Every finding on record at West Hickory Haven

Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program that included a system for an ongoing antibiotic stewardship program Findings include:A review of the facility's Infection Prevention and Control Program on 6/2/26 revealed that the facility was required to maintain an ongoing infection surveillance system designed to analyze data, and implement interventions. The policy further indicated that the facility would maintain an antibiotic stewardship program that monitored antibiotic use, promoted appropriate prescribing practices, and evaluated treatment outcomes.On 6/2/26, a review of the facility's infection surveillance logs revealed incomplete documentation for two months. The logs failed to consistently identify residents with infections, track the type and location of infections, identify causative organisms, or document follow-up actions taken by the Infection Preventionist (IP). On 6/2/26 at 11:30 a.m., an interview was conducted with the IP. The IP stated that infections were documented when staff notified them or when they seen it in the electronic medical record; however, they acknowledged that surveillance data was not consistently tracked or analyzed due to the inconsistencies with the previous IP who was terminated (from employment) two weeks prior. The IP further stated that they had just returned to the facility from a sister facility and would be there two or three days out of the week to restructure their infection control program. A review of antibiotic prescribing records revealed that residents receiving antibiotics were not routinely monitored as part of an antibiotic stewardship program. Documentation failed to identify evidence of antibiotic use reviews, monitoring of antibiotic appropriateness, evaluation of culture and sensitivity reports, antibiotic duration reviews, a risk verses benefit if criteria for antibiotics was not met, or efforts to reduce unnecessary antibiotic use.During an interview on 6/3/26 at 1:45 p.m., the Director of Nursing (DON)acknowledged that the facility did not have an active antibiotic stewardship committee currently and was looking to hire someone for the position. The DON stated that antibiotic use was reviewed but confirmed that they did not follow up with the previous IP before there abrupt departure. There was no additional information provided at the exit of the survey.

Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program that included a system for identifying, water management, hand hygiene and mapping. Findings include:A review of the facility's infection prevention and control program on 6/2/26 revealed that the facility was responsible for maintaining a structured surveillance system to monitor infections, identify trends, and support infection prevention interventions. The program required that infection data be consistently collected, analyzed, and mapped by resident location, infection type, and date of onset to support outbreak identification and prevention efforts. On 6/2/26 a record review showed the facility failed to demonstrate evidence of a systematic infection surveillance process. Infection logs were incomplete and did not consistently include resident identifiers, unit assignments, infection diagnoses, or dates of onset. The facility was unable to provide documentation showing that infection data was trended over time or mapped to identify clusters or patterns of infection within specific units or the facility as a whole. April and May were both incomplete. On 6/2/26 at 11:30 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated that infections were documented when staff notified them or when they seen it in the electronic medical record; however, they acknowledged that surveillance data was not consistently tracked or analyzed due to the inconsistencies with the previous IP who was terminated from employment two weeks prior. The IP further stated that they had just returned to the facility from a sister facility and would be there two or three days out of the week to restructure their infection control program. During an interview on 6/3/26 at 1:45 p.m., the Director of Nursing (DON)acknowledged that the facility did not have an active antibiotic stewardship committee currently and was looking to hire someone for the position. The DON stated that antibiotic use was reviewed but confirmed that they did not follow up with the previous IP before there abrupt departure. Further review revealed no evidence of an infection mapping tool or tracking system (nothing from April and May) used to visualize infection distribution across the facility. The facility could not demonstrate that infections were analyzed by location, organism type, or frequency in a manner that would allow early identification of potential outbreaks. On 6/01/2026 a record review of the Water Management Program (WMP) binder included the facility policy titled Water Management Program Policy & Procedure Effective: July 2017 Revised: October 2024 was conducted. The policy listed the key elements for a WMP, but there was minimal additional documentation that supported the policy and procedures: a water system flow diagram dated 2017 was included. Additional materials in the program binder included World Health Organization (WHO) and CDC reference materials but no listing of a water management team (WMT) members or meetings, no text description of the water system, no site-specific risk assessment, no control measures, no action steps, and no verification or validation steps for legionella prevention. Also provided by the maintenance director (MD) K were backflow preventor testing records, weekly resident room water temperature monitoring logs for scald prevention, and water sample results taken 9/23/2025 for chemical and bacteriological parameters. These water test results were not for legionella as WMP validation. On 6/01/2026 at 10:45 AM interviewed the Nursing Home Administrator (NHA) about the WMP. When asked about additional WMP documentation and more recent sample results, the NHA indicated the corporate environmental services (CEVS) staff member helps with that and she would get additional documentation from him. When asked about the WMT, she indicated that MD K provides updates during monthly Quality Assurance and Performance Improvement (QAPI) Infection Control and Safety Committee meetings and she would provide meeting minutes. QAPI Committee Minutes dated 3/10/2026 were later provided and a line item for Environmental Facility and Plant Operations notes went over the Emergency books and water management for emergency. On 6/01/2026 at 1:45 PM toured with MD K to observe the on-site water supply, storage tanks and hot water system. At this time, MD K indicated 1 of the 3 wells has been offline for over a year, but not sure which and would need to check with CEVS staff member. MD K indicated that the CEVS staff member is on site 2-3 times/month and helps with the water management and works with their contact at the Michigan Department of Environment, Great Lakes, and Energy ([NAME]). When asked about responsibilities related to the water management program, MD K indicated that he logs resident room hot water temperatures to be sure they are within a safe range; if more than 120 degrees F he will adjust in the boiler room and re-check; there are no point of use mixing valves in place. MD K indicated flushing fixtures at any vacant rooms and eyewash stations regularly but does not document this. Additional monthly water sample results were provided later in the day by NHA including the most recent 5/29/26 that was absent of total coliform. No water sample results were for legionella. Record review of an additional policy: Emergency Response Plan for the [NAME] Hickory Haven water supply system provided the name and contact of the water supply operator and basic information about the on-site water wells but does not provide information related to WMP for legionella prevention. No additional WMP documentation was provided by the end of survey. CEVS staff person was not available for interview by survey exit.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: On 06/01/2026 at 9:00 AM during a kitchen tour with dietary manager (DM) J observed the walk-in cooler gasket soiled with black build up. When queried, DM J indicated she concurred it was soiled and in need of cleaning and would ensure it was cleaned or possibly changed.According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.On 06/01/2026 at 9:03 AM Observed 2 in-use juice guns visibly soiled with dried red build up inside the nozzles. When queried, DM J said they should be cleaned daily and they currently needed to be thoroughly cleaned.On 06/01/2026 at 9:05 AM observed the only kitchen handwash sink was blocked by a cart. On 06/01/2026 at 9:10 AM observed interior top of microwave soiled with dried food build up. At this time DM J indicated she also saw that, and this surface should be cleaned. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. On 06/01/2026 at 9:15 AM observed the main dining room serving area with a steam table unit used for meal service and no handwash sink in this room. A hand sanitizer dispenser on the wall nearest this area was empty. DM J indicated it would be refilled before lunch service.According to the 2022 FDA Food Code section 5-204.11 Handwashing Sinks. A HANDWASHING SINK shall be located: (A) To allow convenient use by EMPLOYEES in FOOD preparation, FOOD dispensing, and WAREWASHING areas; . On 06/01/2026 at 9:40 AM observed several unused pieces of equipment stored outside the kitchen door in the exterior receiving area including: a pile of approximately 12 empty unused milk crates, large clear panels stored behind a shed, and a wheeled hot food holding unit/cabinet. DM J indicated that none of those items are used by dietary services and suggested asking maintenance about disposal of those items. On 06/01/2026 at 11:40 AM observed lunch service in the Sunshine Dining Room also with no handwash sink. CNA L touched the garbage can lid with her hands while depositing garbage then returned to the line to serve a resident dining tray and handle utensils without hand hygiene. At this time when asked about hand hygiene, CNA L indicated that resident hands were washed ahead of the meal. When it was clarified about staff hand hygiene, CNA L indicated they would use sanitizer if needed and did not use hand sanitizer at this time.On 06/01/2026 at 11:43 AM observed CNA M also touch garbage can lid then return to serve a resident dining tray without hand hygiene. When asked about hand hygiene, CNA M indicated she should use sanitizer between service to each resident and after touching garbage can lid and proceeded to complete hand hygiene.On 06/01/2026 at 11:55 AM interview with DM J about hand hygiene practices for dietary serving staff. DM J indicated she would ask for and review the facility hand hygiene policy.On 06/01/2026 at 1:20 PM observed kitchen handwash sink blocked with soiled tray cart. When queried kitchen staff N about handwash sink procedures, they said it should be kept stocked with soap, paper towel and be kept accessible. Staff N did not move the cart blocking the sink. According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use.On 06/01/2026 at 1:25 PM observed kitchen staff P handling clean dishes in the dishwashing area and touching her face and hair then again handling clean dishes without handwashing. When asked at this time about handwashing, staff P acknowledged she should wash her hands after touching her face and hair but did not proceed to wash hands. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.On 06/01/2026 at 1:45 PM observed unused equipment outside the back door of kitchen with Environmental Services Director (ESD) K. When queried, he was not sure what those items were for and suggested asking the Dietary Manager or the administrator.On 06/01/2026 at 2:15 PM interview with NHA about the unused equipment items outside the kitchen door. NHA indicated they are still working on going through things and would provide a related policy, if available. NHA later reported there is currently no related policy.According to the 2022 FDA Food Code section 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter.Record review of facility policy Beverage Dispenser Nozzle Cleaning dated June 2017 indicated in part, at end of day: remove nozzles from valves or dispensing gun, rinse in warm sanitizer water for five minutes.Record review of facility policy Hand Hygiene effective December 2000, Revised September 2022 indicated:Hands may be cleaned using liquid soap and water or alcohol hand rub- after handling contaminated environmental objects.and then further included the reference to the Food Code requirements for when to wash

This citation pertains to complaint 2797202.Based on interview and record review, the facility failed to provide the legal representative a written notice of transfer/discharge and send a copy to the Ombudsman for one (R902) of four residents reviewed for discharge. Findings include:Review of a complaint reported to the State Agency included allegations that the facility sent R902 to the hospital on 3/5/26 and refused to allow them to return, and the family never received written discharge notices as required.Review of the clinical record revealed R902 was initially admitted into the facility on 2/19/26 and was discharged to hospital on 3/5/26 and had not returned. Diagnoses included: chronic kidney disease stage 3A, anxiety disorder, personal history of traumatic brain injury, vascular dementia severe with other behavioral disturbance, dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, mild cognitive impairment of uncertain or unknown etiology, and age-related cognitive decline. The clinical record further identified that R902's wife was their responsible party, emergency contact #1, and power of attorney for care and financial decisions.According to the admission Minimum Data Set (MDS) assessment dated [DATE], R902 had severe cognitive impairment, had physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others, which occurred 1 to 3 days that significantly interfered with the resident's care and significantly interfered with the resident's participation in activities or social interactions, put others at significant risk of physical injury, significantly disrupted care or living environment, and had wandering behavior that placed the resident at significant risk of getting to a potentially dangerous place or significantly intruded on the privacy or activities of others, was independent with mobility, required supervision or touching assistance with walking at least 10-150, and was frequently incontinent of bowel and bladder.Progress notes included an entry on 3/6/26 at 1:36 AM by Nurse 'H' that read: Ems (Emergency Medical Services) attempted return of resident at this time staff nurses made Ems aware that we could not provide care for resident d/t (due to) his behavior [name redacted] from [name of local hospital resident was sent to] called to inquire why resident was refused writer explained that order were given for a do not return r/t (related to) facility unable to maintain his needs r/t aggressive and combative behavior and that resident has again attacked a staff member, he was given Admin (Administrator) and [NAME] (Director of Nursing) information and stated he would reach out to facility in the am (morning).Review of the transfer/discharge documentation available for R902 included:A form titled, Emergent Transfer Requirement dated 3/5/26 by Nurse 'H' and Medical Records Staff 'B' on 3/6/2. This form instructed staff to:Print the following items for the Transfer Packet, and initial once completed.There was a check mark next to face sheet, MAR/TAR (Medication Administration Record/Treatment Administration Record), Applicable Progress Notes, Applicable HCP (Health Care Provider) notes, Applicable Labs, Preferred Treatment Option, ADL (Activities of Daily Living) Care Plan, Complete the eINTERACT Transfer Form - Transfer Out to Hospital. There were two areas that were not checked off (left blank) for: Below are regulatory forms inside of this packet that need to be completed with the resident or responsible party. This can be done verbally with two nurse witnesses. Prepared transfer notice form; signed or witnessed acknowledgement AT TIME OF TRANSFER and bed hold policy. (MCL 333.21702 483.15 Admission, Transfer, Discharge Rights) and FIT-100 Form - All Informational Boxes Addressed with postage prepared envelope for appeal request. (Facility Initiated Transfer).Further review of the form titled MCL 333.21702 483.15 Admission, Transfer, Discharge Rights revealed there were two check marks placed next to Reason for Transfer (Check all that apply) The Welfare and needs of the resident cannot be met in the facility and An emergency exists in which the safety of individuals in the home is endangered. The bottom portion of the form was signed by one nurse (Nurse 'H') on 3/5/26. The section for Witnessing Licensed Nurse was left blank.This form also identified the Local Ombudsman as [name of former local ombudsman] (not updated with accurate information).Review of a form titled, FACILITY-INITIATED TRANSFER FOR NURSING HOMES dated 3/5/26 was noted as Reason(s) for facility-initiated transfer.Behavioral needs cannot be met in the nursing home.Explanation for the reasons identified above: combative with STAFF hitting, kicking, spitting, had her shirt collar and pulling her shirt up around her neck.On 3/9/26 at 10:06 AM, an interview was conducted with the facility's social services staff (SS 'C'). When asked about the process for discharge notifications, especially involuntary discharges, SS 'C' deferred to their Director of Nursing (DON).On 3/9/26 at 10:30 AM, an interview was conducted with the DON. When asked to explain the facility's process for discharge and requirements, the DON reported if someone was to be discharged acutely the nurse does e-interact form and vitals and the paperwork. The DON reported the paperwork included face sheet, diagnoses, immunizations, orders, order summary, pertinent progress, dr notes, labs and reported that assessment was completed for R902.When asked about the section of the discharge papers for the bed hold notification, the DON reported the bed hold notification and another form that goes with the bed hold notification, including the representative is called, the physician is called, then the Administrator and I am called. The DON further reported the Nurse calls a report to EMS and hospital transfer - sometimes EMS asks for paperwork but sometimes they don't.When asked if they were involved in R902's transfer to the hospital, the DON reported they were not but did report they received a call after 10:00 PM that he was sent out after assaulting staff.When asked if they had spoken to anyone about not allowing R902 to return, the DON reported (name of hospital) called and asked if we would take them back and we said no. We also called the ombudsman and spoke with Ombudsman 'J' and let her know we were not accepting R902 back. The DON reported Ombudsman 'J' reported they would have to advocate for R902.When asked about the facility's discharge paperwork that included the bed hold notification as well as the involuntary discharge documentation, and lack of completion per the instructions on the form, the DON reported that was done by their financial staff and the checklist for completion had to be signed off by Staff 'E'. The DON reported Staff 'E' was not in the facility today.The DON reported they did send the bed hold policy and notice of transfer packet with the resident with EMS. When asked if the family was present at the time of discharge, the DON reported they were not sure.On 3/9/26 at 11:50 AM, Ombudsman 'J' was attempted to be contacted by phone, and a message was left to return the call. There was no return call by the end of the survey.On 3/9/26 at 12:45 PM, a phone interview was conducted with Nurse 'F'. When asked to recall the events from the night R902 was sent out, Nurse 'F' reported the same events as their documented progress note. Nurse 'F' was asked about the documentation of the transfer packet, and they reported they sent all of the packet with R902. When asked about the section of the discharge documentation that included a second nurse witness signature, Nurse 'F' reported their understanding was that was something the business office follows-up. Nurse 'F' was asked if family was present at the time of discharge and they reported there was no family around at that time.When asked if they had spoken to anyone that night about not allowing R902 to return, Nurse 'F' reported they had spoken to R902's wife that night and verbally told her we will not be accepting him back because the abuse that night was very dangerous and was not sure what she didn't understand. Nurse 'F' further reported they spoke to the wife on the phone and gave her a call back because she said she was unfamiliar with the area, so they called her back and gave address and phone number to where R902 was discharged .Nurse 'F' further reported the family questioned about the facility not taking R902 back and they said that was for management to explain and their orders from the DON and Administrator were R902 to be sent out with a no return.On 3/9/26 at 12:36 PM, the facility was requested by email to provide policies for Facility Initiated Discharges, Bed Hold, Hospital and Therapeutic Leave, Re-Admission, and Notice of Transfer or Discharge.On 3/9/26 at 12:59 PM, Admissions/Financial Staff 'E' was attempted to be contacted by phone, and a message was left to return the call.Review of the documentation provided by the Administrator included:A policy titled, Bed Hold Hospital and Therapeutic Leave re-admission dated 8/2017 documented, in part: .When a resident has a temporary absence from the facility for emergency medical treatment, the facility will hold a bed open for ten (10) days for that resident's absence .The facility will re-admit a discharged resident who has an expectation of returning to the facility unless .The discharge was necessary of the resident's welfare and the needs of the resident cannot be met in the facility .The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident . It should be noted that this policy included references of specific federal regulations that were obsolete and had not been updated with current regulatory references.A policy titled, Notice of Transfer or discharge date d July 2023 documented, in part: .Facility Initiated transfer or discharge: A transfer or discharge to which the resident objects, did not originate through a resident's verbal or written request, and / or is not in alignment with the residents stated goals for care and preferences .Facility - Initiated Transfer (FIT) .The FIT-100 form and process will be used when there is a transfer of a resident from the federally certified nursing home to another facility, such as acute care hospital, with the expectation that the resident will return to the federally certified nursing home .Prepare .FIT-100 .Provide the FIT-100 form to the resident and / or authorized representative along with an envelope and postage for an appeal request .A copy of this notice will be placed in the resident's medical record .Involuntary Transfer or Discharge (IDT) and Facility-Initiated Discharge .Prepare the ITD-100 form - Have an initial discussion with he <sic> resident and / or authorized representative to assist in identification of transfer or discharge location .If the destination changes and this change was initiated by the facility, and updated notice with the new destination will be issued. The change restarts the 30-day timeline for transfer or discharge .Provide the completed ITD-100 form to the resident and / or authorized representative at least 30-days prior to an involuntary transfer or discharge along with an envelope and postage for appeal request .A copy of the ITD-100 form must be submitted to Licensing and Regulatory Affairs ([NAME]) .A copy of the ITD-100 form must be included in the resident's medical record .The resident shall not be transferred or discharged from the facility .Before the 34th day following receipt of the notice or the 10th day following appeal hearing decision, whichever is later, and .Without [NAME] approval of the proposed transfer or discharge plan .[NAME] will provide written approval of acceptance of the proposed transfer or discharge plan .The approval of the proposed transfer or discharge plan shall be placed in the residents' medical record .On 3/9/26 at approximately 1:30 PM, an exit conference was conducted with the Administrator and DON. When informed of the concerns for R902's discharge and the facility's decision not to allow R902 to return, the Administrator reported the facility could not meet R902's needs. The Administrator was asked to review the documentation included with the transfer packet which was left incomplete and confirmed the same missing documentation. When asked if they had notified the ombudsman in writing of R902's transfer and decision not to readmit, the Administrator reported they had a phone conversation, but notification did not include the written notification. The Administrator was further informed of the concern that the documentation of the specific local ombudsman had not been updated to reflect the current ombudsman, as well as their policy provided referenced outdated regulations and had not been updated since 8/2017.On 3/9/26 at 2:13 PM, a phone interview was conducted with the Admissions/Financial Staff 'E'. When asked what they could recall regarding the details of R902 not being allowed to return to the facility, Staff 'E' reported they've been out of the facility since Friday (3/6/26) and wasn't there for a majority of it. When asked if they were involved in the involuntary discharge process, Staff 'E' reported they were not, unless it was due to a financial reason.When asked if they were involved in the bed hold process, Staff 'E' reported they would call to discuss bed hold details, but they had not done that for R902 since they've been out since last Friday. When asked if there was back-up person for their role in the event they were out, Staff 'E' reported their back-up was Medical Records 'B' and the Administrator.

