION. THE SOCIAL WORKER SAID THE RESIDENT WOULD GO TO AN EXIT DOOR AND WAIT FOR VISITORS TO OPEN THE DOOR FOR HER. THE SOCIAL WORKER SAID SHE HAD CAUGHT VISITORS OPENING THE DOOR FOR THE RESIDENT. NURSE #4, INTERVIEWED ON 9/8/11 AT 10:55 A.M., SAID RESIDENT #500 EXPRESSED A DESIRE TO LEAVE THE FACILITY, AND ASKED VISITORS TO OPEN DOORS FOR HER. DURING AN INTERVIEW ON 9/8/11 AT 12:45 P.M., CERTIFIED NURSING ASSISTANT (CNA) #6 SAID SHE HAD SEEN RESIDENT #500 AT THE EXIT DOOR ONCE OR TWICE, HOPING TO GO OUTSIDE. DURING AN INTERVIEW ON 9/8/11 AT 1 P.M., CNA #7 STATED THAT RESIDENT #500 WOULD SAY THAT SHE WAS READY TO GO HOME ALL THE TIME. NURSE #10, INTERVIEWED ON 9/8/11 AT 3:45 P.M., SAID SHE SAW THE RESIDENT PUSH THE EXIT DOOR, AND THE ALARM SOUNDED. THE RESIDENT WAS REDIRECTED BACK INTO THE FACILITY. IN A TELEPHONE INTERVIEW ON 9/8/11 AT 10:30 A.M., CNA #1 SAID THAT ON 8/26/11 AT APPROXIMATELY 9:30 A.M., WHILE ON BREAK, SHE WENT TO HER VEHICLE IN THE THE PARKING LOT. CNA #1 SAID SHE FOUND RESIDENT #500 IN THE PARKING LOT, SITTING IN HER WHEELCHAIR BY THE DRIVER'S SIDE DOOR OF CNA #1'S TRUCK. WHEN ASKED WHAT SHE WAS GOING TO DO, THE RESIDENT SAID SHE WAS GOING TO DRIVE HER CAR. WHEN ASKED IF SHE HAD HER KEYS, THE RESIDENT BEGAN FEELING AROUND IN THE SIDES OF HER WHEELCHAIR (W/C). CNA #1 SAID THE RESIDENT WAS WEARING A WANDERGUARD BRACELET ON HER WRIST. CNA #1 TOOK THE RESIDENT BACK INTO THE FACILITY. ACCORDING TO CNA #1, HER TRUCK WAS PARKED IN A VISITORS' LOT IN FRONT OF THE FACILITY. OBSERVATION OF THE VISITORS' LOT AT 10:15 AM ON 9/8/11 REVEALED THAT THERE WERE SIDEWALKS IN FRONT OF THE TWO EXITS FROM THE BUILDING. THERE WAS AN AREA AT THE END OF EACH ENTRANCE WHERE THE CURB FLATTENED. THE REST OF THE SIDEWALK HAD A CURB TO THE DRIVER'S LANE. THERE WAS A DRIVER'S LANE FROM THE ROAD ENTRANCE TO THE FACILITY WHICH PASSED BETWEEN THE VISITOR'S LOT AND THE FRONT OF THE FACILITY AND LED TO A PARKING AREA IN BACK OF THE FACILITY. IN AN INTERVIEW ON 9/8/11 AT 1:30 P.M., NURSE #2 SAID SHE PASSED MEDICATIONS TO RESIDENT #500 ABOUT 8 A.M. ON 8/26/11 AND DID NOT SEE RESIDENT #500 AGAIN UNTIL CNA #1 RETURNED HER TO THE FACILITY AT APPROXIMATELY 10 A.M. NURSE #2 SAID THAT UPON RETURN INTO THE FACILITY, RESIDENT #500 HAD A WANDERGUARD ATTACHED TO THE BOTTOM OF HER WHEELCHAIR. SHE (NURSE #2) SAID SHE HAD THE MAINTENANCE DIRECTOR REPLACE THE WANDERGUARD. NURSE #2 SAID, AFTER READING HER NURSE'S NOTE FOR THAT DATE, IT APPEARED AS IF A WANDERGUARD WAS LOCATED ON THE RESIDENT'S WRIST AS WELL AND THAT SHE CHANGED IT, BUT SHE COULD NOT BE SURE. NURSE #2, WHEN INTERVIEWED ON 9/8/11 AT 1:30 P.M., SAID SHE DID CHECK THE WANDERGUARD'S FUNCTION WHEN THE RESIDENT WAS RETURNED TO THE FACILITY. WHEN INTERVIEWED ON 9/9/11 AT 1 P.M., NURSE #2 SAID SHE DID NOT CHECK THE FUNCTION OF A WANDERGUARD ON THE WHEELCHAIR OR ON THE RESIDENT'S WRIST. NURSE #2 SAID SHE DID NOT HEAR ANY ALARM SOUND INDICATING THAT RESIDENT #500 LEFT THE FACILITY. NURSE #2 FURTHER SAID THAT SHE DID NOT KNOW WHICH DOOR RESIDENT #500 HAD USED TO EXIT THE THE BUILDING. THE MAINTENANCE DIRECTOR WAS INTERVIEWED ON 9/8/11 AT 10:50 A.M. HE SAID HE REPLACED A WANDERGUARD ON RESIDENT #500'S WRIST ON 8/26/11 WHEN RESIDENT #500 WAS RETURNED TO THE FACILITY BECAUSE THE NURSE ON DUTY (NURSE #2) SAID THAT IT WAS NOT WORKING. THE MAINTENANCE DIRECTOR SAID HE COULDN'T REMEMBER WHETHER OR NOT THERE WAS A WANDERGUARD ON THE WHEELCHAIR AS WELL. ACCORDING TO AN 