This citation pertains to complaint 2797202.Based on interview and record review, the facility failed to permit a resident to return to the facility following a transfer to hospital for one (R902) of four residents reviewed for discharge. Findings include:Review of a complaint reported to the State Agency included allegations that the facility sent R902 to the hospital on 3/5/26 and refused to allow them to return, and the family never received written discharge notices as required.Review of the clinical record revealed R902 was initially admitted into the facility on 2/19/26 and was discharged to hospital on 3/5/26 and had not returned. Diagnoses included: chronic kidney disease stage 3A, anxiety disorder, personal history of traumatic brain injury, vascular dementia severe with other behavioral disturbance, dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, mild cognitive impairment of uncertain or unknown etiology, and age-related cognitive decline. The clinical record further identified that R902's wife was their responsible party, emergency contact #1, and power of attorney for care and financial decisions.According to the admission Minimum Data Set (MDS) assessment dated [DATE], R902 had severe cognitive impairment, had physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others, which occurred 1 to 3 days that significantly interfered with the resident's care and significantly interfered with the resident's participation in activities or social interactions, put others at significant risk of physical injury, significantly disrupted care or living environment, and had wandering behavior that placed the resident at significant risk of getting to a potentially dangerous place or significantly intruded on the privacy or activities of others, was independent with mobility, required supervision or touching assistance with walking at least 10-150, and was frequently incontinent of bowel and bladder.Review of the hospital documentation provided to the facility prior to R902's admission included: .History of Present Illness Patient is a [AGE] year old male with a past medical history of Cognitive impairment.that presents to [hospital name] on 01/20/2026 with chronic dementia, agitation, need for inpatient psychiatry evaluation and placement.All of the following history was obtained from patient's son at bedside and best attempt was made at accuracy. Son states that his dad was originally admitted on [DATE] following a behavioral outburst at home. He requires 24-hour care at baseline at home due to his cognitive impairment and that is mostly done by his wife, including feeding, medication administration, personal hygiene, toileting, fecal and urinary incontinence measures. He started having behavioral outburst lasting 8 hours including shouting nonsensical words, slamming doors and tipping over family's table. This event prompted family to seek nursing home/psychiatric facility placement for him. He reports he previously had 10-minute spells of similar behavior. He reports that his dad has had cognitive decline over the past 20 years.Hospital discharge notes: Son reports that patient routinely requests his wife to shower with him, becomes aggressive, and she feels that she does not want to do so. Per son, patient's wife feels that she is overwhelmed with taking care of the patient's needs. Per son, history is complicated with previous discharge from [hospital name] psychiatric health facility, and they were unaware that patient had been discharged . Family is not planning on discharge home however facility had dropped off the patient back at their house, not appropriately dressed for 15 degree weather. House was found locked up, so taxi driver took patient back to [psychiatric hospital] facility where he was rejected. From there, family tried frantically calling the facility however were not able to reach them in a timely manner. Patient was found by a random stranger who happened to know of a group home; she took care of the patient for short while, provided clothes, food and other necessities. After some time in the AFC (Adult [NAME] Care) however the patient escaped left the facility without permission, and per son was not allowed back in the facility. At that time, the group home decided that the patient would not be a good candidate to live in the facility alongside other residents. That is when the two sons [NAME] the patient into the hospital. His son reports that his father is mostly bedbound, requires constant support to get out of bed. He routinely urinates on himself and requires people to help him change clothes. He is also frequently incontinent routinely.One-to-one ordered. Patient had previously escaped the ED (Emergency Department).Psychiatry consulted.PSYCH Consulted. Agitation/Neurocognitive disorder -Continue Seroquel 25mg (milligrams) pO (by mouth) BID (Twice a Day) - RECOMMEND CLOSE Follow up PSYCH at Discharge. His condition improved, symptoms improved, mentation improved to baseline and remained stable.This documentation confirmed the facility had been aware of R902's extensive history of behaviors which included aggression, wandering and non-compliance and continued to accept the resident for admission into their facility.Further review of the progress notes included multiple incidents of R902 exhibiting exit seeking and physical behaviors (swinging, kicking, spitting, swearing) in which nursing staff obtained additional intramuscular (IM) psychotropic medication to administer to R902.Progress notes entries included:An entry on 3/6/26 at 1:36 AM by Nurse 'H' read: Ems (Emergency Medical Services) attempted return of resident at this time staff nurses made Ems aware that we could not provide care for resident d/t (due to) his behavior [name redacted] from [name of local hospital resident was sent to] called to inquire why resident was refused writer explained that order were given for a do not return r/t (related to) facility unable to maintain his needs r/t aggressive and combative behavior and that resident has again attacked a staff member, he was given Admin (Administrator) and [NAME] (Director of Nursing) information and stated he would reach out to facility in the am (morning).Review of a form titled, FACILITY-INITIATED TRANSFER FOR NURSING HOMES dated 3/5/26 was noted as Reason(s) for facility-initiated transfer.Behavioral needs cannot be met in the nursing home.Explanation for the reasons identified above: combative with STAFF hitting, kicking, spitting, had her shirt collar and pulling her shirt up around her neck.On 3/9/26 at 10:06 AM, an interview was conducted with the facility's social services staff (SS 'C'). When asked if they were involved in the admission process for consideration of R902's placement in the facility, SS 'C' reported they were not. When asked about R902's behaviors, SS 'C' reported they assumed he had front lobe dementia, exit seeked, yelled, spit and towards the end was getting aggressive with staff. They reported they were not there when R902 became physical with staff.SS 'C' further reported they believed the resident's admission status was completely different than what they received. When asked what that meant, SS 'C' reported they said he couldn't walk but he could walk just fine. They reported the resident had been followed by psych while at the facility and they had conversation with R902's son about medication requests, but that was up to the psych provider who chose not to order what the family wanted.When asked if they were involved in the discussion with Administration to not allow R902 to return, SS 'C' reported they were not but was aware it was due to exit seeking and aggression. SS 'C' reported they did have discussion with the family about more appropriate placement such as a locked memory unit and they did not want to do that. When asked why the facility would accept R902 given the extensive behaviors that were available, SS 'C' reported they think the facility focused on the fact R902 was bedbound and thought we could handle this.SS 'C' also reported at the time the admission person (Staff 'E') went to see R902 and R902 was just loud and stated he had dementia. When asked when the facility initiated one to one assigned staff, SS 'C' reported that was after his exit seeking behaviors and the night of the transfer, he beat up the one to one and that's when we discharged him and said he was unsafe here for my staff and other residents. When asked about the process for discharge notifications, especially involuntary discharges, SS 'C' deferred to their Director of Nursing (DON).On 3/9/26 at 10:30 AM, an interview was conducted with the DON. When asked if they were involved in R902's transfer to the hospital, the DON reported they were not but did report they received a call after 10:00 PM that he was sent out after assaulting staff.When asked if they had spoken to anyone about not allowing R902 to return, the DON reported (name of hospital) called and asked if we would take them back and we said no. We also called the ombudsman and spoke with Ombudsman 'J' and let her know we were not accepting R902 back. The DON reported Ombudsman 'J' reported they would have to advocate for R902.When asked if they were involved in the admission process, the DON reported their facility's process had a green, yellow, red light for what they could take and believe a corporate person reviews that and notifies the facility and the Administrator decides as to if they can handle the resident. The DON reported they thought someone did onsite him which wasn't done for everyone but was for him.When asked if the facility had been aware of R902's extensive behavior history and was evaluated and determined they could accept the resident, how was it now determined they could not, the DON reported they were aware R902 had those behaviors at home but believed at the hospital the resident was stable. The DON reported when R902 arrived to their facility, he was able to ambulate independently and they thought within 12 hours of arrival, R902 was kicking at the doors.On 3/9/26 at 11:50 AM, Ombudsman 'J' was attempted to be contacted by phone and a message was left to return the call. There was no return call by the end of the survey.On 3/9/26 at 12:45 PM, a phone interview was conducted with Nurse 'F'. When asked to recall the events from the night R902 was sent out, Nurse 'F' reported the same events as their documented progress note. Nurse 'F' was asked about the documentation of the transfer packet and they reported they sent all of the packet with R902. When asked about the section of the discharge documentation that included a second nurse witness signature, Nurse 'F' reported their understanding was that was something the business office follows-up. Nurse 'F' was asked if family was present at the time of discharge and they reported there was no family around at that time.When asked if they had spoken to anyone that night about not allowing R902 to return, Nurse 'F' reported they had spoken to R902's wife that night and verbally told her we will not be accepting him back because the abuse that night was very dangerous, and was not sure what she didn't understand. Nurse 'F' further reported they spoke to the wife on the phone and gave her a call back because she said she was unfamiliar with the area so they called her back and gave address and phone number to where R902 was discharged .Nurse 'F' further reported the family questioned about the facility not taking R902 back and they said that was for management to explain and their orders from the DON and Administrator were R902 to be sent out with a no return.On 3/9/26 at 12:36 PM, the facility was requested by email to provide policies for Facility Initiated Discharges, Bed Hold, Hospital and Therapeutic Leave, Re-Admission, and Notice of Transfer or Discharge.On 3/9/26 at 12:59 PM, Admissions/Financial Staff 'E' was attempted to be contacted by phone, and a message was left to return the call.Review of the documentation provided by the Administrator included:A policy titled, Bed Hold Hospital and Therapeutic Leave re-admission dated 8/2017 documented, in part: .When a resident has a temporary absence from the facility for emergency medical treatment, the facility will hold a bed open for ten (10) days for that resident's absence .The facility will re-admit a discharged resident who has an expectation of returning to the facility unless .The discharge was necessary of the resident's welfare and the needs of the resident cannot be met in the facility .The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident . It should be noted that this policy included references of specific federal regulations that were obsolete and had not been updated with current regulatory references.A policy titled, Notice of Transfer or discharge date d July 2023 documented, in part: .Facility Initiated transfer or discharge: A transfer or discharge to which the resident objects, did not originate through a resident's verbal or written request, and / or is not in alignment with the residents stated goals for care and preferences .Facility - Initiated Transfer (FIT) .The FIT-100 form and process will be used when there is a transfer of a resident from the federally certified nursing home to another facility, such as acute care hospital, with the expectation that the resident will return to the federally certified nursing home .Prepare .FIT-100 .Provide the FIT-100 form to the resident and / or authorized representative along with an envelope and postage for an appeal request .A copy of this notice will be placed in the resident's medical record .Involuntary Transfer or Discharge (IDT) and Facility-Initiated Discharge .Prepare the ITD-100 form - Have an initial discussion with he <sic> resident and / or authorized representative to assist in identification of transfer or discharge location .If the destination changes and this change was initiated by the facility, and updated notice with the new destination will be issued. The change restarts the 30-day timeline for transfer or discharge .Provide the completed ITD-100 form to the resident and / or authorized representative at least 30-days prior to an involuntary transfer or discharge along with an envelope and postage for appeal request .A copy of the ITD-100 form must be submitted to Licensing and Regulatory Affairs ([NAME]) .A copy of the ITD-100 form must be included in the resident's medical record .The resident shall not be transferred or discharged from the facility .Before the 34th day following receipt of the notice or the 10th day following appeal hearing decision, whichever is later, and .Without [NAME] approval of the proposed transfer or discharge plan .[NAME] will provide written approval of acceptance of the proposed transfer or discharge plan .The approval of the proposed transfer or discharge plan shall be placed in the residents' medical record .On 3/9/26 at approximately 1:30 PM, an exit conference was conducted with the Administrator and DON. When informed of the concerns about R902's discharge and the facility's decision not to allow R902 to return, the Administrator reported the facility could not meet R902's needs. The Administrator was asked to review the documentation included with the transfer packet which was left incomplete and confirmed the same missing documentation. When asked if they had notified the ombudsman in writing of R902's transfer and decision not to readmit, the Administrator reported they had a phone conversation, but notification did not include the written notification. The Administrator was further informed of the concern that the documentation of the specific local ombudsman had not been updated to reflect the current ombudsman, as well as their policy provided referenced outdated regulations and had not been updated since 8/2017.On 3/9/26 at 2:13 PM, a phone interview was conducted with the Admissions/Financial Staff 'E'. When asked what they could recall regarding the details of R902 not being allowed to return to the facility, Staff 'E' reported they'd been out of the facility since Friday (3/6/26) and wasn't there for a majority of it. When asked if they were involved in the involuntary discharge process, Staff 'E' reported they were not, unless it was due to a financial reason.

This citation pertains to Complaint #2709480.Based on observation, interview, and record review, the facility failed to appropriately evaluate the placement of the bed to prevent accident hazards for one (R901) of one resident reviewed for accident hazards, resulting in R901 sustaining a thermal burn to their right great toe after it made contact with the baseboard heater which was directly next to the bed. Findings include: A review of complaints submitted to the State Agency revealed an allegation that R901's foot had direct and prolonged contact with an exposed Hydronic (water) baseboard heat. Due to R901 having neuropathy (damaged nerves), they were unaware they were being burned. When staff pulled their foot away from the metal heater, it resulted in skin tearing and severe bleeding, consistent with a significant burn injury. It was noted R901 had a diagnosis of Alzheimer's Disease.On 1/20/26 at 10:38 AM, R901 was observed lying in bed. R901 was pleasant, but when asked questions, was unable to clearly answer them. R901's bed was located a floor mat's length away from a metal baseboard heat register. When touched, the metal on the top of the heater was warm to the touch. On 1/20/26 at approximately 10:40 AM, an observation of R901's right great toe was conducted with Licensed Practical Nurse (LPN) 'C'. The bottom of R901's right great toe was observed to have a round, dry, black area covering most of the bottom of the toe. A review of R901's clinical record revealed R901 was admitted into the facility on 2/21/22 and readmitted on [DATE] with diagnoses that included: cerebral atherosclerosis, type 2 diabetes mellitus with neuropathy, and peripheral vascular disease (circulatory disease). A review of R901's Minimum Data Set (MDS) assessment dated [DATE] revealed R901 had moderately impaired cognition, required substantial/maximal assistance for rolling left to right. R901 was signed onto hospice services on 6/24/25.A review of R901's progress notes revealed the following:An Alert Note dated 1/3/26 at 8:29 AM written by Licensed Practical Nurse (LPN) 'D' that read, Writer was started [sic] shift and rounds at approx. 6:45 am. Resident was observed sleeping. After a few rounds were complete by CNA (Certified Nursing Assistant). CNA was proceeding to do care when she observed his (R901) foot with injury and bleeding. Resident was accessed [sic] by writer for injury and pain .Resident appeared confused due to facial expression. Right big toe was observed bloody and newly injured. Normal saline, 4x4 and Kerlex [sic] was applied. Resident is a hospice patient. DON (Director of Nursing) was contacted as immediately as she is the abuse officer, family and hospice nurse was also notified. Awaiting hospice nurse to call back with transfer to the hospital preference .An Interdisciplinary Documentation note dated 1/3/26 at 10:23 AM written by the DON that read, In to see resident .Examined right foot. On plantar (bottom) surface of right great toe open blister 4 cm (centimeters) x (by) 3 cm with serous (thin, watery) fluid. Adjacent to blister is open area 0.5 cm x .3 (0.3) cm x 0.2 cm . (R901) does not have sensation to feet or lower legs .Hospice will be in to evaluate today .A review of a Hospice Visit Note Report dated 1/3/26 revealed the following documentation, Received patient in dining area .Writer then located facility DON .who reports that facility aide went in to [sic] patient's room this morning to get him up and discovered that patient had hung his right leg over the bed and found his right great toe was touching the baseboard heating unit. Patient has neuropathy and does not have feeling to his feet. Aide discovered large blister to bottom of right great toe with small area where skin was open. Some bleeding also present .Wound Assessment .Patient with burn to plantar surface of right great toe .A review of a Progress Note dated 1/5/26, written by Physician 'E' revealed, Resident is seen today .to assess an injury involving residents right great toe which occurred on 1/3/2026. Resident had been noted, at that time, to have his right big toe resting on the heater in this room. There was initial bleeding to the area and subsequent blister .DIAGNOSIS AND ASSESSMENT .Blister of great toe .A review of a Health Care Practitioner Note dated 1/5/26, written by Nurse Practitioner (NP) 'F', revealed, .Nursing home staff interviewed and reported on plantar surface of right great toe the member had sustained a burn that occurred on 01/03/25 (2026) from the heater next to member's bed. A hospice nurse came out on 01/03/26 to assess the wound, she spoke with the on-call MD (Medical Doctor) per her notes who approved current treatment plan .The right great toe + (positive for) erythema (redness), + swelling, warm to touch, the plantar surface of the toe had a dry flat denuded (outer layer of skin missing) blister with scant serous drainage, underneath the blister was what appeared to be a hematoma (bruise) .Assessment .Plan .Burn Active Acute right great toe .On 1/20/26 at 12:16 PM, an interview was conducted with Maintenance Director 'G'. When queried about whether beds were typically positioned against the baseboard heater units, Maintenance Director 'G' reported he believed that was how the rooms were set up. Maintenance Director 'G' reported after the incident with R901, all beds were moved away from the heaters and fall mats, nightstands, and/or PVC pipes were used to ensure the beds did not get pushed against the heaters. A review of an incident report for R901 dated 1/3/26 at 7:30 AM, completed by LPN 'D', revealed, Resident was observed during rounds by writer sleeping. Within 15 to 30 minutes later aide was assisting resident with ADL (activities of daily living) care and stated she witnessed Resident's right foot, specifically right big toe on the heater in his room and proceeded to remove it and noticed bleeding coming from the right toe . In the Notes section it was documented on 1/19/26 that On January 3, 2026, (R901) sustained a thermal injury (burn) to the right great toe when his extremity came into contact with a wall heating register. The incident occurred while the resident was positioned in bed, which had been placed adjacent to the heating unit .The root cause of the incident was the placement of the resident's bed in close proximity to a wall-mounted heating register, creating an environmental hazard. The bed placement was intended to mitigate fall risk and facilitate transfers, however, it inadvertently introduced a unforeseeable burn risk .On 1/20/26 at 2:53 PM, an interview was conducted with LPN 'D' via the telephone. LPN 'D' explained when she did rounds on 1/3/26, she did not notice R901's foot on the heater, but did ensure she called his name and he responded with no signs of distress. About 10 to 20 minutes later, a CNA yelled out for her and when LPN 'D' went to R901's room, the CNA told her R901's foot had to be pulled off of the heater which was next to the bed. At the time LPN 'D' entered the room, the CNA had already moved R901's foot and it was bleeding. LPN 'D' reported she had to apply pressure to stop the bleeding. LPN 'D reported when she did rounds R901 was positioned on his side with his right foot lying over the left foot. On 1/20/26 at 3:36 PM, an interview was attempted with CNA 'H' via the telephone. There was no option to leave a message. CNA 'H' was not available prior to the end of the survey. A review of an investigation conducted by the facility revealed the following:A written statement from CNA 'H' that noted, On January 3, 2026, I (CNA 'H') was passing hall trays, when I got to (R901) room I noticed blood on the wall, the lady passing waters stated that his legs bleed. So I went over to observe. I didn't see anything on his legs that's when I lifted the bottom of his foot and noticed the injury. I then notified the nurse.A written statement from LPN 'D' that noted, .Upon rounding I observed patient position on his side breathing and without pain or discomfort. I called his named [sic] and he responded with no sounds of distress. That was approximately 6:45 AM. I was rounding on other patient, counting and getting report from nurse on previous shift. After tending to another patient with blood sugar matter, CNA called out for a nurse. I responded and she told me 'Resident foot was removed from heat register and was bleeding.' I went into his room inspect the right big toe to observed the bleeding .On 1/20/26 at 3:15 PM, an interview was conducted with the DON. When queried about what happened with R901, the DON reported the nurse did not observe R901's foot on the heater during rounds and about a half hour later a CNA notified her that R901's foot was on the heat register and when she moved it, it was bleeding. The DON assessed the wound, as well as the hospice nurse sent a picture to the hospice physician to determine appropriate treatment. The DON reported it was determined the wound was a burn, but did not know the degree of the burn. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the following: On 1/3/26, R901's bed was moved away from the heat register, first aid was provided, the wound was assessed, the care plan was updated, and R901 was observed for 72 hours for safety and positioning. On 1/5/26, R901's wound was assessed by facility medical provider and additional treatment orders and antibiotics were started. A facility-wide assessment identified other residents potentially affected and environmental barriers were placed (fall mats, nightstands, and the use of PVC pipes), and bed positioning was corrected. Staff education was initiated regarding minimum clearance requirements between beds and heating units. Daily environmental rounds were conducted to ensure compliance and prevent recurrence, and findings were reviewed by Quality Assurance Committee to ensure continued compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake 2615411Based on record review and interview, the facility failed to secure medication storage in an unlocked medication cart (Sapphire Cart) allowing one resident (R904) to gain access to another resident's medications resulting in one medication, Namenda (medication to treat moderate to severe dementia) never recovered.Findings Included:A Facility Reported Incident (FRI) received by the State Agency revealed on 9/1/25 at 9:30 AM, R904 was observed with three pill packets and several loose pills in their left pant pocket. All medications were reconciled apart from the Namenda.Clinical record review revealed R904 was admitted to the facility on [DATE] for long term care and had a medical history of diabetes, urinary retention, and falls related to muscle weakness. R904 was independent in a wheelchair for short distances, alert and orientated to person and place and was their own responsible party. R904 had a documented Brief Interview mental Status (BIMS) score of 8/15 indicating moderate cognitive impairment.A telephone interview on 1/20/26 at 2:33 PM, with Registered Nurse (RN) B acknowledged and took full responsibility for leaving the Sapphire Medication Cart unlocked. On 9/1/25 RN B recalled they were very busy that morning and when they went to assist another resident with their breakfast, they must had walked away from the medication cart and did not lock it. RN B said they were informed by one of the Certified Nurse Assistants (CNA) they saw R904 had pill packets hanging out from their pant pocket and when confronted, R904 blamed another resident had the medications, took them from them, and was going to tell the staff. RN B said they immediately notified the Director of Nursing (DON), which a cart audit was conducted, and all medications were accounted for except one (Namenda).On 1/20/26 at 4:05 PM, the DON and Nursing Home Administrator (NHA) confirmed no nursing staff could start their shift without one-to-one education with the DON on the Medication Storage Policy. Observation audits were conducted for the entire month of September 2025 daily and at each eight-hour shift verifying medication cart were locked.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education of the medication storage policy and documented observation audits verifying medication carts were locked. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Complaint #2649116 and Incident #2652020.Based on observation, interview, and record review, the facility failed to ensure physical restraints were not utilized for staff convenience to restrict movement of the resident's arms for one (R801) of three residents reviewed for abuse, resulting in a severely cognitively impaired resident's shirt sleeves being tied together to prevent them from grabbing onto staff causing psychosocial harm using the reasonable person concept. Findings include: A review of a complaint submitted to the State Agency (SA) revealed an allegation that R801, who had severe dementia and could not communicate, had her sleeves tied together by Certified Nursing Assistants (CNAs) 'C' and 'D' in order to treat her.A review of a second complaint submitted to the SA revealed an allegation that R801, who had Alzheimer's Disease and did not have the capacity to make decisions, had the hands of her sleeves tied together by staff on 10/15/25 because she was aggressive and agitated. It was alleged staff left the room for at least an hour and left R801 in restraints, unattended. It was alleged there were concerns R801 was not being aggressive or agitated when she was restrained because she had never behaved in that manner. It was noted R801 was prescribed Ativan (a medication used to treat anxiety) and Morphine (a medication used to treat severe pain) as comfort medications if she became aggressive or agitated that they were not given. On 10/29/25, an onsite investigation was conducted.On 10/29/25 at 8:50 AM, R801 was observed lying in bed. R801 appeared thin and frail. An interview was attempted. R801 made eye contact but was not able to answer any questions. A review of R801's clinical record revealed R801 was admitted into the facility on 4/11/25 and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition, unclear speech, did not have any behaviors during the assessment period, and was dependent on staff for all activities of daily living (ADL), transfers, and bed mobility. R801 signed onto hospice services on 5/20/25. A review of R801's progress notes revealed an Interdisciplinary Documentation note dated 10/21/25 that read, On 10-14-2025 (R801) had an incident that was reported to the (SA) as she was observed with her shirt sleeves to be tied together. Upon identification the nurse did evaluate her and she had no injuries from the incident .Through staff interviews and investigation of the incident it was identified that she has increased behaviors and can be combative with care at times .Further review of R801's progress notes revealed no documentation of behaviors exhibited by R801 on 10/14/25, the night of the incident mentioned above. A review of a Facility Reported Incident (FRI) investigation submitted to the SA revealed the following Investigation Summary:On 10/14/25 around 10:10 PM-11PM, (CNA 'C') tied (R801's) shirt sleeves together in attempt to prevent (R801) from physically scratching, hitting or pinching (CNA 'C') during care. (R801) is care planned for 2 assist with bed mobility, but (R801) instead provided care by herself and tied the sleeves together instead of having a second staff assist and distract. Staff untied (R801's) shirt sleeves around 11PM .The documented Allegation Details noted, DHCS (Director of Health Care Services) received a voice mail message on 10/15/25 from (CNA 'G') that a resident (R801) was noted with her shirt sleeves tied together. The CNA reported that resident was unable to move her arms. The nurse was notified and untied the resident.On 10/29/25 at 11:35 AM, an interview was conducted with CNA 'C' via the telephone. CNA 'C' confirmed she was no longer employed by the facility. When asked why, CNA 'C' reported she was not sure. When queried about what happened with R801 on 10/14/25, CNA 'C' reported herself and CNA 'D' went into R801's room to do a last check and change (at the end of the afternoon shift). CNA 'C' reported CNA 'D' wiped her down while R801 was lying on her back. CNA 'C' explained R801 had an indwelling urinary catheter and CNA 'D' was wiping down her front. CNA 'C' further reported R801 began scratching at CNA 'D' and scratching at her (CNA 'C'), digging her finger nails into CNA 'C' and was combative. CNA 'C' reported R801 had the same reaction when nurses did her wound treatments. CNA 'C' explained she then put the end of her sleeves together so she couldn't scratch us. CNA 'C' reported they were about to weigh R801 using the mechanical lift and Registered Nurse (RN) 'F' entered the room and asked CNA 'C' and CNA 'D' to stop providing care to R801 and assist with another resident who was trying to get out of bed. CNA 'C' further reported they stopped what they were doing, left the room to attend to the other resident, and forgot to go back to (R801) and she was left with her sleeves tied. CNA 'C' reported she notified RN 'F' that R801 was fighting with them during care, but no direction was given. CNA 'C' explained she did not think tying R801's sleeve together was a restraint, and she was just trying to look out for her (CNA 'C') and CNA 'D's safety. On 10/29/25 at 12:15 PM, an interview was conducted with CNA 'D' via the telephone. CNA 'D' confirmed she worked day shift on 10/14/25 and stayed over for the afternoon shift. When queried about what happened with R801 on 10/14/25, CNA 'D' explained that shift was chaotic. CNA 'D' reported she worked with CNA 'C' to try to tend to everything going on. CNA 'C' asked CNA 'D' to assist with weighing R801 and CNA 'D' told her she was going to help another resident and then would come to assist with R801. CNA 'D' reported she went into R801's room around 9:00 PM or 10:00 PM and CNA 'C' had already completed care for R801 and she was lying on the sling for the mechanical lift. CNA 'D' controlled the lift and then RN 'F' frantically entered the room and said we had to get out there to help another patient so we immediately left out of the room. CNA 'D' reported she did not notice R801's sleeves being tied together. When queried about any behaviors R801 had, CNA 'D' reported R801 did grab and pinch when she was in pain during care, mainly wound care, but you could usually get her to let go. When queried about any other care provided to R801, CNA 'D' reported she checked her urinary catheter drainage bag earlier, but did not provide any other care. When queried about whether R801 exhibited any behaviors when she was assisting CNA 'C', CNA 'D' stated, Just the usual. Yelling out in pain a little bit, but not in distress or anything like that. It should be noted that CNA 'C' and CNA 'D's statements conflict with one another in regards to whether CNA 'D' was in the room when CNA 'C' tied R801's sleeves together. A review of the statements included in the facility's investigation file revealed the following:An unsigned statement obtained via the telephone from CNA 'C' on 10/15/25 documented, (R801) fights, bites, scratches, and claws during personal care. On 10/14 at around 10:10 PM to 10:20 PM I tied her sleeves together so she would not hurt me as I was washing her up and doing peri care. (CNA 'D') was helping me with care. We had to get a weight for (R801). As we were doing that, nurse (RN 'F') called us urgently to help with (another resident) because she was climbing out of bed. I meant to go back and untie the sleeves, but I forgot. I did not tell (RN 'F') about (R801) fighting because she always fights and everyone knows it .A statement signed on 10/23/25 obtained via the telephone on 10/25/25 from CNA 'D' documented, On afternoon shift on 10/14 at around 10:20 PM, (CNA 'C') was doing (R801) while I was doing (another resident). As soon as I was done I went into the room with (R801). I did not help with (R801's) care at all. When I came in, the sling was under (R801) so we could get her weight As we were doing that, (RN 'F') called us to help with (another resident) who was climbing out of bed so we left (R801) and went to (the other resident). (R801) always fights. She grabs at you, claws, pinches, scratches. She does this all the time when you give her care. She will even pull on the curtain if she can reach it. I did not tell the nurse this. It is known that she always does this. When we were doing (R801's) weight, I was on the lift controls and was reading the weight. I did not notice her sleeves were tied together. I did not know it .On 10/29/25 at 12:38 PM, an interview was conducted with RN 'E', the nurse who worked on 10/15/25 when R801 was found to be restrained by her sleeves. RN 'E' reported she no longer worked at the facility. When queried about what happened with R801 on 10/15/25, RN 'E' reported R801 was very fragile, elderly, contracted, with bed sores. RN 'E' explained when laying still, R801 did not exhibit any signs or symptoms of pain, but when providing care she became very active, cries, yells, flails. On 10/14/25, RN 'E' reported the off-going CNAs (CNA 'C' and CNA 'D') left suddenly. RN 'E' reported she thought they worked a double shift, had a lot going on, and just wanted to leave. RN 'E' said she did not receive any report from the CNAs. The oncoming CNAs (CNA 'G' and CNA 'H') were checking on their residents at the beginning of the shift and one came to get RN 'E' and asked why R801's hand would be tied up. RN 'E' went to look at R801 and saw she had on a thin, long sleeved t-shirt and the openings of each sleeve were tied together. RN 'E' reported as soon as she saw that, she had the CNA untie the sleeves and RN 'E' left the room. RN 'E' reported she stayed in the room for a minute or two and did not observe any signs of distress from R801. RN 'E' reported the CNAs from the previous shift (CNA 'C' and CNA 'D') arrived at the end of her shift (midnight shift) coming on for the day shift and when she asked why they tied up R801's sleeves, one CNA said it was because R801 was pinching them during care. On 10/29/25 at 12:55 PM, an interview was conducted with RN 'F', the nurse who worked the night R801 was restrained. When queried about whether any behaviors exhibited by R801 were reported to her during that shift, RN 'F' reported nothing was reported to her. When queried about R801's behaviors, RN 'F' reported at her baseline, R801 put her hands back and fussed when care was provided, but that was her baseline. RN 'F' reported there were many interventions that could be used with R801 to make her more comfortable during care, but she was not notified. RN 'F' reported she did not see that R801 was restrained on that shift, as she only provided a nutritional supplement earlier in the shift around 4:00 PM and 5:00 PM. RN 'F' denied asking CNA 'C' and CNA 'D' to leave R801's room to help another resident and said she only asked CNA 'C' to assist with a skin assessment, but that request was made in the hallway and not in R801's room.On 10/29/25 at 1:23 PM, an interview was conducted with CNA 'G' via the telephone. When queried about what happened with R801 on 10/14/25, CNA 'G' reported she arrived for her shift (midnight shift) with another CNA and they talked to the two CNAs who were leaving their shift (afternoon shift). CNA 'G' reported the other CNAs (CNA 'C' and CNA 'D') worked for 16 hours and did not want to do rounds with CNA 'G' and CNA 'H' and they were in a hurry to get out of there. CNA 'G' explained typically the on-coming and off-going CNAs walked from room to room prior to leaving, but they said everyone was fine and left. CNA 'G' began rounds when CNA 'H' came to her and showed her that R801's shirt sleeves were tied together. CNA 'G' described it as both sleeves were tied together so when R801 lifted her hands it formed a circle. CNA 'G' explained CNA 'H' got the nurse and CNA 'H' and the nurse untied R801's sleeves. CNA 'G' reported when she left for her shift, the same CNAs (CNA 'C' and CNA 'D') arrived for their shift (day shift) and she brought up how she found R801 restrained and they denied that they did it. When queried about any behaviors R801 had, CNA 'G' reported R801 was on hospice and can't really move. CNA 'G' explained that when anyone does any kind of care, R801 was kind of resistive, but does not strike out or yell or anything. She tries to hold her gown or a blanket. CNA 'G' felt R801 did that because she had pain. Further review of R801's clinical record revealed no documented behaviors for 10/14/25. A review of R801's care plans revealed no specific or individualized targeted behaviors or interventions until after R801 was physically restrained on 10/14/25.On 10/29/25 at 2:06 PM, an interview was conducted with the Administrator. The Administrator reported she was not the Abuse Coordinator for the facility and that was the Director of Nursing (DON) who was not available during the survey. The Administrator reported she was still made aware of any abuse situations in the facility and was made aware of R801 being physically restrained. The Administrator reported CNA 'C''s employment with the facility was terminated after the incident. On 10/29/25 at 2:44 PM, an interview was conducted with Unit Manager, RN 'A'. When queried about R801 and what staff should do if she became resistive to care or had any combative behaviors, RN 'A' reported staff should stop care and reapproach after a moment and notify the nurse in case the resident was experiencing any pain. RN 'A' reported typically one staff member held R801's hand while the other one provided the care.A review of a facility policy titled, Restraint Protocol, revised November 2008, revealed, in part, the following, It is the policy of this facility to ensure the residents right to be free from physical .restraints used for the purpose of discipline or for staff convenience .Physical Restraints: Is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .

This citation pertains to Complaint #2649116 and Incident #2652020.Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the Abuse Coordinator and State Survey Agency within the required timeframe for one (R801) of three residents reviewed for abuse, resulting in a delay in investigation and the alleged perpetrators continuing to work with the victim. Findings include:A review of a complaint submitted to the State Agency (SA) revealed an allegation that R801, who had severe dementia and could not communicate, had her sleeves tied together by Certified Nursing Assistants (CNAs) 'C' and 'D' in order to treat her.A review of a second complaint submitted to the SA revealed an allegation that R801, who had Alzheimer's Disease and did not have the capacity to make decisions, had the hands of her sleeves tied together by staff on 10/15/25 because she was aggressive and agitated. It was alleged staff left the room for at least an hour and left R801 in restraints, unattended. It was alleged there were concerns R801 was not being aggressive or agitated when she was restrained because she had never behaved in that manner. It was noted R801 was prescribed Ativan (a medication used to treat anxiety) and Morphine (a medication used to treat severe pain) as comfort medications if she became aggressive or agitated that they were not given. On 10/29/25, an onsite investigation was conducted.On 10/29/25 at 8:50 AM, R801 was observed lying in bed. R801 appeared thin and frail. An interview was attempted. R801 made eye contact but was not able to answer any questions. A review of R801's clinical record revealed R801 was admitted into the facility on 4/11/25 and readmitted on [DATE] with diagnoses that included: Alzheimer's Disease. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition, unclear speech, did not have any behaviors during the assessment period, and was dependent on staff for all activities of daily living (ADL), transfers, and bed mobility. R801 signed onto hospice services on 5/20/25. A review of R801's progress notes revealed an Interdisciplinary Documentation note dated 10/21/25 that read, On 10-14-2025 (R801) had an incident that was reported to the (SSA) as she was observed with her shirt sleeves to be tied together. Upon identification the nurse did evaluate her and she had no injuries from the incident .Through staff interviews and investigation of the incident it was identified that she has increased behaviors and can be combative with care at times .A review of a Facility Reported Incident (FRI) investigation revealed the following was submitted to the SA on 10/15/25 at 8:30 PM, Staff alleges mistreatment of resident . It was documented the incident occurred on 10/14/25 at 11:00 PM, approximately 22 hours before the incident was reported to the SA. Further review of the FRI investigation revealed an Investigation Summary that noted the following:On 10/14/25 around 10:10 PM-11PM, (CNA 'C') tied (R801's shirt sleeves together in attempt to prevent (R801) from physically scratching, hitting or pinching (CNA 'C') during care. (R801) is care planned for 2 assist with bed mobility, but (R801) instead provided care by herself and tied the sleeves together instead of having a second staff assist and distract. Staff untied (R801's) shirt sleeves around 11PM .The documented Allegation Details noted, DHCS (Director of Health Care Services) received a voice mail message on 10/15/25 from (CNA 'G') that a resident (R801) was noted with her shirt sleeves tied together. The CNA reported that resident was unable to move her arms. The nurse was notified and untied the resident.On 10/29/25 at 11:35 AM, an interview was conducted with CNA 'C' via the telephone. CNA 'C' confirmed she was no longer employed by the facility. When asked why, CNA 'C' reported she was not sure. When queried about what happened with R801 on 10/14/25, CNA 'C' reported herself and CNA 'D' went into R801's room to do a last check and change (at the end of the afternoon shift). CNA 'C' reported CNA 'D' wiped her down while R801 was lying on her back. CNA 'C' explained R801 had an indwelling urinary catheter and CNA 'D' was wiping down her front. CNA 'C' further reported R801 began scratching at CNA 'D' and scratching at her (CNA 'C'), digging her finger nails into CNA 'C' and was combative. CNA 'C' reported R801 had the same reaction when nurses did her wound treatments. CNA 'C' explained she then put the end of her sleeves together so she couldn't scratch us. CNA 'C' reported they were about to weigh R801 using the mechanical lift and Registered Nurse (RN) 'F' entered the room and asked CNA 'C' and CNA 'D' to stop providing care to R801 and assist with another resident who was trying to get out of bed. CNA 'C' further reported they stopped what they were doing, left the room to attend to the other resident, and forgot to go back to (R801) and she was left with her sleeves tied. CNA 'C' reported she notified RN 'F' that R801 was fighting with them during care, but no direction was given. CNA 'C' explained she did not think tying R801's sleeve together was a restraint, and she was just trying to look out for her (CNA 'C') and CNA 'D's safety. A review of the statements included in the facility's investigation file revealed the following:An unsigned statement obtained via the telephone from CNA 'C' on 10/15/25 documented, (R801) fights, bites, scratches, and claws during personal care. On 10/14 at around 10:10 PM to 10:20 PM I tied her sleeves together so she would not hurt me as I was washing her up and doing peri care. (CNA 'D') was helping me with care. We had to get a weight for (R801). As we were doing that, nurse (RN 'F') called us urgently to help with (another resident) because she was climbing out of bed. I meant to go back and untie the sleeves, but I forgot. I did not tell (RN 'F') about (R801) fighting because she always fights and everyone knows it .On 10/29/25 at 12:38 PM, an interview was conducted with RN 'E', the nurse who worked on 10/15/25 when R801 was found to be restrained by her sleeves. RN 'E' reported she no longer worked at the facility. When queried about what happened with R801 on 10/15/25, RN 'E' reported R801 was very fragile, elderly, contracted, with bed sores. RN 'E' explained when laying still, R801 did not exhibit any signs or symptoms of pain, but when providing care she became very active, cries, yells, flails. On 10/14/25 (midnight shift), RN 'E' reported the off-going CNAs (CNA 'C' and CNA 'D') left suddenly. RN 'E' reported she thought they worked a double shift, had a lot going on, and just wanted to leave. RN 'E' said she did not receive any report from the CNAs. The oncoming CNAs (CNA 'G' and CNA 'H') checked on their residents at the beginning of the shift, and one came to get RN 'E' and asked why R801's hand would be tied up. RN 'E' went to look at R801 and saw she had on a thin, long-sleeved t-shirt and the openings of each sleeve were tied together. RN 'E' reported as soon as she saw that, she had the CNA untie the sleeves and RN 'E' left the room. RN 'E' reported she stayed in the room for a minute or two and did not observe any signs of distress from R801. RN 'E' reported the CNAs from the previous shift (CNA 'C' and CNA 'D') arrived at the end of her shift (midnight shift) coming on for the day shift and when she asked why they tied up R801's sleeves, one CNA said it was because R801 was pinching them during care. When queried about whether she reported R801 being physically restrained to anyone, RN 'E' reported she did not and stated, I just got busy and got wrapped up with my duties. RN 'E' reported CNA 'C' and CNA 'D' arrived for their next shift on 10/15/25 (day shift) and said R801 was pinching and swinging and that was why her sleeves were tied. RN 'E' reported she then left the facility. RN 'E' acknowledged she should have reported the incident to the Director of Nursing (DON).On 10/29/25 at 1:23 PM, an interview was conducted with CNA 'G' via the telephone. When queried about what happened with R801 on 10/14/25, CNA 'G' reported she arrived for her shift around 10:30 PM (midnight shift) with another CNA and they talked to the two CNAs who were leaving their shift (afternoon shift). CNA 'G' reported the other CNAs (CNA 'C' and CNA 'D') worked for 16 hours and did not want to do rounds with CNA 'G' and CNA 'H' and they were in a hurry to get out of there. CNA 'G' explained typically the on-coming and off-going CNAs walked from room to room prior to leaving, but they said everyone was fine and left. CNA 'G' began rounds when CNA 'H' came to her and showed her that R801's shirt sleeves were tied together. CNA 'G' described it as both sleeves were tied together so when R801 lifted her hands it formed a circle. CNA 'G' reported R801 was unable to move her arms. CNA 'G' explained CNA 'H' got the nurse (RN 'E') and CNA 'H' and the nurse untied R801's sleeves. CNA 'G' reported when she left for her shift, the same CNAs (CNA 'C' and CNA 'D') arrived for their shift (day shift) and she brought up how she found R801 restrained and they denied that they did it. When queried about whether she reported R801 being physically restrained to anyone other than RN 'E', CNA 'G' reported she thought the nurse would have given her an incident report to fill out, but she did not. CNA 'G' reported she thought the nurse reported the incident and the facility would contact her for a statement. CNA 'G' explained she left her shift and went home and slept and when she woke up realized nobody called her. At that time, she contacted the DON, approximately 9-10 hours after she initially saw R801 restrained. On 10/29/25 at 1:26 PM, an interview was attempted via the telephone with CNA 'H'. CNA 'H' was not available for an interview prior to the end of the survey.A review of a statement given by CNA 'H' that was included in the facility's investigation revealed CNA 'H' said, I came in as (CNA 'C' and CNA 'D') were leaving (on 10/14/25). They said there was nothing special to report. I started rounds and found (R801) with her shirt sleeves tied together at the end. I got (CNA 'G') and we both agreed it was not right .could not move her arms freely. I waited until (RN 'E') was done with narcotic count to report to (RN 'E') .(RN 'E') and I went to (R801's) room and untied her sleeves .On 10/29/25 at 2:06 PM, an interview was conducted with the Administrator. The Administrator reported she was not the Abuse Coordinator for the facility and that was the Director of Nursing (DON) who was not available during the survey. The Administrator reported she was still made aware of any abuse situations in the facility and was made aware of R801 being physically restrained. When queried about the process for reporting any alleged or actual abuse, the Administrator reported staff were required to report immediately to the Abuse Coordinator and the alleged perpetrator was suspended immediately pending investigation. The Administrator reported RN 'E' should have reported it as soon as she found out, as well as CNA 'G' and CNA 'H'. The Administrator reported RN 'E's employment was terminated, but explained it was for other reasons. CNA 'G' and CNA 'H' were educated about abuse reporting with the rest of the staff but did not receive any disciplinary action. A review of CNA 'C's time punches revealed she punched in at 6:40 AM on 10/14/25 and punched out at 10:41 PM. CNA 'C' punched in at 6:35 AM and punched out at 9:49 PM which indicated she worked almost two whole shifts the following day after she physically restrained R801.A review of CNA 'D''s time punches revealed she punched in at 6:27 AM on 10/14/25 and punched out at 10:42 PM. CNA 'D' punched in at 6:27 AM on 10/15/25 and punched out at 2:43 PM which indicated she worked the entire day shift on 10/15/25, the day after R801 was found to be restrained. A review of a facility policy titled, Abuse/Suspected Abuse; Crime Investigation & Reporting, revised February 2023, revealed, in part, the following, .Any person(s) witnessing or having knowledge of potential or actual abuse or crime must immediately report the incident to the Administrator and/or designee .the facility will report all alleged violations to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigations .Reports are submitted online into the (SSA electronic reporting system) .Immediately but no later than 2 hours if the alleged violation involves abuse . The policy noted the facility had 24 hours to report mistreatment, however, that does not meet regulatory requirements for abuse reporting.