8/26/11 STAFFING SHEET, CNA #3 WAS ASSIGNED TO CARE FOR RESIDENT #500. CNA #3 WAS INTERVIEWED ON 9/8/11 AT 11:20 A.M. CNA #3 SAID SHE DID NOT KNOW ABOUT RESIDENT #500'S ELOPEMENT ON 8/26/11 UNTIL "A FEW DAYS LATER." CNA #3 SAID SHE MAY HAVE BEEN ASSIGNED TO CARE FOR RESIDENT #500 THAT DAY, BUT SHE COULD NOT REMEMBER ANY DETAILS. THERE WERE NO ENTRIES FOR THE DAY SHIFT ON THE CNA DOCUMENTATION RECORD FOR RESIDENT #500 ON 8/26/11. UNIT MANAGER #4 WAS INTERVIEWED ON 9/8/11 AT 10:55 A.M. AND AGAIN ON 9/9/11 AT 9:15 A.M. SHE SAID SHE WAS ON DUTY 8/26/11 AND DID NOT HEAR AN ALARM SOUND INDICATING THAT RESIDENT #500 HAD left the faciity on [DATE]. UNIT MANAGER #4 SAID SHE WAS NOT AWARE THAT RESIDENT #500 ELOPED UNTIL THE FOLLOWING WEEK. THE UNIT MANAGER SAID SHE CHECKED THE RESIDENT'S WANDERGUARD THE MORNING OF 8/26/11 TO MAKE SURE IT FUNCTIONED APPROPRIATELY. STAFF INITIAL A "SAFETY AUDIT" INDICATING THAT THEY CHECKED PLACEMENT AND FUNCTION OF A RESIDENT'S WANDERGUARD. NURSE #4'S INITIALS WERE NOTED NEXT TO THE RESIDENT'S NAME ON THE SAFETY AUDIT. THE SAFETY AUDIT DID NOT INDICATE THE LOCATION OR NUMBER OF WANDERGUARDS ON THE RESIDENT OR ON THE WHEELCHAIR. THE FACILITY POLICY, UNDATED, FOR WANDERGUARDS, DIRECTED STAFF TO PLACE THE UNIT ON THE RIGHT WRIST OR ANKLE OF THE RESIDENT AND INDICATE LOCATION OF THE UNIT ON THE TAR (TREATMENT ADMINISTRATION RECORD). ACCORDING TO THIS POLICY, EACH SHIFT, STAFF ARE DIRECTED TO CHECK THE FUNCTION (ALARM) AND LOCATION OF EACH WANDERGUARD IN USE. WHEN THE SURVEYOR ASKED THE DIRECTOR OF NURSING ON 9/8/11 AT 4:15 P.M. ABOUT DOCUMENTATION ON THE TAR FOR RESIDENT 500'S WANDERGUARD, THE DON SAID THAT THE UNIT, WHERE RESIDENT #500 RESIDED, HAD NOT BEEN DOCUMENTING ON THE TAR, BUT WAS USING THE SAFETY AUDIT FORM INSTEAD. ACCORDING TO THE DON, THE UNIT BEGAN USING THE TAR FOR DOCUMENTATION ON 9/3/11. REVIEW OF THE SAFETY AUDIT FORMS, DATED 8/10/11 THROUGH 8/26/11, FOR DOCUMENTING THAT THE WANDERGUARD WAS CHECKED FOR FUNCTIONALITY AND LOCATION FOR RESIDENT #500 REVEALED THAT THE WANDERGUARD WAS CHECKED ON ALL THREE SHIFTS ON ONE DAY (8/18/11). THE WANDERGUARD WAS CHECKED ON TWO SHIFTS ON 8 DAYS, ONE SHIFT ON 5 DAYS, AND IT WAS NOT CHECKED ON ANY SHIFT ON 3 DAYS. THE IMMEDIATE JEOPARDY BEGAN ON 8/26/11 WHEN RESIDENT #500, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, EXITED THE FACILITY BETWEEN 8 A.M. AND 9:30 A.M. UNBEKNOWNST TO STAFF AND WAS FOUND IN THE FACILITY PARKING LOT BETWEEN TWO VEHICLES. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY AT 2:35 P.M. ON 9/12/11. THE DEFICIENT PRACTICE PLACED RESIDENT #500 AND FOUR OTHER RESIDENTS IDENTIFIED AS ELOPEMENT RISKS AT HIGH RISK OF SERIOUS HARM, INJURY AND/OR DEATH. THE SURVEYOR VERIFIED ON 9/14/11 AT 1 P.M. THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 8/26/11 RESIDENT #500 WAS RETURNED TO THE FACILITY. THE RESIDENT WAS ASSESSED AND FOUND TO HAVE NO INJURIES. AN ELOPEMENT RE-ASSESSMENT WAS COMPLETED. THE RESIDENT WAS IMMEDIATELY PLACED ON EVERY 15 MINUTE CHECKS AND CONTINUED FOR 24 HOURS. FAMILY AND PHYSICIAN WERE NOTIFIED. THE RESIDENT'S WANDERGUARD BRACELET WAS REPLACED ON HER WRIST AND WHEELCHAIR AT THE TIME OF THE INCIDENT. A NURSE CHECKED PLACEMENT AND FUNCTION OF THE WANDERGUARD BRACELET EVERY SHIFT. THE PLAN OF CARE AND THE CARE CARDEX WERE UPDATED. 2. ON 8/29/11 NURSING STAFF ASSESSED ALL RESIDENTS IN THE FACILITY TO DETERMINE ELOPEMENT RISK USING THE RISK FOR ELOPEMENT SECTION OF THE NURSING COMPREHENSIVE ASSESSMENT FORM, PART OF THE ELOPEMENT MANAGEMENT SYSTEM. FOUR OTHER RESIDENTS WERE IDENTIFIED AS AN ELOPEMENT RISK. CARE PLANS AND CARE CARDEXES WERE UPDATED. ON 8/30/11 THE INTERDISCIPLINARY TEAM BEGAN DISCUSSING ALL ELOPEMENTS DURING THE MORNING MEETING AND WILL DISCUSS RESIDENTS AT RISK FOR ELOPEMENT WEEKLY FOR ONE MONTH AND THEN MONTHLY DURING THE CARE MANAGEMENT RISK REVIEW MEETING. ON 9/12/11 THE DIRECTOR OF NURSING OR DESIGNEE BEGAN AN AUDIT OF CARE PLANS FOR RESIDENTS AT RISK FOR ELOPEMENT ONCE A WEEK FOR 30 DAYS AND ONCE A MONTH THEREAFTER. AS OF 8/29/11 RESIDENTS WILL CONTINUE TO BE REASSESSED UPON ADMISSION, QUARTERLY, ANNUALLY, AND WITH SIGNIFICANT CHANGE OF CONDITION. THE INTERDISCIPLINARY TEAM WILL EVALUATE EACH ASSESSMENT AND UPDATE CARE PLANS AND CARE CARDEXES AS NECESSARY. ON 9/3/11 ALL RESIDENTS AT RISK FOR ELOPEMENT HAD THEIR WANDERGUARD PLACEMENT VERIFIED AND DOCUMENTED ON THE TREATMENT ADMINISTRATION RECORD (TAR). ON 9/3/11 TARS WERE UPDATED TO INCLUDE INSTRUCTIONS TO CHECK EVERY SHIFT FOR PLACEMENT OF CODE ALERT BRACELETS FOR RESIDENTS AT RISK FOR ELOPEMENT. ON 8/29/11 DON OR DESIGNEE BEGAN AUDIT TO ENSURE DOCUMENTATION OF WANDERGUARD BRACELETS ON THE TAR. AS OF 8/29/11 THE MAINTENANCE DEPARTMENT WILL CONTINUE TO MAINTAIN A LOG FOR REPLACEMENT OF THE WANDERGUARD DEVICE AND REPLACE THE DEVICE IN ACCORDANCE WITH MANUFACTURER'S RECOMMENDATION. THE NIGHT SHIFT NURSE VERIFIES FUNCTION OF THE WANDERGUARD DEVICE USING A TESTING DEVICE AND DOCUMENTS FINDINGS ON THE TAR ONCE EVERY 24 HOURS IN ACCORDANCE WITH THE ELOPEMENT MANAGEMENT POLICY. 3. BEGINNING 8/29/11 ALL readmitted RESIDENTS ARE ASSESSED FOR ELOPEMENT RISK USING THE RISK FOR ELOPEMENT SECTION OF NURSING COMPREHENSIVE ASSESSMENT FORM. REASSESSMENTS WILL BE DONE QUARTERLY, ANNUALLY, AND WITH SIGNIFICANT CHANGE OF CONDITION. AS OF 8/29/11 CARE PLANS AND CARE CARDEXES WILL CONTINUE TO BE UPDATED TO INCLUDE INTERVENTIONS TO ADDRESS EXIT SEEKING BEHAVIOR. NURSES NOTIFY PHYSICIANS AND FAMILY MEMBERS OF IDENTIFIED CHANGES. BEGINNING 8/30/11 THE INTERDISCIPLINARY TEAM WILL DISCUSS ALL ATTEMPTED ELOPEMENTS DURING THE MORNING MEETING AND DISCUSS RESIDENTS AT RISK FOR ELOPEMENT WEEKLY FOR ONE MONTH AND THEN MONTHLY DURING THE CARE MANAGEMENT RISK REVIEW MEETING. ON 9/11/11 STANLEY SERVICE INSTALLED A SECOND CONTACT TO THE WANDER GUARD SYSTEM ON THE OPPOSITE DOOR AT THE SUBACUTE EXIT FIRE DOOR. THE CENTER HAS INITIATED A REQUEST FOR APPROVAL TO MOVE A MAG LOCK TO THE SUB-ACUTE LOBBY. ON 9/9/11 ALL FACILITY STAFF HAD BEEN RE-EDUCATED BY THE ADMINISTRATOR OR DESIGNEE REGARDING THE DOOR ALARM SYSTEM AND THE IMPORTANCE OF IMMEDIATELY RESPONDING TO AN ACTIVATED DOOR ALARM WITH 15-SECOND LOCKOUT TIME. ON 9/9/11 ALL FACILITY STAFF HAD BEEN RE-EDUCATED BY THE DIRECTOR OF NURSING OR DESIGNEE ON THE ELOPEMENT MANAGEMENT POLICY THAT WAS LAST REVISED ON FEBRUARY, 2010. ON 8/31/11 THE INTERDISCIPLINARY TEAM REVIEWED ITS ELOPEMENT POLICY AT AN AD HOC QA&A MEETING AND DETERMINED IT APPROPRIATE FOR THE CENTER'S USE. BEGINNING 8/29/11, THE DIRECTOR OF NURSING OR DESIGNEE BEGAN CONDUCTING RANDOM OBSERVATIONS DAILY OF WANDERGUARD BRACELETS TO ASSURE THEY ARE IN PLACE AND FUNCTIONING PROPERLY. THIS WILL OCCUR EVERY DAY FOR TWO WEEKS AND MONTHLY THEREAFTER. BEGINNING 9/12/11 THE DON OR DESIGNEE BEGAN AUDITING CARE PLANS OF RESIDENTS AT RISK FOR ELOPEMENT ON A WEEKLY BASIS FOR ONE MONTH, BIWEEKLY FOR ONE MONTH AND MONTHLY THEREAFTER. BEGINNING 9/12/11 THE DON OR DESIGNEE BEGAN AUDITING THE TARS ON A WEEKLY BASIS FOR ONE MONTH, BIWEEKLY FOR ONE MONTH AND MONTHLY THEREAFTER. THE DON OR DESIGNEE WILL TREND THE RESULTS OF THE AUDITS AND DISCUSS RESULTS DURING THE MONTHLY QUALITY ASSESSMENT AND ASSURANCE COMMITTEE MEETING. 