This citation has two deficient practices.Deficient Practice #1This citation pertains to intake #2581294Based on interview and record review the facility failed to prevent an avoidable accident for one resident (R203), of three residents reviewed for accident hazards, resulting in injury requiring transfer to the emergency room. Findings include:Based on interview and record review the facility failed to prevent an avoidable accident for one resident (R203), of three residents reviewed for accident hazards, resulting in injury requiring transfer to the emergency room. Findings include:A complaint received by the State Agency alleged R203 was not properly secured during a ride in the transport van and sustained a fall from their wheelchair that resulted in injury requiring a transfer to the emergency room. On 8/26/25 at 10:41 AM, a review of R203's closed clinical record revealed they admitted to the facility on [DATE] and discharged to the emergency room on 3/17/25. R203's diagnoses included: heart disease, muscle wasting, abnormal posture, anxiety disorder and adjustment disorder. R203's Minimum Data Set assessment dated [DATE] revealed R203 had moderately impaired cognition and used a wheelchair for mobility.A review of a note entered into the record by the facility's Director of Nursing (DON) dated 3/17/25 at 12:43 PM, was reviewed and read, .Called to lobby by administrator who states resident fell out of chair during transport. Daughter at resident side and states that while stop <sic> Mom fell forward out of wc (wheelchair). Foot pedals on <sic> and resident fell to knees and then fell forward and hit head on seat in front .Assisted resident to bedroom and assisted to bed.Resident co (complained of) pain to left hip with ROM (range of motion), skin tears to bilateral shins dressed, during assessment 02 (oxygen level) declined to 83% and o2 <sic> (oxygen therapy) started and O2 above 90%. Noted development of hematoma during assessment. 911 called to transport for evaluation.On 8/26/25 at 12:43 PM, a review of a facility provided incident report dated 3/17/25 was reviewed and read, Witnessed fall.Incident Location: Out of Facility/During Transport.Nursing Description: Called to lobby by administrator who states resident fell out of chair during transport. Daughter at resident side <sic> and states that wat <sic> stop Mom fell forward out of wc (wheelchair).Resident Taken to Hospital? Y (yes). The report documented a bruise to the chest, a bruise to the face, a hematoma (localized area of blood outside of the blood vessels) to face, and skin tears to the right and left lower legs. Continued review of the report read, Notes.Resident expresses pain to mouth and bilateral shins.called out in pain with ROM to left hip.Abrasion across nose bridge. Blood from mouth.SPO2 (oxygen saturation) 83% (Normal levels 95%-100%) .911 called to eval and treat at ED (emergency department).Notes 3/17/25 Staff and daughter interview: (Staff Member ‘A') reported that she did not have the seatbelt latched properly and when she stopped the van, (R203) fell out of wc. Daughter.reports that they were on way <sic> to schedule <sic> doctors appt (appointment) and there was an accident.root cause: Resident was not restrained properly in van. When van stopped resident came forward and fell.Conclusion: (R203) had an accident while (Facility Name) van was transporting. (Facility Name) admitted that (R203) was not secured properly in the van and was sent to the hospital for evaluation of injuries.On 8/26/25 at 2:42 PM, an interview was conducted with the facility's Administrator. The Administrator indicated Staff ‘A' admitted they secured the wheelchair to the van but while talking to R203's daughter they got distracted and forgot to place a seatbelt across R203's waist, and when they stopped R203 fell forward out of the wheelchair.On 8/26/25 at 3:12 PM, a request for a policy regarding accidents and providing a safe environment was made and the Administrator indicated the facility did not have a policy.Deficient Practice #2This citation pertains to intake #2581294Based on observation, interview, and record review, the facility failed to immediately intervene and thoroughly investigate the details of an elopement, by two residents (R#'s 201 and 202) resulting in the potential for resident elopements in the future. Findings include:A complaint received by the State Agency alleged R201 and R202 eloped from the facility and were found in the parking lot by a male staff member.On 8/26/25 at 9:30 AM, a review of R201's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (R201) is alert to self and often ambulates throughout the facility.On 5/3/25 and 5/10/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility. He was visualized by staff the entire time.A review of R201's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, adjustment disorder, mood disorder, and delirium. R201's Minimum Data Set (MDS) assessment dated [DATE] was reviewed and revealed R201 had severely impaired cognition and was independent with mobility.It was noted there was no progress note in R201's record that documented the elopements on 5/3/25 and 5/10/25.On 8/26/25 at 10:25 AM, a review of R202's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (R202) is alert to self and often ambulates throughout the facility with walker.On 5/3/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility.A review of R202's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia, traumatic brain injury, falls, and muscle weakness. R202's MDS assessment dated [DATE] revealed R202 had severely impaired cognition and was independent with mobility with a walker. It was noted there was no progress note in 202's record that documented the elopement on 5/3/25.On 8/26/25 at 11:10 AM, a request for any incident/accident reports with accompanying investigations were requested for R201 and R202. There were no reports or investigations regarding R201's elopements on 5/3/25 and 5/10/25 or R202's elopement on 5/3/25 provided.On 8/26/25 at 1:45 PM, phone calls were placed to all male nursing staff members who worked on 5/3/25 who may have had knowledge of R201 and R202's elopements. A voicemail was left for Certified Nurse Aide (CNA) ‘C', and CNA ‘D', and an interview conducted with CNA ‘E' who denied any knowledge of the incident.On 8/26/25 at 2:55 PM, an interview was conducted with the facility's Administrator, Director of Nursing (DON) and Corporate Nurse ‘J'. They were first asked if a progress note should have been entered into R201 and R202's records on the date they eloped from the facility and said there should have been a note entered into the records. They were then asked why an investigation into the incident(s) was not conducted and the Administrator indicated they had a soft file regarding what happened. They were asked if they would provide the file and said they would.A review of the file revealed only R201 and R202's face sheets and a typed paragraph summarizing the incident. about the incident that read, On 5/3/25 at approximately 3:10 PM CNA ‘K' went to the front door due to it alarming and put the code in to turn off the alarm at approximately 3:15 PM, CNA ‘D' was coming in from his break and saw (R201) walking in the parking lot.At this same time Nurse ‘L' saw (R202) walking by the [NAME] emergency exit door and went out and brought him in.CNA ‘K' received an education that if there is no one around the door that you cannot just turn the alarm off, that you must go outside and check the surrounding area. On 8/26/25 at 3:00 PM, multiple questions were posed regarding the paragraph summarizing the incident. The Administrator and DON were first asked how R201 and R202 exited the locked front door. They said they held the egress door for 15 seconds, the door unlocked and they walked out. They were then asked about the progress note documented by Nurse ‘B' on 5/16/25 regarding the incident on 5/3/25 that read, .he (R201) did exit the facility through the front doors and staff saw him and redirected him into the facility. He was visualized by staff the entire time. and how if R201 was visualized the entire time, he was found by CNA ‘D' in the parking lot, to which they had no explanation. They were then asked what door R202 eloped from since they were observed by Nurse ‘L' outside of the [NAME] hallway emergency exit and said they did not know but thought it was the front door. They were asked if they reviewed any camera footage from front lobby door to aid their investigation and said they did not. Finally, they were asked if they interviewed any involved staff members regarding the incident and said they did not.On 8/26/25 at 3:20 PM, a review of a facility provided policy titled, Accident/Incident Reports was conducted and read, Policy: It is the policy of this facility to complete an accident/incident report for.accidents or incidents where there is injury or the potential to result in injury.Purpose: To establish a standard accident/incident completion and to ensure the facility meets the responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and take appropriate preventive action.3. RESPONSE TO A SOUNDING DOOR ALARM.b. Check the exit door for any exiting residents by means of a visual check. A visual check means observing the area around the exit and may require leaving the building and checking the grounds. c. If an exit door alarm is triggered, the cause is evaluated and re-set after the resident is re-directed and their safety is assured.

This citation pertains to intake #2581294Based on interview and record review the facility failed to notify the resident's responsible parties of an elopement for two residents (R#'s 201 and 202) of three residents reviewed for changes of condition. Findings include:A complaint received by the State Agency alleged two resident's eloped from the facility and their responsible parties were not notified.On 8/26/25 at 9:30 AM, a review of R201's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (R201) is alert to self and often ambulates throughout the facility.On 5/3/25 and 5/10/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility. He was visualized by staff the entire time.A review of R201's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, adjustment disorder, mood disorder, and delirium. R201's Minimum Data Set (MDS) assessment dated [DATE] was reviewed and revealed R201 had severely impaired cognition and was independent with mobility. Documentation in the record did not indicate R201's responsible party had been notified of the elopement.On 8/26/25 at 10:25 AM, a review of R202's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (R202) is alert to self and often ambulates throughout the facility with walker.On 5/3/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility.A review of R202's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia, traumatic brain injury, falls, and muscle weakness. R202's MDS assessment dated [DATE] revealed R202 had severely impaired cognition and was independent with mobility with a walker. Documentation in the record did not indicate R202's responsible party had been notified of the elopement.On 8/26/25 at 12:35 PM, an interview was conducted with R201's family member/responsible party and they were asked if they had been made aware R201 had eloped through the front door of the facility and said they had not been made aware.A review of a facility provided policy titled, Wandering Resident Exit Seeking Management was conducted and read, .7. Upon return of an eloped resident:.c. The resident's family/legal representative shall be notified of the resident's status.

This citation relates to Intake: 1195243. Based on observation, interview, and record review, the facility failed to provide a safe, comfortable homelike environment for six Residents (R400, R401, R402, R403, R404, R405) of six residents reviewed for resident rights. Findings include: A complaint was received by the State Agency on 6/30/25, which alleged the air conditioning was not working in the residents' rooms on the Emerald Hall, causing it difficult for staff to complete resident care and excessively hot resident room temperatures. On 7/24/25 at 11:11 a.m., a digital thermostat encased in plastic was observed on Emerald Hall with the two temperatures, 70 degrees Fahrenheit and 75 degrees Fahrenheit. It was unclear which was the one the time was set to, and which one was the temperature in the hallway, as there was no designation observed. On 7/24/25 at 11:16 a.m., an orange large air mover unit was observed on Emerald Hall, circulating the hallway air as staff entered the hall. R400 On 7/24/25 at 11:15 a.m., R400 was observed in their room, seated in a manual wheelchair. R400 agreed to be interviewed. R400's room was palpably warm. On 7/24/25 at 11:17 a.m., R400 was asked about their stay, R400 reported there was no air conditioning in their room, and it was sometimes too hot. R400 stated the only way to get cool air was when they left their outer room door opened, as then they could get some cooler air from the hallway. Review of R400's Minimum Data Set (MDS) assessment, dated 6/03/25, revealed a score of 15/15 on the Brief Interview for Mental Status (BIMS) assessment, which showed they were cognitively intact. R401 On 7/24/25 at 11:27 a.m., R401 was observed in their hospital bed wearing a gown. R401's room was palpably warm. There was no thermostat observed in their room. R401 agreed to be interviewed. On 7/24/25 at 11:28 a.m., R401 stated their room was hot (room [ROOM NUMBER]). R401 explained they wanted their door opened but sometimes they needed to close their door due to wandering residents. R401 said, It's hot, almost 72 (degrees Fahrenheit). R401 reported their roommate provided them with a fan. R401's roommate, R402, reported the room was too hot for them too. R401 reported they stayed in their room in their bed typically. R401 clarified staff were aware of their concerns. Review of R401's MDS assessment, dated 5/15/25, revealed a BIMS assessment score of 15/15, which showed R401 was cognitively intact. R402 On 7/24/25 at 11:35 a.m., R402 was observed in their hospital bed, wearing only a brief and a t-shirt. R402 agreed to be interviewed. On 7/24/25 at 11:37 a.m., R402 was asked if they wished to be draped to cover them. R402 reported they were too hot, which happened often, and said they did not want a sheet over them even. R402 clarified they stayed in their room frequently, in their bed. R402 stated, They (staff) say this room is the hottest. It feels warm today. R402 stated they and R401 liked their outer room door closed due to wandering residents who they did not want to enter their room. R402 explained with the door closed their room was too hot. R402 said they felt like, they (staff) are torturing me, and they wanted to be able to open their room window due to the heat, which was observed secured fully shut, to get a breeze sometimes. R402 clarified they knew not to open their window when it was humid outside. R402 shared they and R401 had reported their concerns to staff and management. On 7/24/25 at 11:50 a.m., a tall plastic fan was observed at the foot of R402's bed. R402 stated their family purchased this for them, as a fan was not provided to them by the facility. R402 reported a fan was also provided by their family for R401, their roommate. Review of R402's MDS assessment, dated 5/20/25, revealed a BIMS assessment score of 14/15, which showed they were cognitively intact. On 7/24/25 at 11:56 a.m., a thermostat was observed at the nurse's station, across the hall from rooms 68 to 70, which read 76 degrees on a top bar and 81 degrees on a bottom bar. A white plastic digital thermostat unit was observed above as blank (not working). R403 On 7/24/25 at 12:06 p.m., R403 was observed seated upright on the edge of their bed, eating their lunch, wearing short sleeves and capri pants. On 7/24/25 at 12:07 p.m., R403 said, It is hot. On a hot day it is hot in here.It has been going on for a month. R403 confirmed they dressed in lighter clothing due to the heat in the facility. Review of R403's MDS assessment, dated 5/20/25, revealed a BIMS assessment score of 10/15, which showed moderate cognitive impairment. The sensory assessment showed they were able to be understood and understand others. R404On 7/24/25 at 12:08 p.m., R404 was observed in their bed sleeping, wearing a gown. Family Member, (FM) C, was observed seated in R404's room and asked to speak with this Surveyor. R404's room felt palpably hot. No fan was observed in their room. On 7/24/25 at 12:09 p.m., FM C stated, It's so hot, it's horrible .It has bothered (R404). (R404) does not have a fan. FM C said whatever they bought R404 disappeared. FM C reported R404 was recently less alert and was receiving hospice care. Review of R404's grievances revealed some missing items had been reported to facility management. Review of R404's MDS assessment, dated 5/05/25, revealed they were receiving hospice care. 4On 7/24/25 at 1:48 p.m., Certified Nurse Aide (CNA) F said they typically worked on Emerald Hall and reported they usually worked with the residents in Rooms 68 to 70. CNA F stated, It's very hot. Families and residents are complaining about the heat in the residents' rooms.It's hot and sweltering and the rooms with concentrators (oxygen) are even hotter on Emerald Hall. CNA F explained management was aware as they talked to them about the hot rooms every day and said the shower rooms were hot. CNA F reported R402 complained about the heat the most, and R402 also complained often about the heat being too high in their room. 4On 7/24/25 at 1:55 p.m., Registered Nurse (RN) G reported they worked on Emerald Hall often and stated residents and their family members were frequently complaining about the heat, stating, It is hot. RN G stated they were able to manage themselves with the heat using portable fans which were at their nurse workstations or on their person. RN G stated the facility provided ice water to residents when this occurred, and a large air pusher on Emerald Hallway but clarified this did not help cool the residents' rooms, only the hallway. When asked about any resident outcomes, RN G reported R405 called 911 to go to the hospital when R405 stated it was too hot in their room and they became too hot. RN G explained when they returned, they also stated it was too hot. RN G said they could not confirm the heat or higher temperatures resulted in their hospitalization. On 7/24/25 at 2:10 p.m., CNA H reported they worked on Emerald Hall 90% of the time. CNA H stated there were still hot temperatures on Emerald Hall in the residents' rooms, despite the air conditioner being fixed, reportedly. CNA H explained, Today it was hot, and a couple of residents really suffer. One of the residents (R405) has MS (Multiple Sclerosis) and she was saying the heat messes her up (increases her MS symptoms) . CNA H reported this bothered the residents but mainly R405. CNA H reported R405 preferred their room door closed, and said they tried to put a fan in R405's doorway when R405 allowed their room door to be opened, since the residents' rooms did not have air conditioning. On 7//24/25 at 3:04 p.m., the Maintenance Director, Staff I, confirmed last month the air conditioner had broken and they had it repaired and said it initially it worked fine. Staff I clarified there was only air conditioning in the resident hallways, not in the residents' rooms. Staff I reported there were few options to add air conditioning units in the facility, as there were concrete walls and the residents' rooms had slider windows. Staff I said they did not believe there was an option to add air conditioning to the residents' rooms. Staff I stated for residents who wanted their doors closed, the hallway air could not circulate the cooler hallway air into their rooms, causing them to be hot. Staff I explained another maintenance staff member temped and logged the residents' rooms temperatures daily in the morning, at around 6:30 a.m., and said they always found the unit and residents' room temperatures between 71 to 81 degrees. Staff I was asked why their staff did not temp the unit including room temperatures during the hotter times of day, such as during the afternoons, when the air temperature would increase. Staff I had no explanation and reported they understood the concern.Staff I was asked during further interview if there was a viable solution, given staff and resident multiple complaints of being uncomfortable and feeling distressed. Staff I stated while it was not possible to install portable air conditioning units, they could purchase more mini-splits (ductless air conditioners) in the facility and said they would need to talk with an air-conditioning specialist to see if there were other options for air conditioning in the residents' rooms, which they had not done. Staff I was asked if they had obtained any fans for residents for their rooms, given the higher temperatures in residents' rooms, and residents, family, and staff complaints, and responded, No. Staff I confirmed they had no extra fans in the buildings for residents, and any fans observed were purchased by residents' families. Staff I reported the large orange air pusher unit observed on Emerald Hall was only available for the hallways and not in the residents' rooms. Staff I explained there was a mini-split unit on Emerald Hall which was not working, and said management were aware of the concern. Staff I added there were hallway circulating ports (larger holes) observed along the hallway ceilings outside residents' rooms, however these were only circulating the air in the hallways, not in the residents' rooms. Staff I said they thought these may be able to be hooked to mini splits but could not be certain. Given multiple staff and resident interviews related to hot room temperatures, Staff I was asked if they had consulted with any corporate maintenance staff and answered they had not, since they said they were unsure what would work best to reduce the air temperatures in the residents' rooms. Staff I was unable to describe a clear plan to keep the air temperatures tolerable for the residents. Staff I agreed to temp select residents' rooms on Emerald Hall using their air temperature gauges. Staff I acknowledged most of the thermostats on Emerald Hall were not working accurately when asked. On 7/24/25 at approximately 3:30 p.m., the air temperature in R405's room was checked by Staff I, with this Surveyor present, using two room temperature gauges. R405's room felt warm in temperature. It was noted R405 had a mini electronic cooling unit running on their nightstand, which R405 explained was brought to them by a friend. R405 said this reduced the air temperature somewhat but said their room still felt hot to them. The air temperature gauges showed the room temperatures ranged from 79 to 81 degrees (Fahrenheit) in most of the room near the cooling unit, with one corner of the room by the closet temping at 82 degrees (Fahrenheit). On 7/24/25 at approximately 3:40 p.m., the air temperature was checked in R401 and R402's room. The temperature read 82.4 degrees and 83 degrees with each gauge respectively. R402 was in their hospital bed uncovered, and stated they were hot. R402 was heard to say leaving the room their clock on their wall said the room temperature was 86 degrees. Staff I acknowledged they observed these readings, and they confirmed were above the regulatory guidance temperature range. Staff I reported the room temperatures should have been between 71- degrees and 81-degrees Fahrenheit, and understood the concern in room [ROOM NUMBER]. R405 On 7/24/25 at 4:03 p.m., R405 was observed seated in their wheelchair in their room. R405's room was palpably hot. R405 agreed to be interviewed. On 7/24/25 at 4:04 p.m., R405 stated, .The (room) temperature is not tolerable. R405 shared in the beginning of June (2025), they had a week of really hot weather, and said, It was unbearably hot. R405 explained since they had MS, they had heat intolerance. R405 reported one day last month they became lethargic, with sweating, and developed a fever from the heat, and said they had to call 911 to go the hospital. When asked what the hospital found, R405 stated they had a virus, and were treated with antibiotics and a steroid. There was no mention of a heat-related diagnosis. R405 said when they returned to the facility, they were told their room door needed to remain closed due to their infection, and said they could not open their window to get some air as it was secured shut. R405 stated their room was still too hot when they returned to the facility, stating, It was over 90 degrees in this room. R405 added, They fixed the air conditioner, and the only air conditioning working was in the hallway, and I wasn't allowed to open my door . R405 reported the Ombudsman visited them due to this and asked the facility or their family to buy them a portable air conditioner. R405 said, I'm not buying it, as they believed the facility should have been financially responsible, not them. There was no portable air conditioner or window air conditioner observed in R405's room. On 7/24/25 at approximately 4:21 p.m., R402's digital clock was observed in R401's and R402's room. The clock time was accurate, and the temperature read 86 degrees, which the survey team and R402 confirmed. R402 reported their digital clock temperature was accurate. On 7/24/25 at 4:52 p.m., Physician D was asked if there were any resident outcomes related to the hot temperatures, given residents, staff, and family respective concerns related to discomfort from elevated room temperatures, including R402 and R405. Physician D reported there was no clear outcome, including for R405's hospitalization on 6/09/25, as they were seen and treated by them the same day for a respiratory infection, and were not deemed appropriate to be sent out. Physician D clarified R405 called 911 themselves, and since they had been readmitted , there was no diagnosis related to heat. Physician D explained R405 was diagnosed with a virus at the hospital and treated accordingly. Physician D reported they were aware during their visits the facility was warm and toasty at times and had found the facility was keeping the residents hydrated, the air circulating, and the heat had not been found to be dangerously high, causing any emergency or emergent care. Physician D clarified they were not aware of the residents' rooms not being air conditioned. On 7/24/25 at approximately 5:20 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were asked about the concerns with high temperatures found today in R401 and R402's rooms, R405's reporting hot room temperatures causing them to be hospitalized , and if there were any adverse outcomes for residents, given multiple residents and staff reporting hot room temperatures this summer, and no air conditioning in their rooms. The NHA and DON stated they planned to address the concerns to ensure residents were kept comfortable and continue to ensure they were well-hydrated and would explore additional options to reduce the room temperatures on the hot days, including fans. Both denied any resident outcomes or emergency care related to the elevated room temperatures and planned to do immediate follow-up to ensure the rooms on Emerald Hall were within the regulatory guidance of less than 81 degrees (room [ROOM NUMBER]) and understood the concern. The NHA reported they would explore options including with corporate maintenance and vendors to continue to address the concerns. On 7/24/25, review of the regional temperature showed a high of 95 degrees Fahrenheit. Review of the policy, Rights of Residents in (State) Nursing Home Facilities, received 7/24/25, revealed on Page 6, .Safe Environment: You have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety.

Based on observation, interview and record review the facility failed to ensure residents personnel clothing was routinely returned to them from laundry for three residents (R39, R57 and R56) and multiple residents who asked to remain anonymous at the resident council meeting. This had the potential to affect all residents who relied on the facility to care for their laundry. Findings include: Resident Council On 3/12/25 at 10:00 AM, a Resident Council meeting was conducted with 10 residents who asked to remain anonymous. The residents were asked about life in the facility and any concerns they might have. Multiple residents expressed issues pertaining to their clothing not being returned to them. One resident reported that laundry is sent out of the facility and many times it does not come back to their room. They noted that the person in charge of laundry had been out for over two months, and they believed that added to the confusion. Another resident reported that they had a special [NAME] football shirt that had never been returned and/or replaced. A third resident reported that several sweaters had not been returned. The resident's indicated that the facility is aware of the issue however, they still do not get their own clothes back. R39 On 3/11/25 at approximately 10:37 AM, R37 was observed lying in bed. The resident was alert and reported that they had entered the facility in February 2025. When asked about concerns at the facility, R39 reported they were missing some clothing items. The resident specifically noted that shirts containing the names and numbers of local football players was missing from their room. An observation of the residents' clothes located in their closet did not have any names or labels on the clothes. R37 reported that they did not have a proper pen to label their clothes and noted if they did have one, it may have been difficult for them to write their own names. A review of R39's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses of type II diabetes and pressure ulcers. The resident had a Brief Interview for Mental Status (BIMS) Score of 14/15 (cognitively intact cognition). *It should be noted that an inventory list could be located in the resident's clinical record. R57 On 3/11/25 at approximately 10:27 AM, R57 was observed lying in bed. The resident was alert and able to answer all questions asked. R57 was asked about life in the facility and reported that they had been a resident for several years. They indicated that they were mostly happy with the care provided with the exception of a delay in turning them as well as missing clothing items. R57 reported that they had several shirts of various colors (blue, purple and red) as well as pajamas provided by family that were never returned. On 3/13/25 at approximately 8:18 AM, an observation and interview were conducted with the Administrator and Laundry Staff D. The interview took place in the Laundry/Storage room. Resident clothes were observed hanging up on hangers. Laundry Staff 'D reported that they had been working at the facility for over [AGE] years and noted that they had been out over the past two months. They further indicated that laundry is always sent out to an outside company. Laundry Staff D indicated that clothing should be labeled, but it's not always and this makes it difficult to return to the right resident. Further, at times laundry does not even come back to the facility and might be lost at the outside laundry company. Laundry Staff D noted that at times they believe Agency staff need to be further educated on resident's laundry and the process at the facility. The Administrator noted that they recognized the problem and attempted to replace clothing when made aware, however they were aware that this did not negate that residents' original clothes should not go missing. 39592 R56 On 3/11/25 at 10:55 AM, R56 was observed lying on their bed. R56 appeared sleepy, and did not answer questions asked. On 3/11/25 at 1:33 PM, R56's Durable Power of Attorney (DPOA) was interviewed by phone and asked about care at the facility. The DPOA explained she had to keep buying R56 clothing and blankets because the facility kept losing R56's belongings in the laundry . on Christmas Day, when she came to visit, R56 was in a facility provided gown and had only a thin blanket on the bed which was under a window and it was very cold that day, she went out to her car to get her emergency blanket to take it back in and put it on R56 . has seen other residents wearing R56's clothes . sometimes other residents clothes are in R56's closet. R56's DPOA was asked if R56's clothing and blankets were labeled with R56's name. The DPOA explained she makes sure all R56's clothing and blankets are labeled. On 3/13/25 at 8:58 AM, Laundry Aide D was interviewed and asked about the laundry process. Laundry Aide M explained they used a local laundry and never have had an issue with them, but felt that agency staff did not understand the facility's laundry system. On 3/13/25 at 9:55 AM, Certified Nursing Assistant (CNA) N was interviewed and asked about the laundry. CNA N explained she was a recent hire at the facility and had to adjust to how the facility did laundry . they put all the personal clothing into one bag and all the commercial stuff like towels and linens into another bag . then the laundry aide will bring back the personal clothes and stock the linen closets. On 3/13/25 at 10:00 AM, observation of R56's clothes in the closet revealed R56's name written in permanent marker on the inside of the neck of their tops. On 3/13/25 at 10:28 AM, the Administrator was asked about the laundry at the facility. The Administrator explained Laundry Aide D had worked at the facility for years and pretty much knows what clothes belong to which resident, but when Laundry Aide D is not there, sometimes the other staff can not read the name written on the clothing. When asked if they had a label machine for clothing, the Administrator explained they did not. Review of a facility policy titled, Missing Items(s) revised July 2008 read in part, .Residents are entitled to retain and use personal clothing and possessions as space permits . When resident's personal clothing is lost, the facility staff will investigate its location and return the item to the resident or provide written response to the resident about the investigation .