4. ON 8/31/11 AN AD HOC SUBCOMMITTEE OF THE QUALITY ASSURANCE AND ASSESSMENT COMMITTEE MET TO DISCUSS AND APPROVE THE "CREDIBLE ALLEGATION OF COMPLIANCE". THE MEDICAL DIRECTOR APPROVED THE PLAN ON 8/31/11. BEGINNING 8/31/11 THE COMMITTEE WILL MEET ON A WEEKLY BASIS FOR ONE MONTH AND MONTHLY THEREAFTER. FINDINGS FROM THE AUDIT RESULTS AND OVERSIGHT WILL BE REPORTED TO COMMITTEE ON A MONTHLY BASIS. THE COMMITTEE WILL MAKE RECOMMENDATIONS FOR POLICY CHANGES OR FURTHER EDUCATION WHERE NECESSARY. BEGINNING 9/12/11 THE REGIONAL CLINICAL DIRECTOR WILL REVIEW THE MEETING MINUTES MONTHLY FOR 3 MONTHS. THE IMMEDIATE JEOPARDY THAT BEGAN ON 8/26/11 WAS REMOVED ON 8/29/11, BUT THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL CONTINUED IMPLEMENTATION OF THE NEW POLICIES AND PROCEDURES HAVE BEEN VERIFIED. ( )

Based on observation, interview and record review, the facility failed to monitor, supervise and remove the oxygen tank in 1 of 4 sampled residents (#104) resulting in an Immediate Jeopardy when Resident #104 who, after being escorted to the front lobby by facility staff to go out for a cigarette, was observed smoking outside the facility front entrance with a nasal cannula (tube that supplies oxygen via the nose) in her nose and a portable oxygen tank attached to the back of the her wheelchair placing Resident #104 and 86 additional residents (10 of whom are on oxygen and 1 who is on oxygen and is a smoker) residing in the facility, at high risk for serious harm, injury, and/or death. Findings include: On 4/13/11 at 1:20 p.m. Resident #104 was observed outside of the facility's front entrance with Licensed Practical Nurse (LPN) "I" who was observed giving Resident #104 a cigarette, lighting it for her, and then walked away, leaving Resident #104's oxygen tank on her wheelchair and the nasal cannula in her nose. Resident #104 was observed smoking a cigarette with a nasal cannula in her nose and a portable oxygen tank attached to the back of her wheelchair. On 4/13/11 at 1:25 p.m. after the surveyor observed the unsafe smoking situation, the Administrator removed the oxygen tank from Resident #104's wheelchair (prior to this surveyor being able to see if oxygen was on) and assisted her away from the front entrance of the facility. The surveyor also observed two "No smoking" signs posted in front of the facility's main entrance where Resident #104 was observed smoking. According to the posted signs smoking was allowed in designated areas only and no smoking was allowed near oxygen. The facility policy, entitled "Safe Smoking," revised June 2007, documented "Warning: Smoking is NOT permitted while oxygen is in use." According to the policy, all unsafe smokers were to be supervised at all times. Resident #104 was not supervised on 4/13/11 when observed unsafely smoking, with an oxygen tank attached to her wheelchair, in a prohibited area. According to Resident #104's care plan, entitled "Injury from Smoking" updated 4/4/11, Resident #104 was to have reinforcement to remember to turn off her oxygen when smoking. Smoking materials were to be maintained by staff and smoking was to be in designated