Based on observation, interview and record reviews the facility failed to ensure all staff, including agency staff could timely identify a resident's code status (R72) in the event of an emergency, failed to ensure the physician orders reflected the resident's wishes regarding their code status for four (R's 72, 51, 56 & 174 of four residents reviewed for code statuses. This deficient practice had the ability to affect all 74 residents residing in the facility at the time of the survey. Findings include: R72 A review of R72's Nursing notes revealed a note dated [DATE] at 7:42 AM, that documented in part . Writer alerted by CNA (Certified Nursing Assistant) @ (at) 4:30am that resident on side of bed writer entered room and resident found at side of bed warm to touch, pale in color resident assisted into bed by nursing staff and assessed by writer very faint pulse Code Blue called and CPR (Cardiopulmonary Resuscitation) initiated @ 4:38am . time of death at 5:08am police on site . This note was documented by Licensed Practical Nurse (LPN) B, who was later identified as an agency nurse (not facility-hired staff, but contracted). Review of the medical record revealed R72 was admitted to the facility on [DATE], with diagnoses that included respiratory failure. On [DATE] at 12:09 PM, a telephone interview was conducted with LPN B. When asked about the noted delay in initiating CPR (Caridopulminary Rescussitation), LPN B explained how they worked for an agency and remember R72, because they had not returned to the facility to work after R72 expired. LPN B stated once they identified R72 with no pulse they went on the computer to find R72's code status and was unable to locate it. LPN B stated they called the Director of Nursing (DON) at home to tell them what was going on and that they were unable to find R72's code status. LPN B stated the DON informed them of a binder located on the unit that contained papers of every resident wishes. LPN B stated they eventually found the binder and found R72's paper located in the binder but the document was unclear and it was a number system that they did not understand. LPN B stated there was one other nurse on duty that came over and reviewed the document and informed LPN B that the number documented for R72 meant that R72 was considered a full code. LPN B stated the code was called and they went to R72's room to initiate CPR. LPN B stated in part . It was so unclear (R72's code status) and that's why I have not gone back yet (to work at the facility) . I will never go back . their (facility) code system is just unclear . A review of R72's physician orders revealed no implementation of R72's code status. Further review of the physician orders noted the following order . Refer to Preferred Treatment Option for Advanced Directives . After review of the electronic medical record, located under the facility's Document tab, a Resident Preferred Treatment Option document was found. Review of the Resident Preferred Treatment Option document noted the resident to be Option of Status 4. This required the reader to go to option Status 4 and read the document that noted . Status 4: The resident is to be hospitalized for any treatments that exceed the nursing home's capabilities and that are necessary to extend life or maintain comfort. Such treatments are to include resuscitation and surgical intervention . At the bottom of the document noted the Physician's signature and writing that noted Full Code . This system did not ensure immediate identification of the residents' code status in an event of an emergency. On [DATE] at 9:22 AM, the Administrator was asked to provide the facility's orientation documentation and check list for all agency staff. A review of the orientation documentation and check list for agency staff provided by the facility's Administrator revealed no documentation or review of the facility's code status system or Preferred Treatment Option for Advance Directives system. This revealed that the agency staff was not trained on where to locate the resident code status and the agency staff was not trained on the facility's Preferred Treatment Option Advance Directives. R51 Review of the clinical record revealed R51 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: hemiplegia (paralysis) affecting left nondominated side, major depressive disorder and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R51 had intact cognition. Review of physician orders revealed an order with a start date of [DATE] that read, Refer to Preferred Treatment Option for Advanced Directives. Further review of the physician orders revealed no implemented order of R51's code status. Review of the Document tab for R51 revealed a document titled, RESIDENT PREFERRED TREATMENT OPTION that was marked with Status 4 and signed [DATE] with a hand written note at the bottom that read, Status 4 - Full Code and signed by the physician. R56 On [DATE] at 10:55 AM, R56 was observed lying on their bed. R56 appeared sleepy, and did not answer questions asked. Review of the clinical record revealed R56 was admitted into the facility on [DATE] with diagnoses that included: dementia, heart failure and anxiety disorder. According to the MDS assessment dated [DATE], R56 had severely impaired cognition. Review of physician orders revealed an order with a start date on [DATE] that read, Refer to Preferred Treatment Option for Advanced Directives. Further review of R56's physician orders revealed no order implemented for the DNR. Review of the Document tab for R56 revealed a document titled, DO NOT RESUSCIATE ORDER EXECUTED BY ATTENDING PHYSICIAN AND DPOA OR GUARDIAN that was signed [DATE]. The tab also revealed a document titled, RESIDENT PREFERRED TREATMENT OPTION that was marked Status 3: The resident is to be hospitalized for any treatments that exceed the nursing home's capabilities and that are necessary to extend life of maintain comfort. Such treatments are not to include resuscitation Surgical intervention is limited to conditions with a high probability of a successful outcome. signed [DATE]. R174 A review of R174's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The resident was noted to have a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] (moderately cognitively impaired). There was no indication in the resident's electronic record that noted the resident's code status and additional end of life wishes. During the Survey, the facility had reported that resident's code status would be found in a binder located near the nurse's station. An attempt to locate the binder, including R174's code status and end of life wishes was made on [DATE] at approximately 12:35 PM. Two Certified Nursing Assistants (CNAs) attempted to locate the facility code status binder. They were not able to find it and thought perhaps code status would be found in the resident's closets. At approximately 1:00 PM on [DATE], the DON was asked to locate the binder. The DON did point out where the binder was located. A document titled, Resident Preferred Treatment Option was reviewed and noted the resident was Status 3: The resident is to be hospitalized for any treatments that exceed the nursing home's capacities and that are necessary to extend life or maintain comfort. Such treatments are not to include resuscitation. Surgical intervention is limited to conditions with a high probability of a successful outcome. A second review of R174's electronic record was conducted. Again, no documentation was found. On [DATE] at 1:57 PM, the Administrator and DON was interviewed and informed of the concern regarding the delay of the agency staff not being able to immediately identify R72's code status, informed of the resident's code status to not be located under the facility's physician tab and the concern of the current residents' code status to not be immediately available in an event of an emergency. The Administrator and DON acknowledge the concern, however, the DON asked if the corporate Clinical Support Nurse (CSN) C could join the interview to explain the facility's process. At 2:08 PM, CSN C entered the conference room and stated the facility has a paper copy that is kept in a binder at the nurses station. CSN C stated although the code status order is not located under the physician orders, the physician signs the bottom of the Preferred Treatment Option Advance Directives document and they considered that to be the physician's order. CSN C stated the document should be uploaded in the document tab once signed by the physician. At this time R174's electronic record was then pulled up. The Administrator, DON and CSN C reviewed the documentation under the Documents tab and confirmed that the Resident Preferred Treatment Option was not located in the resident's record and should have been. CSN C stated they understood the concern regarding the agency staff to not be trained on the code status system. CSN C was asked why in the facility's Electronic Medical Record where there was a line that read Code Status: it had a link that read (Advance Directive), but when the link was clicked on, it brought up No Files Found. CSN C explained it would be helpful if the link would actually pull up the document, but they were not able to link it. CSN C also explained they did not want to put the code status in there because they were afraid of someone entering it wrong and providing the wrong information. Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR) dated [DATE], revealed no clarification or directive for staff on where to locate, find and identify the residents who requested CPR or DNR (Do Not Resuscitate) status. No further explanation or documentation was provided by the end of the survey. 34275 39592

Based on observation, interview and record review, the facility failed to appropriately transfer a resident per their assessed needs for two (R51 and R64) of six residents reviewed for falls. Findings include: R51 On 3/12/25 at 9:43 AM, R51 was observed sitting on the side of the bed. An ankle-foot orthosis (AFO) brace on their left foot was observed. R51 was asked if they had fallen recently. R51 explained as they were transferring from their wheelchair to the toilet, their feet got tangled up because they have a paralyzed foot. R51 was asked how many staff members were present when they were being transferred. R51 explained there was only one. When asked how many staff are usually present when they were being transferred, R51 explained usually there would be only one staff present. Review of the clinical record revealed R51 was admitted into the facility 3/3/22 and readmitted [DATE] with diagnoses that included: hemiplegia (paralysis) affecting left nondominant side, need for assistance with personal care and lack of coordination. According to the Minimum Data Set Assessment (MDS) dated [DATE], R51 had intact cognition, had upper and lower body impairment on one side, and was dependent on staff for transfers. Review of R51's Activities of Daily Living (ADL) care plan revealed an intervention revised 2/28/25 that read, TRANSFER: Two Assist, AFO to left leg when out of bed. Additional review of all R51's revised ADL care plans revealed from the initial care plan dated 3/7/22, R51 was always a two person assist for transfers. Review of R51's progress notes revealed an Interdisciplinary Documentation by Registered Nurse (RN) G dated 3/10/25 at 1:43 PM that read in part, Writer notified of CNA (Certified Nursing Assistant) having to lower resident to the floor due to resident losing her balance during a transfer to the toilet . On 3/12/25 at 10:18 AM, CNA E, an agency CNA, was interviewed and asked how they knew what the transfer status of a resident was. CNA E explained each residents' care plan was posted on the inside of their closet door. On 3/12/25 at 10:26 AM, observation was made of RN G of assisting R51 and a Family Member out of the bathroom and telling R51 she was assisting because R51 was a two person assist. R51 replied in a surprised voice, I am?. On 3/12/25 at 10:97 AM, observation of R51's closet revealed R51's ADL care plan posed in plastic sleeves and read the same, TRANSFER: Two Assist, AFO to left leg when out of bed. On 3/12/25 at 10:31 AM, the Therapy Director (TD) was interviewed and asked about R51's transfer status. The TD explained R51 was a two person assist due to their left leg paralysis, and that R51 overestimated their abilities. On 3/12/25 at 10:38 AM, the Director of Nursing (DON) was interviewed and asked about R51's fall. The DON explained she had been told R51 did not want to wait for another staff member, so the CNA just transferred R51 by herself. The DON was asked if it was ever acceptable to transfer a resident assessed as a two person assist with only one person. The DON explained there should always be two people if they are care planned for two people. When asked who the CNA was, the DON explained it was CNA I, who was an agency CNA. Review of CNA I's employment file revealed an Education Acknowledgement signed 8/1/24 that included Care Plans. On 3/13/25 at 10:36 AM, a phone call was made to CNA I and a voice mail was left. No return call was received prior to the end of the survey. 34275 R64 On 3/11/25 at approximately 11:03 AM, R64 was observed sitting in a large activity/dining room with other residents. R64 was alert but not able to answer questions appropriately. A review of the resident clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (ischemic stroke). A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 7/15 (severe cognitive impairment). Progress Note (11/13/24): Staff was transferring resident off the toilet to her wheelchair when her foot began to slide from under her . R64's care plan was reviewed and documented, in part: Focus: R64 has altered functional mobility and ADL's (activities of daily living) .Interventions: .Ability to leave on toilet - No (2/1/24) .Bed Mobility: asses of two .Ambulatory: Non-Ambulatory (2/1/24) .Fall Risk Management: Encourage Non-skid Footwear (2/1/24) .11/13/24 .Resident is to wear shoes during all transfers .Transfer: One Assist, Right AFO (ankle foot orthosis - brace requiring a shoe) on when out of bed .Transfer: .Two Assist (2/1/24) . An Incident/Accident (IA) report provided by the facility was reviewed and documented, in part: Witnessed Fall .Date: 11/13/24 at 2:05 PM .Staff was transferring resident off the toilet to her wheelchair when her feet began to slide from under her .Immediate Action Taken .Shoes placed on residents feet .Notes: R64 is a 2 assist for transfers and as staff were assisting to transfer her form the toilet to w/c (wheelchair) she became weak .At the time of resident occurrence, CNA verbally re-educated on need for non-skid foot protection with for ambulation and .transfers and resident need 2 assist, and required to follow care plan . *It was noted on the IA that the CNA involved in the incident was CNA R. An attempt to contact CNA R was made via telephone on 3/13/25 at approximately 1:45 PM. No return call was made prior to the end of the Survey. The Survey personnel file noted that the CNA R resigned from the facility on 11/21/24. On 3/13/25 at approximately 2:01 PM, an interview was conducted with the Director of Nursing (DON). When asked about the incident causing R64 to fall to the floor, the DON reported that they did not recall the entire event, however recalled educating CNA R that that R64 was a two person assist.

Based on observation, interview, and record review, the facility to provide adequate care coordination related to hospice services for one Resident (R52) of two residents reviewed for hospice services. Findings include: Review of R52's Minimum Data Set (MDS) assessment, dated 2/14/25, revealed R52 was admitted to the facility on [DATE], with diagnoses including lung disease, alcohol abuse, pressure ulcers, and dementia. The assessment revealed R52 could feed themselves with set-up, and was dependent for toileting, bed mobility (rolling), and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 14/15, which showed R52 was cognitively intact. The pain assessment showed R52 had at least moderate pain frequently over the past five-day assessment period, which occasionally interfered with their sleep. The nutritional assessment showed R52 was edentulous, was 61 tall, and weighed 79 pounds upon admission. The assessment showed no behaviors or symptoms of depression. The assessment showed R52 was receiving oxygen, on hospice care, and was receiving opioid pain medication. On 3/11/25 at 11:07 a.m., R52 was laying in their hospital bed, wearing a hospital gown, and was receiving oxygen via a nasal canula. R52 appeared thin and underweight, with protruding bony prominences, and an empty pudding cup container on their bedside table. R52 stated they knew they were pressing their call light frequently. When asked why, they stated, I feel lonely. R52 appeared unsettled and anxious, and said they were uncomfortable. R52 was observed fidgeting with their hands and demonstrated little eye contact. On 3/11/25 at 11:09 a.m., R52 stated, No, it is not going well here. R52 reported they struggled when they had to wait anywhere from 15 minutes to a half hour to receive their pain meds for very high pain in their stomach. R52 reported they could receive their pain medication every two hours, and they needed it to be on time, as they had high pain when the pain medication was wearing off. R52 pushed their soft touch pad call light for pain medication during the interview, as they believed it was due. On 3/11/25 at 11:11 a.m., R52's nurse, Licensed Practical Nurse (LPN) S, an agency nurse, answered their call light. R52 stated they wanted their pain medicine due to high pain. LPN S explained to R52 they were due for their pain medication in 15 minutes. R52 expressed they needed their pain medication now but understood they had to wait and shared with LPN S it was difficult to wait due to excessive pain. R52 looked at the clock, read the time, and said the morphine and Tylenol were due at 11:26 a.m R52 was alert and oriented to herself, place, time, and situation. On 3/11/25 at 11:17 a.m., R52 stated they could not wait a half hour for their pain meds for severe stomach pain. On 3/11/25 at approximately 11:45 a.m., the Director of Nursing (DON) arrived, and was informed of R52's concerns regarding their unmanaged pain and needing more chocolate pudding, which R52 also shared with the DON. The DON reported to this Surveyor that R52 appeared to be receiving the maximal pain medication, as they received morphine every two hours, and they had called the hospice agency due to R52's high pain, who had scheduled their morphine every 3 hours. Review of R52's physician orders showed their morphine (short acting) was scheduled every four hours, and every two hours prn (as needed) for breakthrough pain. On 3/12/25 at 1:46 p.m., R52's nurse, Registered Nurse (RN) J, was asked for assistance finding R52's hospice care book, to review their hospice plan of care and review the communication notes, per standards of practice and regulatory requirements, as the facility management reporting they used binders for hospice documentation. RN J looked at the unit nurse's station with this Surveyor, and in the Electronic Medical Record (EMR), and did not find the communication notes or current hospice plan of care. A hospice communication book was found in R52's name, with blank green cardstock pages which were not completed. RN J agreed this was not completed, and asked the Unit Manager, RN U, to assist them. RN U looked for another communication book for R52 and agreed it was not on the unit with the other hospice care books. RN U said they would search in other places for the book, but the expectation was R52's hospice communication book would be located there. On 3/12/25 at 1:54 p.m., a second manager, RN C, came to assist to locate R52's hospice binder with care plan and communication documentation. Both managers found the old hospice notes prior to R52 admitting to this facility in the EMR in the documentation section as Referral Notes (not labeled hospice or company name), however both reported they could not locate any current notes showing hospice care and facility coordination from R52's admission to the facility from 2/04/25 to 3/12/25. The expectation per standards of practice for hospice care in the facility per both unit managers was the hospice communication notes would have been on the unit typically, and the plan of care would have been there or in the EMR, so staff could readily access the notes, for care coordination, appropriate interventions, any significant change, and record keeping requirements for hospice care. On 3/12/25 at 2:15 p.m., this Surveyor emailed the Nursing Home Administrator (NHA) to see if they could provide R52's missing hospice documentation, including all hospice visit communication notes, a current care plan, and assessments, from 2/04/25 to the present, 3/12/25. This Surveyor shared with the NHA they remained missing, per review by both unit managers, RN J, and Surveyor. The NHA emailed this Surveyor back they did not have the missing hospice care documentation, and would attempt to locate the documents. They reported they understood the concern. On 3/12/25 at approximately 3:45 p.m., R52's hospice care notes were received, in part, during their current stay, from the NHA. It was noted they did not include any nursing visits beyond 2/21/25, which was shared with the NHA, who reported they would continue to request the remainder of R52's hospice care notes from R52's hospice care provider. Surveyor noted this would be concerning if R52 had not been seen by the hospice nurse since 2/21/25, per the current records. The NHA reported they understood the concern. On 3/12/25 at 4:28 p.m., R52 was observed in their hospital bed, appearing tired, wearing her oxygen via nasal canula. R52 spoke softly, and reported they were not having a good day. When asked why, R52 stated they wanted their pillows adjusted. R52 appeared restless and was fidgeting with their bedding, trying to reach their pillow. R52 pressed their call light and Certified Nurse Aide (CNA) V arrived, and adjusted R52 by pulling them up in bed and adjusting their pillows. An empty chocolate pudding cup was observed on R52's bedside table. This Surveyor asked R52 what would help them to feel calm. R52 stated getting their pain medication on time, getting chocolate pudding whenever they wanted it, and having their call light answered on time would bring them peace and comfort. On 3/12/25 at approximately 4:40 p.m., CNA V reported R52 was attention seeking, and doing about anything to get to keep them in their facility room, as they struggled to be alone. CNA V reported R52 sometimes used their bed remote to raise their head of the bed all the way in the air, so they appeared to be almost sliding down when they left the room, to get them to return to their room. CNA V stated they were worried about them falling out of the bed. CNA V explained they had been in their room [ROOM NUMBER] to 30 times already on their day shift, and R52 was on their call light every five to ten minutes. CNA V stated they had other residents to care for and could not sit in R52's room. CNA V reported they were giving R52 pudding constantly and they did not know how to handle these requests, as R52 was not satisfied when they had pudding, and soon after would request pudding again. CNA V asked if anything else could be done, and if this Surveyor had any ideas. CNA V was asked if they had followed up with their nurse or nursing management and stated they had not. Review of R52's nursing hospice note dated 2/21/25 revealed in the narrative section, .SNV (Skilled Nursing Visit). Received patient (R52) lying in the hospital bed, awake and alert. Patient (R52) was yelling out into hallway. 4 people to come (sic) into her room. Patient (R52) appeared agitated/restless throughout visit and spoke with facility nurse manager, who states patient is restless most of the day, constantly asking for pudding cups, but does not eat all her meals . The hospice note showed R52 was using Lorazepam a few times a day as needed, and they recommended Lorazepam to be increased to scheduled twice a day. The note showed R52's medical and behavioral presentation had changed little from 2/21/25, and there were no other hospice notes available. On 3/13/25 at 11:11 a.m., Physician Q (who was familiar with R52) was asked (in person) about R52's ongoing agitation, restlessness, reports of high pain, and psychosocial distress, including self-reported loneliness, as evidenced frequent use of their call light, possible attention seeking behaviors (verses pain), as well as their seeming insatiable appetite for pudding, without reported satiety. Surveyor and Physician Q reviewed the EMR, Egress, the electronic filing system, and the hospice nursing care notes, which still showed the last hospice nursing visit was on 2/21/25. Physician Q was asked to explain the process for care coordination with R52's hospice and facility care team, and documentation expectations. Physician Q reported the expectation was R52 would be seen by a hospice nurse weekly, and the notes should have been available and found in the EMR. Physician Q acknowledged they had not seen any current hospice care notes. Physician Q reported the hospice team should have had their social worker making more recent visits due to R52's ongoing anxiety, restlessness, and agitation, and may have considered involving pastoral (spiritual) services, pending R52's wishes. Physician Q shared they believed the social worker and/or care team should have worked to identify the cause of R52's pervasive anxiety, such as were they afraid of dying, wanting to go home, or other unknown reasons. Physician Q conveyed their expectation would be the most recent, current hospice documentation would be readily available in the EMR, and there should be ongoing communication documented between the hospice providers and the nursing and physician/medical care team in the medical record (which was not currently found with mutual record review). Physician Q reported if they had been made aware of R52's ongoing psychosocial concerns and high anxiety, they may have requested psych services would have been involved in R52's care and planned to follow-up. Review of the R52's physician orders on 3/13/25 with Physician Q revealed they had concerns regarding R52's medications. Physician Q stated if they had been made aware of R52's high anxiety, they could have potentially prescribed an anxiety medication which was longer acting, such as Clonazepam, to mitigate (mood) peaks and troughs, as they explained their current medication, Lorazepam, was shorter acting, and may have contributed to R52's ongoing reports and observations of anxiety, including their restlessness and behavioral presentation. Physician Q reported they planned to speak with the hospice provider immediately to address R52's medication concerns. Physician Q stated they had a concern if the hospice provider was adjusting the medication and not doing a follow-up, since the recent nursing documentation was unavailable. Physician Q additionally noted new orders were just placed in the EMR during the interview on 3/13/25 by hospice to increase R52's short acting Morphine to every three hours (received from the DON) and reported there were possibly better medication options, such as MS Contin, which was a longer acting morphine, as R52 was currently on Roxanol, which was a shorter acting Morphine. Physician Q reported they would have been expected to have been contacted by the hospice provider and a discussion to have ensued to coordinate R52's medications, as they were frequently in the facility (including on 3/13/25) and oversaw R52's care as their facility physician provider, along with the medical director. Physician Q stated they were both readily available and accessible. Physician Q explained a longer-acting pain medication would help R52 not to be using her call light around the clock to try to get her pain medication exactly two hours later when it was due, which may have been challenging for staff at times. Physician Q reported they had communication concerns with R52's hospice provider. On 3/13/25 at approximately 11:56 a.m., the NHA was asked if they had obtained any additional hospice records, per their earlier report there may have been some missing documents in the first batch of hospice notes received. At 12:02 p.m., the NHA reported they had received some additional hospice notes a few minutes prior and were placing them into Egress, the State facility shared electronic filing system. On 3/13/25 at 12:05 p.m., review of the Egress Electronic filing system showed additional hospice visit notes for R52 were uploaded, including nursing visits notes after 2/21/25. On 3/13/25 at 12:10 p.m., the NHA was asked why the hospice notes were not readily available for facility staff to have access and available to review for a resident (R52) currently on hospice care. The NHA reported their health information manager no longer worked at the facility, and they wondered if the records had gone to their email and had not been printed. The NHA stated, This is a process we are going to have to get better at ., and reported they understood the concern. The NHA was asked if they had a policy respective to documentation filing and availability, given these concerns. The NHA reported they did not have a policy related to this. A hospice policy was provided, upon request, but did not include documentation expectations. On 3/13/25 at 12:20 p.m., Physician Q followed up with this Surveyor, and showed this Surveyor R52's new orders they had just received from the DON, which included a psych consult (for psychosocial concerns), and MS Contin was ordered yet the short acting Roxanol remained in place. Physician Q' reported they planned to follow up with the hospice provider regarding the new orders, as they had some concerns and planned to provide hospice care coordination before approving the orders, as they were reviewing the pain medication orders further. Physician Q was made aware of the missing hospice nursing notes newly available by the NHA, which showed nursing visits had occurred after 2/21/25. On 3/13/25 at 12:38 p.m., the DON asked to meet with this Surveyor, and reviewed the newly received hospice nursing notes and the new physician orders, as described by Physician Q. The DON provided notes which showed the newly available hospice nursing notes, which showed the hospice nurse saw R52 on: 3/07/25, 2/28/25, 2/21/25, and prior, and their visit was due this week. This Surveyor asked the DON about the records not being available in the facility for their staff. The DON reported they understood the concern related to documentation being unavailable, per the NHA's description. The DON clarified they understood the concern related to the need for improved hospice care coordination and updated interventions with the facility, respective to R52's ongoing agitation, restlessness, pain, and behavioral concerns. On 3/13/25 at 1:25 p.m., R52's hospice nurse, Registered Nurse (RN) W, was asked about their hospice care coordination with the facility during a phone interview, respective to R52's ongoing concerns related to restlessness, agitation, pain, behavioral presentation, psychosocial needs, and decreased satiety. RN W reported the disconnect on the notes may have been R52 was transferred to the current facility from another skilled care facility, and there may have been a delay in facility receipt due to this process. RN W reported they completed their notes timely and submitted them to their hospice provider, and could not speak to that process, i.e. what happened after they completed their electronic documentation. RN W clarified they logged their visits by hand on a green log form in a hospice binder in the facility, and were unclear why this was not found during the survey for R52. RN W explained they were only at the facility once a week, and since R52's anxiety medication had been increased, they had not been made aware by facility staff of R52's symptoms of anxiety including restlessness and agitation remained an ongoing concern. RN W reported they had been made aware of medication changes and typically with palliative medication changes, they went through the hospice physician and did not communicate with R52's in house physician team, including Physician Q and or the facility Medical Director, per their hospice process. Review of the policy, Hospice Care, revised June 2018, revealed, It is the policy of this facility to screen terminally residents who may be eligible for Hospice Benefit and provide the resident and / or authorized representative with options for these services. Purpose: To support the family and resident and provide the Interdisciplinary Team with additional expertise in pain management, symptom control and bereavement assistance when determined reasonable and necessary .Procedure: 1. Pursuant to regulations, hospice services must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions .2. Hospice is responsible for providing hospice services. The nursing facility provide room and board and care unrelated to the terminal illness. 3. The process of delivering palliative services continues within the dual regulations of the Nursing Facility and Hospice. 4. The Care Plan will reflect the hospice philosophy and be based on an assessment of the resident's needs and specific living arrangements within the nursing home. 5. The plan of care will reflect the residents' current medical, physical, psychosocial, and spiritual needs .a. Hospice will reflect these coordinated services on the facilities template for the plan of care within the medical record. b. The plan of care will reflect which services are provided by the nursing facility and which are provided by hospice. c. The facility and hospice (provider) are responsible for performing their respective functions, which have been agreed upon and included in the jointly developed Plan of Care .7. During the provision of hospice services, the attending physician remains in charge . Review of the facility and provider hospice contract, signed 2/04/25, revealed on Page 12: 4.2.4. Facility shall promptly inform Hospice of any change in the condition of a Patient. This includes, without limitation, a significant change in a Patient's physical, mental, social, or emotional status, (and/or) clinical complications that suggest a need to alter the Plan of Care .4.3: Mutual responsibilities. Hospice and Facility shall communicate with one another regularly and as needed for each particular patient. Each Party is responsible for documenting such communication in its respective clinical records to ensure that the needs of patients are met 24 hours a day. Hospice shall periodically review with the facility representative to verify that Hospice supplied Facility with a copy of each Patient's (Hospice) Plan of Care .