areas only. The care plan did not address that the oxygen tank should be removed from the wheelchair prior to smoking and that Resident #104 should be supervised during smoking. On 4/13/11 at 1:35 p.m. during an interview with the Director of Nursing (DON), the DON stated the facility relies on the nursing staff to monitor Resident #104 during smoking and to remove her oxygen prior to smoking. A clinical record review conducted on 4/13/11 at 2:30 p.m. revealed Resident #104 was re-admitted to the facility on [DATE] and had been identified as "At Risk" for unsafe smoking on her previous admission to the facility based on a "Safe Smoking" evaluation dated 1/20/11. The clinical record revealed Resident #104 had demonstrated behaviors in the past which proved her to be a risk for unsafe smoking, including being observed by staff smoking inside the facility in her bathroom on 2/22/11. According to the social services progress notes, dated 2/23/11, Resident #104 was "suspected of smoking in her bathroom on two other occasions." In an interview on 4/15/11 at 1:47 p.m. the Social Service worker reported she had a conference with resident #104 and her family regarding her unsafe smoking practices and that resident #104 had agreed at that time to allow facility staff to keep her cigarettes and lighters for safety. On 4/13/11 at 1:35 p.m., LPN "I" could not explain why she did not remove the oxygen tank from resident #104's wheelchair prior to Resident #104 being escorted to the front lobby and going outside to smoke a cigarette. LPN "I" admitted to retrieving resident #104's smoking materials and assisting outside the lobby doors to smoke on 4/13/11 at 1:20 p.m. According to the manufacturer patient instruction sheet entitled "Oxygen Concentrator" oxygen is a drug, it supports combustion, there should be "No Smoking" in the room where oxygen is in use. The safety precautions also include to "not permit the use of oxygen near open flames or burning tobacco (stay at least five to six feet away)." In an observation on 4/13/11 at 1:20 p.m. Resident #104 was alert and oriented, and according to her face sheet she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set assessment dated [DATE] revealed she required assistance with activities of daily living. According to the Administrator on 4/15/11 at 9:20 a.m., the oxygen was not turned on but she removed the oxygen tank and nasal cannula immediately from Resident #104 when she observed the unsafe smoking situation. The Administrator stated, LPN "I" was counseled related to not removing the oxygen from Resident #104's wheelchair prior to smoking. Per the Administrator the facility currently has four (4) actively smoking residents. On 4/18/11 at 3:00 p.m., the Administrator was informed of the Immediate Jeopardy that began on 4/13/11 at 1:20 p.m. when Resident #104 who, after being escorted to the front lobby by facility staff to go out for a cigarette, was observed smoking outside the facility front entrance with a nasal cannula (tube that supplies oxygen via the nose) in her nose and a portable oxygen tank attached to the back of the her wheelchair placing Resident #104 and 86 additional residents residing in the facility, at high risk for serious harm, injury, and/or death. On 4/18/11, the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy. 1. On 4/13/11, the facility held an emergency Quality Assurance Meeting to discuss their Safe Smoking Policy with Emphasis on Oxygen Management. 2. On 4/13/11, LPN #I was counseled and in-serviced on that smoking is not permitted while oxygen is in use and oxygen tanks must be removed from the residents' wheelchair prior to smoking. The Safe Smoking Policy was reviewed with LPN #I. 3. On 4/13/11, Resident #104 was re-evaluated with the facility's "safe smoking evaluation" form. Resident #104 was re-issued a copy of the facility's smoking policy including oxygen precautions. Resident #104 was required to sign and accept the facility's smoking policy and oxygen precautions, she agreed to accept the policy and to adhere to the facility's scheduled smoking times with supervision. Resident #104 is now smoking with staff supervision during the scheduled smoking times. 4. On 4/13/11, 4 residents were identified as active smokers, these residents were re-evaluated utilizing the "safe smoking evaluation" form. Care plans were revised by the Interdisciplinary Team and updated as needed. Residents who choose to smoke were re-issued the facility's smoking policy and were required to sign and accept the facility smoking policy. There were 2 of the 4 residents who smoked that required supervision while smoking. Those 2 residents were re-issued the facility smoking policy, re-signed and accepted the facility's smoking policy related to supervised smoking only. 5. Effective 4/13/11, all facility residents were to be assessed upon admission and re-admission for safe smoking. Current smokers will be evaluated quarterly, annually and with significant changes. The facility policy will be adhered to if a resident's assessment showed the resident cognitive impairment changed, unsafe choices or physical impairment causes the resident to be an unsafe smoker, the facility will follow the smoking schedule for that resident. The facility staff was to maintain the smoking materials for the identified smoking residents. 6. Effective 4/13/11, any additional residents requesting to smoke will be provided with the facility's smoking policy and required to sign an acknowledgement. A safe smoking assessment would be completed and a smoking plan of care initiated. 7. Staff education was provided on 4/13/11 and 4/14/11 on the facility's safe smoking policy with emphasis on oxygen precautions and the interventions for residents that smoke. 159 of 167 employees had completed the education. (8 employees were identified on vacation or medical leave of absence). These 8 employees not present for the education will be required to complete the education prior to starting their next scheduled shift. 8. On 4/13/11, the facility's Quality Assurance and Assessment Committee met to discuss and approve this plan. The Medical Director was present and approved the plan. The Social Services Director/designee will observe the smokers on a weekly basis for one month and then biweekly for one month and then monthly to ensure compliance and demonstration of safe smoking practice including oxygen precautions. Any negative observations will be reported to nursing staff immediately for intervention and re-evaluation. Findings will be reported and reviewed by the QA&A committed monthly. The facility Administrator is responsible for compliance. While the Immediate Jeopardy (IJ) was removed on 4/13/11 at 5:00 p.m., the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been educated and sustained compliance had not been verified by the State Agency.