This citation pertains to intake #MI00148743. Based on observation, interview, and record review the facility failed to ensure a sanitary kitchen, food items past their use date were discarded, and food was labeled with an open and use-by date. This deficient practice had the potential to affect all residents who consume meals from the kitchen. Findings include: A complaint received by the State Agency alleged food was not being stored and served in a sanitary manner. On 12/16/24 at 9:00 AM, the facility's Administrator reported they did not have a kitchen supervisor at the time and the Corporate Registered Dietician (who was not in the building at the time) was overseeing kitchen operations until a new Certified Dietary Manager was hired. On 12/16/24 from 9:10 AM until 10:08 AM, observations of the kitchen, dry storage areas, and walk-in refrigerator and walk-in freezer were conducted with the facility's Administrator and revealed the following: A stainless steel table with a toaster on the top was observed to have a drawer storing clean serving utensils. The bottom of the drawer revealed a large buildup of food crumbs amongst the utensils and in the corners of the drawer. At that time, the Administrator instructed [NAME] 'D' to wash the utensils and clean the drawer. A drawer on the serving/steam table containing clean scoops was observed to have a build up of food crumbs in the bottom and corners, including a half of a hardened crust of bread. The reach-in cooler in the kitchen was observed with two undated foam cups of what the Administrator said was soup. It further contained a plastic serving tray with a clear to-go container of undated cottage cheese, and five undated half peanut butter and jelly sandwiches. At that time, [NAME] 'B' said they had been prepared earlier in the morning. They were asked why they did not have a date on them and said they usually dated them when they prepared them, but it hadn't been done yet. A kitchen rag soiled with brown stains covered the coffee maker over-flow tray. The reach-in refrigerator across from the dry storage area revealed four hard boiled eggs in a plastic storage container with no discard/use-by date, a plastic container of cheese slices with no use-by/discard date, a second plastic container of cheese slices with a use-by date of 12/15, a large plastic container of fruit cocktail with no use-by/discard date, a half of a large stick of butter with no use-by/discard date, and a plastic container labeled banana pudding with a use-by date of 12/5/24. At that time, the Administrator said all food should be labeled with an open date and/or a use-by/discard date per facility policy. The reach in freezer across from the dry storage area revealed a bag of frozen hash brown patties with accumulated ice crystals on them in an open manufacturers paper sack that did not indicate an open or use-by/discard date, a second bag of hash brown patties in an unopened manufacturers paper sack that had rips and tears in it, and a clear plastic sack labeled Salisbury steak patties in black marker that did not have an open or use-by/discard date. The dry storage areas revealed an opened bag of semi-sweet chocolate chips with a use by date of 12/6/24, an open bag of brownie mix with no use-by/discard date, six packets of light ranch salad dressing in a plastic container that had no use-by/discard date (it was further noted there were no manufacturer use by dates on the product), a large case of potatoes with no received or use-by/discard date, an open bag of miniature marshmallows with no open or use-by/discard date, an opened large bottle of imitation vanilla with no open or use-by/discard date, a large can of chili/[NAME] island sauce with dents in the can, three packages of hamburger buns with no received or use-by/discard date, and nine loaves of white bread with no received or use-by/discard date. The area also contained five cartons of thickened orange juice with a use by date of November 2024; of the five, one of the carton's packaging appeared compromised and leaked through the plastic top. The plastic top was observed to be growing a green, fuzzy textured substance on the plastic top and on the top of the carton. Two others observed had a brown sticky substance leaked on the carton packaging. An observation of the walk-in refrigerator revealed an egg carton that held 30 eggs. Four eggs remained in the carton, one was observed cracked and two eggs and several empty slots in the carton were observed with what appeared to be a clear and yellow broken egg substance. Continued observation of the walk-in refrigerator revealed the following: a case of individual boxes of donut holes with instructions on the packaging that indicated the product was to be kept frozen and thawed at room temperature with no date of when they were removed from the freezer, several snack-sized packages of grapes that were observed to have a white, fuzzy substance growing on them, and two cases of bacon with no open or use-by/discard date. An observation of the walk-in freezer revealed a leak from the motor/fan/cooling unit that caused a thin build-up of ice on top of a frozen pizza, two frozen pies, in two frozen pie crusts, and on the floor under the unit. A review of a facility provided policy titled, Food Supply Storage and Dating revised November 2024 was conducted and read, Policy: It is the policy of this facility that food and non-food items and supplies used in food preparation shall be stored according to uniform standards, food storage guidelines supplied by the manufacturer and or qualified food vendors utilized by this facility .1. The 'used by' date is the last date a food can be consumed .Dry Storage .8. Remove from dry storage any items for which the expiration date is expiring . According to the 2017 FDA (Food and Drug Administration) Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.

This citation pertains to intake #MI00148257. Based on observation, interview and record review, the facility failed to ensure monitoring and documentation of specific targeted symptoms/behaviors and attempts and non-pharmacological interventions prior to the use of PRN (as needed) anti-anxiety medications for one resident (R#501) of three residents reviewed for psychotropic medications. Findings include: A complaint received by the State Agency alleged residents were not properly receiving psychotropic medications. On 12/16/24 at 12:25 PM, R501 was observed in their room sitting on their bed. R501 appeared calm with a flat affect. They were asked about their stay at the facility and verbalized one concern about a staff member that was reported to the Administrator. A review of R501's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: schizophrenia, bipolar disorder, respiratory failure, muscle wasting and atrophy, dysphagia, and diabetes. A Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition evidenced by a Brief Interview For Mental Status (BIMS) score of 5/15, however a significant change MDS dated [DATE] revealed an updated BIMS score of 13/15 (intact cognition) after they had been treated with antibiotics for a urinary tract infection. A review of R501's physician orders and Medication Administration Records (MAR) was conducted and revealed the following: November 2024: An order for lorazepam (anti-anxiety medication) 1 milligram (mg) every four hours as needed for nine days initiated 11/26/24. The MAR indicated the medication had been given four times on 11/26/24, 11/27/24, and 11/29/24, and three times on 11/28/24, and 11/30/24. December 2024: Several orders for lorazepam discontinued and re-ordered on different dates for 1 mg every for hours as needed. The MAR indicated the medication had been given four times on 12/2/24, and 12/6/24, three times on on 12/1/24, 12/7/24, and 12/9/24, twice on 12/4/24, 12/5/24 and 12/10/24, and once on 12/8/24 and 12/12/24 thru 12/15/24. It was calculated between 11/26/24 and 12/15/24, R501 had received 46 doses of the as needed lorazepam. Continued review of R501's clinical record including: progress notes, care plans, and behavior monitoring was conducted and revealed no evidence of specifically identified target symptoms/behaviors for R501, nor did the documentation reveal any attempts at non-pharmacological interventions attempted prior to the administration of the as needed lorazepam. On 12/16/24 at 3:04 PM, an interview was conducted with Social Services Director 'B'. They were asked about their knowledge of the use of as needed anti-anxiety medications, the requirements for identified specific target symptoms/behaviors, and the use of non-pharmacological interventions prior to the administration of the medications and said, I don't have any idea, further stating it was, Not brought to me as part of my work-flow. On 12/16/24 at 3:33 PM, an interview was conducted with the facility's Administrator and Director of Nursing (DON) regarding their knowledge and use of as needed anti-anxiety medications. The DON said an order should be written for the medication for 14 days, there should be documentation of the behavior/symptom being treated, evidence of what non-pharmacological interventions were attempted, and a follow-up assessment of the resident. A review of a facility provided policy titled, Psychotropic Medication Gradual Dose Reduction (GDR) Guidance dated May 2018 was conducted and read, Policy: It is the policy of this facility to not provide psychotropic medication to residents unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .Procedure: 1. The facility will not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the residents' behavior(s). a. The holistic approach to behavior management will involve an assessment of underlying contributors to behaviors .b. In collaboration with the family and/or authorized representatives the facility will make attempts to become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, they types and consequences of exhibited behaviors by the resident and the interventions that me be indicated for the type of behavior .3. As needed (PRN) orders for psychotropic medication should be limited to 14 days .12. A behavior monitoring record will be implemented for residents receiving psychotropic medication .

This citation pertains to Intake Number(s): MI00146702. Based on observation, interview, and record review, the facility failed to thoroughly assess a resident with a change in condition and notify the physician for one (R801) of two residents reviewed for changes in condition. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that the staff refused to call the physician at R801's request when she was not feeling well. R801 was diagnosed with COVID-19 and was hospitalized for five days. On 9/25/24 at 12:30 PM, R801 was observed lying in bed. R801 was alert and able to participate in an interview. When queried about any recent hospitalization s, R801 reported in August 2024 she started feeling sick with a severe headache. R801 reported she was concerned because she had multiple sclerosis (MS) and a compromised immune system and there was a COVID outbreak in the facility at that time. R801 explained she notified the nurse of the headache and the nurse gave her pain medication which did not relieve the headache. Then the nurse gave her a different pain medication which did not relieve the headache. R801 reported she asked to be tested for COVID-19, swabbed her own nose, and the test was positive. R801 reported the next shift nurse came in and she still did not feel well. R801 explained that she was afraid of how she felt and really wanted the nurse to contact the physician. R801 reported nobody ever took her vital signs or performed an assessment and the nurse (R801 did not know her name) refused to contact the physician. R801 reported the nurse told her she could not give her additional pain medications and she would not call the doctor because she didn't want to get in trouble. R801 told the nurse she was going to call 911 if she did not call the doctor and the nurse said Do what you have to do. R801 called 911 who stayed on the line with her. R801 reported she was so upset when she called and told them she was sick, alone, afraid, and upset because they were not addressing her medical needs. Eventually there was a knock at the door and it was EMS (emergency medical services) and R801 heard the nurse tell them they could leave because R801 was confused and overstepped her bounds. R801 yelled out I am not confused and EMS came in and took her to the hospital of her choice. R801 reported she was hospitalized for about five days and required intravenous fluids and medications, oxygen because her oxygen level was 90 percent when she arrived at the hospital, and needed potassium supplementation. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] (R801 was hospitalized from 8/18/24 until 8/21/24) with diagnoses that included: COVID-19 (8/18/24) and MS. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition. A review of R801's progress notes revealed the following: A progress note written on 8/18/24 by Licensed Practical Nurse (LPN) 'F' documented, During this shift, resident c/o (complained of) headache. Writer gave PRN (as needed) Tramadol ( a pain medication) and rechecked resident 1 hour post administration. Resident stated the Tramadol did nothing to take away the headache. Writer then gave PRN Tylenol per orders. Resident stated that she felt tired and ache <sic>, but that the Tylenol seemed to be helping with the pain. Writer completed a COVID test and the COVID test was (positive). Notified (physician) and will continue to monitor symptoms . A progress note written on 8/19/24 by Charge Nurse, LPN 'G' documented, Writer called resident to see why she went to the hospital. Resident stated she had a horrible headache that wouldn't go away and she received her prn pain meds but didn't work. Resident stated she asked the nurse to see if she can call the doctor to get something stronger. The nurse stated I can only give what you have in your orders, resident stated she told the nurse she was going to call 911 and the nurse stated Go ahead and do what you need to do. Resident call 911 and was sent to (hospital) on August 18 in the evening. It was documented in a progress note dated 8/21/24 that R801 was readmitted to the facility. There was no progress note that indicated when and why R801 went to the hospital prior to LPN 'G's progress note after she called R801 at the hospital. A review of hospital records for R801 revealed a History of Physical dated 8/19/24 that documented, .COVID-19 infection .acute respiratory failure requiring oxygen .PRN breathing treatment and cough suppressants . On 9/25/24 at 2:56 PM, an interview was conducted with LPN 'F'. When queried about R801 on 8/18/24, LPN 'F' reported R801 complained of a headache, she gave medication to treat it, tested her for COVID-19, notified the physician of the positive COVID-19 test, and passed the information on to the next shift. When queried about whether R801's vital signs were done or any further assessment, LPN 'F' reported vital signs were done daily and documented in the vitals tab. LPN 'F' could not provide any additional information about whether she checked R801's vital signs due to her not feeling well and positive COVID-19 test. On 9/25/24 at 3:00 PM, an interview was conducted with LPN 'G'. When queried about why she contacted R801 at the hospital on 8/19/24, LPN 'G' reported she was not sure what happened and why R801 went to the hospital. LPN 'G' confirmed there was no documentation of why and when R801 went to the hospital but was hearing about what was happening over the weekend and called the resident because she was cognitively intact. LPN 'G' reported there was an agency nurse who worked when R801 went to the hospital and she should have assessed R801, documented the assessment, and contacted the physician if R801 was not feeling well and requested the physician to be contacted. LPN 'G reported it was to be documented in the progress notes. LPN 'G' further reported that nurse was not allowed to work in the facility after that night. On 9/25/24 at 3:15 PM, an interview was conducted with the Director of Nursing (DON) who did not work at the facility at the time of R801's hospital transfer. The DON reported the expectation of the nurse when a resident had a change in condition was to assess the resident, including vital signs, and contact the medical provider. The assessment and physician's response should be documented in a progress note.

This citation pertains to Intake Number: MI00146312 Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident for two (R805 and R808) of five residents reviewed for abuse, resulting in R806 punching R808 in the head and six days later R806 punching R805 in the face, neck and chest causing psychosocial harm using the reasonable person concept. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency revealed R806 came into contact with (R805's) foot with her walker and (R806) then made contact with closed fists to (R805's) face, neck, and chest area. This was witnessed by two staff members. A review of R805's clinical record revealed R805 was admitted into the facility on [DATE] with diagnoses that included: vascular dementia. A review of a MDS assessment dated [DATE] revealed R805 had severely impaired cognition, delusions, and verbal behaviors. A review of R805's progress notes revealed a note dated [DATE] that read, Writer notified of resident's foot being rolled over and hit 3 (times) by another resident . On [DATE] at 10:25 AM, an interview and observation were attempted with R805. However, staff reported R805 was transferred to the hospital that morning and was not currently present in the facility. A review of R806's clinical record revealed R806 was admitted into the facility on [DATE], readmitted on [DATE], and expired on [DATE] with diagnoses that included: dementia with anxiety, adjustment disorder with anxiety, and Alzheimer's disease. A review of R806's MDS assessment revealed R806 had severely impaired cognition and no behaviors. A review of a nursing progress note written on [DATE] at 1:57 PM, revealed documentation that noted R806 rolled over another resident's foot and hit her three times. A review of an investigation conducted by the facility in regards to the incident of R806 running over R805's foot and hitting her three times revealed the following: A handwritten statement from Housekeeper (HK) 'C' noted, I (HK 'C') seen (R806) run over (R805's) foot with her walker. (R805) yelled at her (R806) to stop then (R806) proceeded to punch (R805) 3 (times) on the right side of her chest. A handwritten statement from CNA 'D' noted, I saw (R806) punching (R805) today. They both live across the rooms from each other. (R806) punched (R805) at least 2 to 4 times. She punching her front of ice room on her face and neck. A signed statement written by CNA 'E' dated [DATE] noted, .At times (R806) has showed constant signs of aggression towards staff and other residents. Due to her confusion and the confusion of others aggressive interactions have taken place. Majority of the time (R806) is the one to start the altercation. As between these two residents (R805 and R806) she is known to wander into others rooms the most. I am very familiar with (R805) and can say that she hardly ever leaves her room to go into anyone elses and start any type of problems. A review of a typed investigation summary revealed R805 and R806 were cognitively impaired and unable to participate in an interview. The summary documented the following, Investigation Summary .During interviews with staff and residents it was determined that (R805) had stepped into the hallway near her room as she does periodically during the day to approach staff instead of using her call light. While in the hallway (R806) came up to her with her 4-wheeled walker, unaccompanied by staff and made contact with (R805's) foot using her walker, seemingly unintentionally (It should be noted that the intentional act of rolling over R805's foot was not addressed in either statement by the witnesses). (R805) reacted, telling (R806) to stop. (R806) then struck (R805) with closed hands to her face, neck, and chest area .(R806) was placed on 1:1 observation assigned to a staff member to lessen the likelihood of additional incidents .Conclusion .the facility is able to verify that the alleged incident in fact did occur as witnessed by two staff members . Further review of R806's progress notes revealed the following: A note written on [DATE] that read, .Writer got called to room by room mate because resident is walking around room bottom naked with roommate clothes on after leaving bm (bowel movement) on her bed and roommate's bed . A note written on [DATE] that read, Resident's roommate was interviewed and she stated that the resident threw BM at her in the middle of the night . A note written on [DATE] at 8:45 PM that read, .refused a shower .went for a walk. Around 10 min (minutes later) the main entry alarm went off and stopped soon after .resident was up front trying to get out and saying she wanted to kill herself .yelling at staff .grabbed the guide rail at the side of the wall and became combative, yelling, swatting, grabbed at CNA (Certified Nursing Assistant)'s shirt and tried to rip it .Resident took off her own shirt and tried to rip it .grabbed CNAs hoodies and started hitting her with her slipper, swore at her and attempted to bite her .grabbed the nursing cart and was yelling and started throwing medicine cups onto groups and trying to rip off side of cart .grabbed a cup out of another resident's hand . A note written on [DATE] that read, Resident continues to go in and out of rooms .easily agitated and difficult to redirect. Staff member is with resident at all times . A note written on [DATE] that read, Resident was in another room .flipped writer the middle finger and said <expletives> . A note written on [DATE] that read, Resident found in an empty room bathroom putting on pull ups . A note written on [DATE] that read, Early in shift resident was found in neighbor's closet. Yelled at writer to get out .At lunch time resident went into bathroom and had BM on floor and in toilet . Further review of the facility's investigation into the incident between R806 and R805 revealed no mention of R806's behaviors that she exhibited prior to the incident on [DATE]. On [DATE] at 4:14 PM, an interview was conducted with CNA 'D', one of the witnesses to the incident between R806 and R805 on [DATE]. CNA 'D' reported she witnessed R806 punch R805 in the face, neck, and shoulder. When queried about whether R806 had a history of aggressive behavior, CNA 'D' stated, She is very aggressive. Always fighting other residents. CNA 'D' further reported that on the unit where R806 resided, There's so much fighting over there. They are all so hyper all the time. On [DATE] at 4:18 PM, a telephone interview was attempted with HK 'C'. HK 'C' was not available for an interview prior to the end of the survey. On [DATE] at 4:44 PM, R808 was interviewed. When queried about any incidents or altercations with other residents, R808 reported a few months ago, R806 resided in the room next door and they shared a bathroom. R806 came through the bathroom into R808's room. R808 told R806 that she was in the wrong room. R806 became very agitated and punched R808 in the face, then laid on R808's bed. A review of R808's clinical record revealed R808 was admitted into the facility on [DATE]. A review of R808's MDS assessment revealed R808 had intact cognition. A review of an investigation conducted by the facility revealed an Investigation Summary that read, On [DATE] at approximately 10:15 am (six days prior to the incident between R806 and R805), R808 was sitting in her room in her wheelchair just inside her door, the door to her room was open toward the bathroom door that sits between her room and another resident's room. The bathroom was shared. The bathroom door was closed. The resident, (R806) has a room on the other side of the bathroom. (R808) was watching television when the bathroom door opened behind her wheelchair pushing the room door into the back of her wheelchair. (R808) rolled her wheelchair forward to allow the doors to open about a foot. (R806) pushed herself through the door as (R808) said Go the other way and something to the effect of this isnt your room. (R806) then made contact with (R808's) left side of her face, temple and head area with a closed fist .(R806) was provided a CNA assigned only to her for 24 hours to reduce the risk of other occurrences .The facility is able to verify that the alleged incident in face occurred even though there were no witnesses as (R808) is cognitively intact and staff heard the commotion and witnessed (R806) in (R808's) room at the time of the alleged incident . A review of a signed statement written by CNA 'D' revealed on [DATE] (the day before the incident between R806 and R808), (R806) went into (another resident's) room all naked .and when I tried to take her back to room, she tried to hit me and on [DATE], (R806) walked into (R808's) room started beating her and when (CNA 'E') and I tried to take her to her room, she tried to hit me as well. On [DATE] at 4:54 PM, an interview was conducted with the facility Administrator who did not work in the facility at the time of the above mentioned incidents. The Administrator could not provide any additional information other than what was documented, but reported it would be expected that effective interventions were implemented to prevent repeated resident to resident abuse.

This citation pertains to intake #MI00143690. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for two (R905 & R906) of nine residents reviewed for abuse resulting in R906's right arm fracture when R906 was pushed to the floor by R905 as heard by (R909). Findings include: Review of a Facility Reported Incident (FRI) dated 3/21/24 revealed there was a resident to resident physical abuse incident which resulted in injury. On 4/10/24 at 11:35 AM, R906 was observed walking in their room with a sling on their right arm. R906 was asked about the sling. R906 explained it (right arm) was broken and it hurt a lot. When asked how their arm was broken, R906 explained they had been taking a puzzle to R905's spouse when R906 pushed them and R906 fell to the floor and broke their arm. R906 was asked if they ever had any interaction with R906 before that incident. R906 explained R905 had been their roommate, but they had a disagreement and R906 had moved out of the room. R906 was asked if anyone had witnessed the altercation when their arm was broken. R906 explained that R909 had told them they had heard the whole thing. Review of the clinical record revealed R906 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses according to the face sheet that included: 3-part fracture of surgical neck of right humerus (right upper arm), dementia with anxiety and insomnia. According to the Minimum Data Set (MDS) assessment dated [DATE], R906 scored 11/15 on the Brief Interview for Mental Status (BIMS) exam, indicating moderately impaired cognition. Review of the closed record revealed R905 was admitted into the facility on [DATE] with diagnoses that included: encephalopathy, adjustment disorder with anxiety and stroke. According to the MDS assessment dated [DATE], R905 scored 10/15 on the BIMS exam, indicating moderately impaired cognition. Review of R905's progress notes revealed a nursing note dated 3/20/24 at 6:02 PM read in part, Resident had a verbal altercation with roommate resident was moved . Review of R906's progress notes revealed a nursing note dated 3/21/24 at 7:01 PM read in part, .Writer heard resident yell out 'OH!' Writer turned around only to observe resident lying in the hallway on (their) right side saying '(R905) pushed me down!' Other resident was standingover [sic] (them) trying to help (them) off the floor. Both residents were separated .ROM (range of motion) attempted on R (right) arm but resident could not move it and was in pain ratin [sic] 10/10 .911 called .transported resident to hospital for evaluation. Review of R906's hospital discharge paperwork revealed a discharge diagnosis, 2-part displaced fracture of surgical neck of right humerus. Review of a psychiatric note for R905 dated 3/25/24 read in part, .Pt (patient) had an altercation with (their) ex-roommate on 3/21; and (they) ended up pushing (their) ex-roommate resulting in a fall and right arm fracture . On 4/10/24 at 2:07 PM, R909 that stated they heard the whole thing was interviewed and asked about the incident between R905 and R906 and explained they were lying in their bed with the door closed, but heard R905 and R906 arguing loudly and heard R906 say, 'Let go of me! You're hurting me!' then there was a loud crash. The resident then proceeded to explain that they got out of bed and opened the door and R905 was on the floor, flat on their back. Review of the clinical record revealed R909 was admitted into the facility on [DATE] with diagnoses that included: heart failure, gastro-esophageal reflux disease and osteoarthritis. According to the MDS assessment dated [DATE], R909 had a score of 13/15 on the BIMS exam, indicating intact cognition. On 4/10/24 at 2:33 PM, the Director of Nursing (DON), who served as the Abuse Coordinator, was interviewed and asked about R906's broken arm. The DON explained there was a physical altercation that occurred between R905 and R906 that resulted in R906 falling and breaking their arm. When informed of the interview with R909 hearing the altercation, the DON explained she had interviewed R909 right after the incident and R909's story was the same. Review of a facility policy titled, Identification of Abuse revised 3/2019 read in part, .Abuse is defined .as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm' .Physical abuse includes hitting, slapping, pinching, kicking etc .Physical abuse has occurred whenever there had been some type of impermissible or unjustifiable physical contact that has resulted in injury or harm .Willful: As used in the definition of abuse, 'means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm'.

This citation has two deficient practice statements Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure effective interventions to reduce injury from falls were in place for one resident (R19) at risk of falling, of seven residents reviewed for accidents/hazards, resulting in R19 sustaining a non-displaced nasal fracture and diffuse bruising to bridge of nose and surrounding left eye. Findings include: On 2/05/24 at approximately 9:09 a.m., R19 was observed in their room, laying in their bed. R19 was observed to have dark bruising above their left eye. R19 was queried how they got the bruise above their eye and they indicated they fell out of the bed on the left side and hit their face on the tile floor and broke their nose. R19 was queried which side they fell out of the bed on and they indicated it was the left side of the bed where their bed remote, nightstand and call button were clipped. R19 was observed to have a mat next to their bed on the opposite side (right side) of the bed and nothing preventing injury from falling on the left side where they reported they had previously fallen. R19 was queried if they had landed on a mat when they had fallen out of the bed and they indicated they did not and that the mat had been on the wrong side when they fell , and that it should be where all their items are located on the left side. On 2/6/24 at approximately 9:00 a.m., R19 was observed in their room, laying in their bed. R19 was observed to still have their Fall mat located next to bed on the right side on the floor. No mat was observed on the left side of the bed where all their items were that they reach for. On 2/07/24 at approximately 9:10 a.m., R19 observed in their room, laying in their bed. R19 was still observed to have the one mat at right side of of their bed. No mat was observed on the other side of the bed where the bed remote and call button were clipped. R19 was queried again if the mat should be on the other side and they indicated that it should and that sometimes they (the staff) had the mats on each side. On 2/5/24 the medical record for R19 was reviewed and revealed the following: R19 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Muscle weakness, Need for assistance with personal care and Morbid obesity. A review of R19's MDS (minimum data set) with an ARD (assessment reference date) of 11/14/23 revealed R19 had a BIMS score (brief interview for mental status) of six indicating severely impaired cognition. A review of R19's comprehensive plan of care revealed the following: Focus-[R19] has the potential risk for falls or injury related to her reduced functional mobility with increased weakness. Requires staff assistance to complete transfers and to reach the toilet. She has a history of frequent falls and no longer recognizes when her movements exceed her functional capabilities. She continues to be self-determined to transfer and ambulate without alerting staff. She demonstrates proper use of call light but does not utilize it consistently. She is prescribed medication that can contribute to a disturbed gait Date Initiated: 01/30/2023. Revision on: 09/14/2023 .Interventions-See ADL (activities of daily living) plan of care for fall risk interventions. Date Initiated: 01/30/2023 . Further review of the comprehensive plan of care revealed the following: Focus-[R19] altered functional mobility and ADL's related to weakness, depression, chronic back issues that causes her weakness .Date Initiated: 01/30/2023. Revision on: 08/14/2023 .Interventions-10/4/23 Fall mat at bedside to prevent injury. Date Initiated: 01/30/2023. Revision on: 01/31/2024 . A review of R19's progress notes, Physician evaluations and Incident/Accident reports pertaining to their falls revealed the following: 10/3/2023-Interdisciplinary Documentation-Writer observed resident sitting on the floor in the bathroom, Resident stated while trying to hold on to the rail to get pants pulled up after a shower resident slid on the floor. 10/4/2023-Interdisciplinary Documentation-Resident had a fall in her room at 1230. She stated she attempted to get from her wheelchair into bed by herself without using her call light. She was found on her knees by the bed trying to crawl into her bed, after her room mate called for assistance. The CNAs (Certified Nursing Assistants) came in to sit with the resident until nursing arrived . 1/21/2024-Interdisciplinary Documentation-Called to residents room. Observed Resident on the floor laying on her back. She stated I hit my head. Nose and left side of forehead red and swollen. Assist back to bed via hoyer lift with 2 staff assist. Obtained order from on call provider to send to ER (emergency room ) for CT (computed tomography) of head. Daughter aware. Message left for Management staff. EMS (Emergency Medical Services) currently on unit. Sending to [Name of local hospital]. An incident/accident report dated 1/21/24 revealed the following: Incident Description: Nursing Description: Observed Resident on the floor next to her bed laying on her back. Resident Description: I rolled out of bed and hit my head .Notes: .1/22/2024 RCA (root cause analysis): Resident rolled out of bed onto the floor reaching for her bed controls .1/22/2024 Facial bruising with non-displaced nasal fracture . A Physician evaluation dated 1/22/24 revealed the following: Chief Complaint / Nature of Presenting Problem: Fall with nasal fracture. History Of Present Illness: Patient had fall out of bed last night and sustained a non-displaced nasal fracture per ER (emergency room ) paperwork. She does complain of pain and is requesting some stronger pain medication at this time. She has diffuse bruising to bridge of nose and surrounding left eye. She states it is tender to touch and the [NAME] (pain medication) is not relieving the pain .DIAGNOSIS, ASSESSMENT AND PLAN .Nasal fracture-Non-displaced with no surgical intervention needed. Will continue to monitor for healing. Add Tramadol 25mg BID (twice daily) x 5 days for pain and schedule [NAME] 500mg (milligrams) TID (three times a day) x 5 days .Fall-Patient with high risk of falls due to debility and dementia .Dementia without behavioral disturbance Patient continues to require 24 hour care and supervision . 2/3/2024-Interdisciplinary Documentation-Observed resident at bedside on her knees facing the head of the bed. Her upper body was leaning on the top of her mattress. Staff, was assisting resident with peri care and was going to put a new brief on her. Staff asked resident to turn to her L (left) side and as the resident turned, she rolled out of bed and onto her knees on the floor. 2/4/2024-Interdisciplinary Documentation-Note Text: .continues for witnessed change of elevation. LOC (level of care) and ROM (range of motion) remain baseline. Small yellow bruise measuring 3cm (centimeters) x3xcm observed to R (right) knee. On 2/7/24 at approximately 1:46 p.m., during a conversation with Nurse O, Nurse O was queried if they were the Nurse assigned to R19 on 1/21/24 and they indicated that they were. Nurse O was queried if R19 was a high risk of falling and they indicated that they were. Nurse O was queried regarding R19's fall on 1/21 and they reported that they came to the room to find R19 on the floor and that they had hit their face after rolling out of the bed. Nurse O was queried if the mat was down to prevent injury from the fall and they indicated that there was no mat on the floor on the side that R19 fell out of, so they hit their face on the tile floor. Nurse O indicated after the fall they told the DON (Director of Nursing) that R19 should have had mats on both sides of the bed since their bed remote, call light button and table were located on the side that they fell out of. On 2/07/24 at approximately 11:36 a.m., R19's falls were reviewed with the Director of Nursing (DON). The DON was queried if R19 was at risk for falling out of the bed and they reported that they were. The DON was queried regarding R19's fall mat only being on one side of the bed when they fell on [DATE] and landed on the tile floor and they indicated that the mat should have been located on the side that they had fallen out of in which all their items were clipped on (the left side) such as bed control, call button, bedside table etc were located. At that time, the DON was informed that the mat had been located on the opposite side of the bed (the side that did not contain the items) when R19 fell and fractured their nose and they reported that they would have to get R19 another mat. On 2/7/24 a facility document titled Accident/Incident Report-Fall Management was reviewed and revealed the following: 6. It is recognized that not all falls can be prevented, the facility will utilize applicable elements of the systematic process of assessment, intervention, and monitoring to minimize fall risk and injury including: a. Fall risk screening b. Care plan interventions c. Evaluation of the response to interventions and balancing risk with the residents right to self-determination and independence d. Comfort Rounds and promotion of a culture of safety e. Assessment of sensory contributors f. Medication Review g. Orthostatic Hypotension h. Behavioral and Diagnosis risk factors i. History of falls with root cause analysis j. Pain management . 32568 DPS #2 Based on observation, interview, and record review, the facility failed to provide adequate supervision for one (R49) of four residents reviewed for accidents, resulting in R49 repeatedly wandering into other residents' rooms and consuming a topical skin ointment. Findings include: On 2/6/24 between 8:30 AM and 8:45 AM, R49 was observed wandering on the [NAME] and Sapphire Units going in and out of other residents' rooms. On 2/6/24 at 1:12 PM, a confidential interview was conducted with residents who attend the resident council meetings at the facility. When queried about any additional concerns the residents had regarding the care and services provided by the facility, one resident who wished to remain anonymous reported R49 walked in and out of resident rooms and took their personal belongings. The same resident reported he woke up to R49 standing over him in bed and stated, That scared the hell out of me! A second resident who wished to remain anonymous reported R49 entered other residents' rooms and took their remote controls, had gotten in other residents' beds, and that it was an ongoing problem. That same resident reported that R49 came into her room with a female resident, sat on the other bed, and he began taking his shirt off. The resident had to alert staff to get them out of her room. All six residents reported they had a problem with R49 entering their rooms. They expressed understanding that R49 had cognitive impairment, but reported it still made them uncomfortable when he entered their rooms. Review of R49's clinical record revealed R49 was admitted into the facility on [DATE] with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had severely impaired cognition and behaviors that included physical, verbal, other, rejection of care, and wandering. Review of R49's progress notes revealed the following: On 1/30/23, it was documented in a progress note that R49's wife was concerned about the resident's increased wandering into other residents' rooms and that the other residents were getting mad and R49 ate other resident's chocolate. R49's wife requested increased supervision for R49. On 2/1/24, it was documented in a progress note that R49 was discovered to have eaten multiple packets of chamoysn, which is a topical skin protectant ointment that contains menthol and Zinc Oxide. On 2/7/24 at approximately 10:10 AM, an interview was conducted with Clinical Care Coordinator (CCC), Licensed Practical Nurse (LPN) 'B'. When queried about the incident when R49 ate topical skin protectant ointment, LPN 'B' reported a Certified Nursing Assistant (CNA) reported to her that she thought R49 ate the ointment because there were empty packets in the trash can. LPN 'B' assessed R49 and his mouth was observed to be coated with a thick, pink substance that looked the same as the ointment packets found in the trash. When queried about how R49 accessed the topical medication, LPN 'B' reported she did not know how he got it, but it was discovered some of the CNAs were storing the ointment in resident rooms for easy access instead of having it locked in the treatment cart. LPN 'B' reported it should have been locked up. LPN 'B' explained that wandering is not a new behavior for R49 and that it was something he did constantly. LPN 'B' stated, It is an issue with him and he is actually becoming more aggressive now an sometimes threatening so it is harder to redirect him. LPN 'B' reported she was aware that other residents were upset with R49 wandering into their rooms and the facility tried to put up stop sign barriers to try to deter R49 from entering, but it did not always stop him. LPN 'B' reported R49's wife was concerned about the increased wandering and requested that he received one to one supervision. LPN 'B' explained it was suggested to the DON but she said it was not in the facility budget to provide one to one supervision long term unless the family paid for it. When queried about what was currently in place to prevent R49 from wandering into other residents' rooms, LPN 'B' reported they just had to try to redirect him. On 2/7/24 at 10:31 AM, an interview was conducted with the DON. When queried about R49's wandering behaviors, the DON reported she was aware that he walked in and out of other residents' rooms. When queried about what interventions were in place to prevent that from happening in order to keep other residents safe and comfortable, as well as R49, the DON reported the CNAs and nurses were responsible to redirect R49. When queried about whether one to one supervision was ever discussed per R49's wife's request, the DON reported she was not sure about one to one supervision, but staff should be watching him. On 2/7/24 at 10:45 AM, while conducting an observation of the medication room located behind the nurse's station with the Director of Nursing (DON), R49 was observed using a walker and entered the nurse's station and walked toward the medication room. The DON redirected R49 back to the hallway. At approximately 10:55 AM, R49 wandered back into the nurse's station toward the medication room. The DON redirected R49 to the hallway a second time and closed the half sized barrier door that separated the nurse's station from the hallway (resident area). At that time, the DON instructed staff to take R49 to an activity. However, staff did not prevent R49 from entering the nurse's station area. On 2/7/24 at approximately 11:05 AM, an interview was conducted with the Administrator. When queried about the facility's ability to supervise residents with constant wandering behaviors on a one to one basis, the Administrator reported they do not have the capacity to provide one to one supervision on a long term basis, but can for periods of time until the resident was deemed safe. Interview with Administrator. 1:1 not for long term but until they can be deemed safe. Review of R49's care plans revealed no care plan to address R49's wandering into other residents' rooms, taking their belongings, or consuming topical medication. Review of R49's Wandering Risk Assessment Scale dated 1/10/24 revealed R49 was assessed to be at high risk to wander. Review of the CNA task for Behavioral Care for R49 revealed wandering was not included as a behavior that was monitored. Review of a facility policy titled, Wandering Resident Exit Seeking Management, revised on 1/2023, revealed, in part, the following, .Wandering: Aimless or purposeful motor activity that causes a social problem such as becoming lost, leaving a safe environment, or intruding in an inappropriate place .The MDS process .will be utilized to continue to assess and evaluate the risk quarterly and post significant change in status .The 24-hour report will be used to communicate a change in resident wandering behavior or cognition on an on-going basis .Each resident's level of supervision .will be modified according to these assessments. The plan of care will be updated accordingly .

This citation pertains to intake: MI00138956. Based on interview and record reviews the facility failed to consistently provide adequate supervision to prevent further falls for one (R707) of two residents reviewed for falls, resulting in the resident to have been transferred to the hospital and to have received four stitches to their lip for a through and through laceration, obtained multiple bruising, and a hematoma to left outer orbital area with slight bruising and pain using the reasonable person concept. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . It was discovered that (R707 name) had a through and through laceration that required four stitches . (R707 name) also had a prior laceration on her elbow that should have been repaired, but it was too late. (R707 name) is covered in bruises. The bruises could be from falling, but (R707 name) does have a bruise on her right wrist. The bruise looks almost like she was grabbed (thumbprint), but it is unknown for sure. There is a concern that (R707) had injuries that needed further care, and she did not receive it . This concern was submitted by a Medical Doctor (MD) A. Review of the medical record revealed R707 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, psychotic disorder with hallucinations and delusions, anxiety, postconcussional syndrome and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of a Fall Management assessment dated [DATE], documented in part . Has the residents Behavior changed in the previous 90 days? Yes . Standing Balance . Not able to attempt test without physical support . Ambulates with problems and uses assistive devices .During the past 90 days there have been: 3+ Falls .has had multiple falls recently r/t (related to) medications changes, and terminal restlessness . The resident fall score was documented at 16.0. Review of the progress notes and the facility's Incident and Accident (I&A) reports revealed the following: A progress note dated [DATE] at 10:01 AM, documented in part . Resident attempted to sit in seat, missed chair and fell to floor on bottom . A progress note dated [DATE] at 5:23 AM, documented in part . Resident observed sitting on the floor in her bedroom in front of her bed in an upright position with her back leaning on her bed. Resident unable to describe related to baseline confusion . Review of a I&A dated [DATE] at 3:26 AM, documented in part . had an unwitnessed change in plane from bed to a seated position on the floor in her room . Resident Unable to give Description . Review of a second, I&A dated [DATE] at 4:36 AM, document in part . Resident observed sitting on the floor in her bedroom in front of her bed in an upright position with her back leaning on her bed . Resident unable to describe related to baseline confusion . Review of progress note dated [DATE] at 11:49 PM, documented in part . Resident was observed on the floor near the side of the bedside . Review of a progress note dated [DATE] at 5:53 PM, documented in part . Pt (patient) was sitting in chair and slid down to floor . Further review of the progress notes and I&A's revealed R707 continued to have multiple falls on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of a Nurse Practitioner (NP) consultation dated [DATE], documented in part . Chief Complaint . Fall, bruising, Agitation, anxiety . Patient with increased anxiety and agitation. Staff is unable to redirect and patient has experience unwitnessed falls resulting in a bruise to her arm and also to her left forehead. Patient is on hospice care and much of the issue is trying to find the right formula of medications for her, where she is comfortable, but not over-medicated . Patient did have an unwitnessed fall this morning which resulted in a large bruise with hematoma to left outer orbital area with slight abrasion. EMS was called to building to assess, however patient remained in facility due to hospice status . Review of a NP consultation dated [DATE], documented in part . Patient with continued increased anxiety and agitation. Seroquel was increased at last visit and Ativan was added on a PRN (as needed) dosing schedule. Agitation continued through the weekend and hospice increased timing of Ativan, along with adding Morphine on a PRN basis . Patient is continuing to pace facility with increased fall risk secondary to debility. She is difficult to re-direct and requires 1:1 attention . Review of a progress note dated [DATE] at 8:12 AM, documented in part . S/W (spoke with) (hospice nurse name and hospice company name) who reported a decline in the offer of resident 1:1 staffing. Resident has medication available to assist with residents restless behavior . Review of the medical record revealed no documentation of the facility to have provided the one-on-one attention as documented by the NP. Review of a progress note dated [DATE] at 4:56 AM, documented in part . Alarm sounding, entered room observed (R707 name) trying to get up out of bed, noted bleeding on her face and her lower lip is split. Uncertain how this occurred . Review of a progress note dated [DATE] at 7:02 PM, documented in part . resident room mate who is A & O x4 (alert and oriented x4) . reported seeing (R707 name) get up from the floor at the early morning hours. (R707) had struck her lip on the feet of the bedside table resulting in an open area to the lip . resident to the hospital for stitches . (R707 name) has return <sic> from the hospital via ems (emergency medical services) with lip laceration repair . Review of a progress note dated [DATE] at 8:03 AM, documented in part . Resident was observed on the floor in the hallway. There is a skin tear on the right arms <sic> . On [DATE], a NP note documented in part . Patient with continued anxiety and agitation at various times during the day. Medications have been adjusted multiple times in discussion and agreement with hospice. Continued medication adjustments are needed and patient continues with increased agitation and restlessness. She has had multiple falls over the last week and continues to run around facility in a manic state at times. She did strike her face against bedside table causing a laceration to her lower lip. She was sent out to ER (emergency room ) for sutures and returned shortly after. Since that time she has chewed out the sutures lip is open . Will continue to monitor . Discussion with nursing staff, hospice RN, hospice NP and pharmacist have ensued for possible medication management of agitation as staff is providing all non-pharmologic interventions including 1:1 supervision. Patient is currently on scheduled Ativan BID (twice per day), along with Morphine every 4 hours . She is also receiving Seroquel 25 mg (milligrams) in AM and afternoon and 50mg QHS (every hour of sleep). She is in bed during exam, however agitated and restless . She is restless and moaning . Review of the medical record revealed no documentation of the 1:1 supervision to have been done consistently. Review of a progress note dated [DATE] at 5:17 PM, documented in part . Resident was observed on the floor in the room. There is a skin tear on the back of resident head . Review of the progress notes revealed R707 expired in the facility six days later on [DATE]. On [DATE] at 12:23 PM, the Administrator, DON and Social Worker (SW) B was all interviewed together and asked why the facility did not ensure that a 1:1 was provided at all times for R707 to ensure adequate supervision and safety of the resident considering the medical provider documented that the resident needed 1:1 supervision, the numerous falls and injuries that R707 obtained due to their declining status and the multiple medication changes as documented due to the residents increased restlessness and anxiety, the Administrator replied they would look into it and follow back up. The Administrator, DON, and SW B were asked what the criteria was to implement the 1:1 and remove the 1:1 supervision for R707 and the Administrator again stated they would look into it and follow back up. On [DATE] at 1:40 PM, the Regional Director Nurse (RDN) C entered the conference room and stated they could provide information on R707 since they were covering the building and helping with R707 when they were in the facility. When asked why the facility did not provide consistent 1:1 supervision to R707 for safety as directed by the medical practitioner, RDN C stated 1:1 supervision was provided intermittently based on how R707 presented each shift. RDN C was asked what the criteria was to provide or remove the 1:1, considering there was no documentation on the plan of care for the criteria of the 1:1. RDN C stated the resident had some good days and bad days. RDN C then stated they had numerous conversations with the hospice group and stated . I told them that we have a distress resident, and we aren't meeting her needs . RDN C stated the resident was not resting at night and they had attempted many medication changes in attempt to stabilize the resident. RDN C was again asked why adequate supervision was not in place for R707 knowing that they were declining, had multiple medication changes to control their restlessness, agitation, and anxiety, had multiple injuries due to falls, had impaired safety judgment and medical professionals to have documented that a 1:1 was needed for R707. RDN C then stated they believed that they could provide documentation to show R707 had a 1:1 most of the time. RDN C was asked to provide the documentation. RDN C returned shortly after and stated they were unable to provide documentation of a 1:1 being provided consistently for R707. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake MI00133977. Based on observation, interview, and record review the facility failed to protect residents' right to be free from sexual abuse by another resident involving four (R40, R63, R10, and R4) of nine residents reviewed for abuse, resulting in Immediate Jeopardy to health and safety of residents when R40, a male resident, engaged in repeated inappropriate sexual contact with R4, R10, and R63, all of whom were severely cognitively impaired females who were unable to consent. Using the reasonable person concept, the sexual abuse resulted in the potential for serious psychosocial harm and/or injury to R63, R10, and R4, and it resulted in the likelihood that that additional sexual abuse would occur with vulnerable residents. Immediate Jeopardy: The Immediate Jeopardy began 01/13/2023. The Immediate Jeopardy was identified on 03/08/2023. The Administrator was notified of the Immediate Jeopardy on 03/08/023 at 4:08 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 03/08/2023 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Findings include: Review of a facility policy provided by the facility entitled Abuse Prevention Overview (revised on 02/2023) read, in part, Policy: It is the policy of this facility to provide the highest quality of care possible and utilize policies that protect residents from acts of abuse .Purpose: To protect the residents right to be free from verbal, sexual, physical, and psychological abuse, corporal punishment, and involuntary seclusion by anyone including, but not limited to, facility staff, other residents . Under the Prevention heading it read, 4. The facility will develop care plans, which include interventions for behaviorally challenged residents ., and under the Respond and Identity heading it read, .2. The facility will identify, correct, and intervene in situations in which abuse, neglect and /or misappropriation of resident property is more likely to occur . Review of a facility policy entitled Identification of Abuse (revised on 03/2019) read, in part, .Procedure: Facility staff will be educated according to the following definitions to assist staff to recognize and report potential abuse Definitions: .Sexual Abuse: 'non-consensual sexual contact of any type with a resident.' R40 Review of the clinical record revealed that R40 was admitted to the facility on [DATE]. Diagnoses included dementia, schizophrenia, conversion disorder with seizure (a brain disease), and high blood pressure. Per the most recent Significant Change Minimum Data Set (MDS) assessment (dated 01/19/2023), R40 required supervision with set up for bed mobility, transfers, and toileting, and R40 was significantly cognitively impaired. Review of R40's care plan found the following: .AMBULATION: Independent as tolerated with rolator walker (4 wheeled with seat) .Date Initiated: 11/21/2022 . On 03/07/2023 at 10:55 AM, R40 was observed attending an activity in the dinning room. R40 presented as confused with unclear speech, and they had a rolator walker next to them. On 03/08/2023 at 09:30 AM, R40 was observed seated in a chair by the back left window of the common room across from the Sapphire nurses' station. There were five female residents (four in wheelchairs, one ambulatory) present in the room, along with one male resident. There were no staff members present. A male CNA (Certified Nurse Assistant) entered the room at 09:30 AM, but they did not interact with R40. At approximately 9:40 AM, a housekeeper entered the room to clean tables, and the CNA left shortly after. There were no staff members at the nurses' station during this entire period. On 03/08/2023 at 09:42 AM, R40 left the common room and walked down the hall to their room-no staff were with them. R40 entered their room and sat in a chair, and at 09:42 AM, Nurse E entered the room to give medication to R40's roommate. At 09:44 AM, R40 exited their room and walked back to the common room across from the nurses' station unaccompanied by staff. There were three female residents present, all in wheelchairs, and one male resident. There were no staff members in the room, nor at the nurses' station. Staff members walked by the room but did not check on R40. At 09:54 AM, R40 again exited the common room and walked back to their room, unaccompanied by staff. On 03/08/2023 at 09:57 AM, R40 left their room and walked up the hall to the common room across from the nurses' station. R40 then sat at a table on the left side of the room. There were staff, including the DON, were in the room tending to an exit seeking resident. Staff left the room at varying times, with the DON remaining the longest. At 10:06 AM, the DON left the room, leaving no staff present with R40 and other residents, including five female residents. On 03/08/2023 at 10:09 AM, R4, who uses a wheelchair, entered the dining room and joined R40 at the table. R40 and R4's faces were in very close proximity to each other. Staff were not present for this. Staff entered the room a few minutes after and took R40 to an activity. On 03/08/2023 at 03:20 PM, R40 was observed in the main dinning room with several residents, including eight female residents, one of which was seated at the same table as R40. There were no staff members present, and staff did not enter the room until 03:23 PM when this writer called their attention to an issue with another resident. Review of the clinical record revealed a progress note dated 01/09/2023 that read, in part, Resident dx, with psychotic disturbance, mood disturbance, anxiety, schizophrenia/unspecified. Resident referred to Social Service due to increased restlessness and impulsivity. Social Worker spoke with resident verbally and through written communication. Social worker discussed personal boundaries with resident and acceptable behavior when feeling the need to hug others. Resident is currently on Transition Hospice. Recommendation is to have resident seen by [psychology] . A progress note dated 01/10/2023 read, in part, Spoke with [hospice]. Resident will be discharged from Hospice as of 1/12/23. Resident was not seen by [psychology] d/t (due to) patients Hospice payor source. Spoke with [psychology service], resident will be seen for a med review on 1/24/23 . Review of a Facility Reported Incident (FRI) submitted to the State Agency on 01/11/2023 read, in part, .On 1/11/23: at 11:10am, [Housekeeper F] observed [R40] and [R63] in the hallway, near the sunshine dining room. [R40] was standing with [their] walker and [R4]in her gerichair. [R40] was standing over [R63] placing closed mouth kisses to [R63's] face and neck. When [R40] saw [Housekeeper F] [R40] stood and walked with [their] walker to his room. [Housekeeper F] then went to report the encounter to the abuse coordinator, [Former Director of Nursing (DON)]. [Housekeeper F] returned to the Sapphire hallway with [Dietary Cook G] a few minutes later. [R40] was with [R63] once again with an open hand on top of [their] clothing on [their] breast. [Dietary Cook G] walked with [R40] to the dining room and [Housekeeper F] moved [R63] into the sunshine dining room. Both informed [Nurse E of the incident . Review of the FRI revealed a witness statement from Housekeeper F that read, I came around the nurse's station on Sapphire Hall, I observed [R40] standing with [their] walker, standing over [R63] who was in [their] chair. [R40] was kissing with a closed mouth to [R63's] cheek and neck. When [R40] saw me and walked to [their] room, I felt [R63] was safe to stay there until I could get help. No one was available on the hall, so I went to tell [Former DON], the abuse coordinator. I went back to the sapphire hall with [Dietary Cook G] a few minutes later and [R40] was standing next to [R63] in the hall again. I saw [R40's] hand placed on [R63], but I could not see where [their] hand was placed. [R40] was leaning his face toward her face again. I pulled [R63's] chair away from [R40] while [Dietary Cook G] walked [R40] to the main dining room. I pushed [R63] in [their] chair into the sunshine dining room and I then told [Nurse E] who was the nurse for Sapphire and [Former DON], the abuse coordinator about the second encounter. Note that Housekeeper F did not provide immediate supervision for either resident after witnessing the first encounter, thereby not safeguarding R63 from experience additional abuse, and amount of time the residents were left unsupervised was not specified. On 03/08/2023 at 05:14 PM, a voicemail was left Housekeeper F. Housekeeper F did not call back by the end of the survey. Review of the FRI revealed a witness statement from Dietary Cook G that read. I was coming to Sapphire Hall with [Housekeeper F] from the main dining room, [R63] was sitting in [their] chair in the hallway, [R40] was standing over [R63] leaning down with [their] open hand on [R63's] breast on top of [their] clothing and kissing [them] with a closed mouth to [their] cheek. I redirected [R40] to the main dining room and told [Nurse E], the nurse on Sapphire Hall. [Housekeeper F] helped separate them and [Attending Physician W] came from the office to assist. On 03/08/23 at 05:14 PM, Dietary Cook G was interviewed via phone. Dietary Cook G shared that they no longer work for the facility as of January. Dietary Cook G recounted the incident as described in their witness statement, stating that they saw R40 kissing R63 with one had on R63's breast. When asked about R40's behavior, indicated that staff all started noticing R40 doing it quite frequently after. When asked for details, Dietary Cook G went on to say that R40 would look for R63 and other female residents, suggesting that it was like R40 was looking for a girlfriend. When asked about specific instances, Dietary Cook G indicated that they did not see other instances, however they heard others talk about the behavior. R63 Review R63's clinical record revealed that they were admitted to the facility on [DATE]. Diagnoses included vascular dementia, depression, heart failure, hypothyroidism, high cholesterol, high blood pressure, and chronic obstructive pulmonary disease (a lung disease). Review of the most recent Quarterly MDS assessment (dated 01/02/2023) revealed that R63 was totally dependent, requiring the assistance of two or more people for transfers and toileting, and extensive assistance from two more people for bed mobility, and dressing. Per this assessment, R63 was not ambulatory nor were they able to move independently in their room or throughout the facility, and they were significantly cognitively impaired. Review of R63 care plan found the following: .AMBULATION: Non Ambulatory .Date Initiated 03/30/2021 . ASSISTIVE DEVICES: Geri-chair (a padded recliner on wheels) .Date Initiated: 10/06/2021 . On 03/07/2023 at 09:41 AM, R63 was observed awake, lying in bed awake. They presented as confused and lethargic with nonsensical speech. A geri chair was near their bed. Review of R63's clinical record revealed an Interdisciplinary Documentation Note dated 01/11/2023 that read, in part, Licensed staff on duty reported that today, [R40] approached [R63] and displayed impulsive, witnessed physical contact including open mouthed-quick kisses to her cheek and neck, and open-handed touching to her chest area. [R63] turned their head away and provided increased personal space reminders to [R40] with an outstretching of her right arm and hand . The note further read, .Notifications were made to [R63's family member(Family Member l)] who requested a room change since the two residents share a unit. Room change request honored and completed. Note that this was not an intervention initiated by the facility, rather a request from Family Member I due to the proximity of R63 to R40. Review of the FRI under the section Immediate Action Taken read, in part, [R40] was placed on 1:1 observation during waking hours and 15-minute checks while sleeping. The FRI also indicated that on 01/12/2023, a referral was made to send R40 to an out of state psychiatric hospital, but on 01/14/2023, this hospital informed the facility that they could not accept R40 due to their recent discharge from hospice care. R40's record did not reveal an indication that referrals were made to other hospitals. A physician progress note revealed that R40 was seen by Physician W on 01/11/2023 for a follow-up regarding the incident between R40 and R63. This note read, in part, Plan: Medications are reviewed with no changes are this time with the exception of ABT (antibiotic) for possible UTI (urinary tract infection). Psych services .Staff to continue to monitor for any adverse repercussions or clinical changes and notify service. Review of the clinical record found no evidence that R40 was followed by psychology. Furthermore, as described above, R40 could not be seen by psychology until they discharged from hospice, and R40 did not discharge from hospice until 01/12/2023. R40 was not seen by psychology until 01/18/2023-see below for details. Documentation of the one-on-one observation was titled [Facility Name] 24 HOUR STAFFING SHEET, which was the staffing schedule for the day, broken down by unit and shift. Each schedule was dated at the top, with a date range on 01/11/2023 to 01/12/2023. Some of the CNA names on the list were highlighted. On 03/08/2023 at 01:36 PM, the DON was asked who was assigned to one-on-observation of R40. The DON indicated the CNA's highlighted were assigned to one-on-one observation of R40. However, R40's name was not on this document to indicate that this person, was in fact assigned to R40, nor was there separate documentation accounting for the one-on-one observation of R40. It should also be noted that, for some days, the CNA highlighted were not assigned to the Sapphire unit, which is where R40 resided. The DON stated that the highlighted CNAs were reassigned to the Sapphire unit to provide one-on-one observation. Documentation was not provided to indicate reassignments. Review of 15-minute check documentation dated 01/12/2023 entitled Resident Visual Observation Assessment with R40's name at the top. At 6:00 AM, 6:15 AM, and 6:30 AM, it was noted that R40 was awake in the hallway, indicating that one on one observation should have been in place, yet CNA highlighted on the 24 HOUR STAFFING sheet for the morning shift indicated that the shift did not start until 6:30 AM. Review of a progress note written on 01/24/2023 by the DON read, Note from 1/13/23 @ 1300 changed to Q (every)15 visual checks based on [R40] not displaying any behaviors while [they] had a 1:1 sitter. Review of Review of 15-minute check documentation dated 01/13/2023 revealed that the form was blank, with no indication that 15-minutes checks were completed, nor was there documentation that 15-minute checks occurred the morning of 01/14/2023. Review of a second FRI read, in part, Date of Incident: 1/14/2023 at 9:50 AM .Sequence of events: On 1/14/23 at 9:50 AM, [Cook L] witnessed .[R10] was sitting in [their] gerichair, in the sunshine dining room while [R40] stood over [R10] with [their] left head under [R10's] blouse, the placement of the hand was on [R10's] abdomen, [R10] was stating to [R40] 'don't do that.' [R40] was redirected away from [R10]. On 03/08/2023 at 05:36 PM, a voicemail was left for Dietary Cook L. Dietary Cook L did not call back by the end of the survey. On 03/08/2023 at 05:31 PM, a phone interview was conducted with Nurse E as they were the nurse assigned to the unit t the time of the incident between R40 and R10. Nurse E indicated that they did not witness the incident, but they knew it was reported. They could not recall details. R10 Review of the clinical record revealed that R10 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, conversion disorders with seizures, history of stroke, high blood pressure, dysphagia (a swallowing problem), and depression. Review of the most recent Quarterly MDS assessment (dated 01/02/2023) revealed that R10 was totally dependent, requiring the assistance of two or more people for bed mobility, transfers, dressing, and toileting. Per this assessment, R10 was not ambulatory nor were they able to move independently in their room or throughout the facility, and they were significantly cognitively impaired. Review of R10's care plan found the following: .AMBULATION: Non Ambulatory .Date Initiated 09/12/2017 . ASSISTIVE DEVICES: High back reclining WC with Left arm bolster, left padded armrest, foot buddy and front and rear anti-tip bars. MECHANICAL LIFT .Date Initiated: 06/06/2017 . On 03/08/2023 at 03:47 P, R10 was observed awake, lying in bed. They were alert, but they presented as very confused. It should be noted that R10's room was directly across from R40s. Review of the FRI under the section Immediate Action Taken read, in part, in part, [R40] was placed on 1:1 observation during waking hours and 15-minute checks while sleeping On 1/14/23 a referral was sent to [an out of state psychiatric hospital] intake unit for [R40] .On 1/14/23 [Clinical Care Coordinator A] received a call from the [out of state psychiatric hospital] indicating that that they were unable to accept [R40] for care at this time related to [their] recent discharge from hospice. R40's record did not reveal an indication that referrals were made to other hospitals. Review of R40's care plan revealed Review of R40's care plan found the following: .*1:1 staffing when up and Q15 minute checks when in bed at night x 48 hours then reassess, due to new onset impulsive behaviors .Date initiated: 01/14/2023. [Facility Name] 24 HOUR STAFFING SHEETs were reviewed for 01/14/2023 to 01/30/2023. Again, per the DON, the CNA names highlighted indicate which staff were assigned to one-on-one observation of R40, and, again, R40's name was not listed to indicate the highlighted CNA, was in fact assigned to R40, nor was there separate documentation accounting for the one-on-one observation of R40. Also, for some dates, the highlighted CNAs were not assigned to R40's unit. Furthermore, the following dates and shifts did not have a CNA assigned to one-on-one observation: 01/18/2023, afternoon shift; 01/21/2023, afternoon shift; 01/22/2023, afternoon shift; 01/26/2023, afternoon shift; 01/30/2023, afternoon shift. No documentation to indicated that one-on-one observation continued past 01/30/2023. No interventions were added to R40's care plan. Documents entitled Resident Visual Observation Assessment were reviewed to assess 15-minute checks while R40 was in bed at night. No documentation was provided for 01/14/2023 to 01/21/2023. For 01/22/2023 at 10:00 PM, R40 was noted to be asleep, in their room at 10:00 PM, but the 15-minute check fields for 01/22/2023 at 10:15 PM to 01/23/2023 at 5:45 AM were blank. From 01/23/2023 at 08:45 AM to 09:45 PM. The Resident Visual Observation Assessment for 01/23/2023 to 01/24/2023, 15-minute check fields were completed, but R40 should have been on one-to-one observation. No documentation was provided for 01/24/2023 to 01/25/2023. The assessment dated [DATE] did not have any 15-minute check fields completed from 10:00 PM to 07:45 AM. The assessment dated [DATE] did not have any 15-minute check fields completed for 10:00 PM to 8:15 AM. The assessment dated [DATE] did not have any 15-minute check fields completed for 10:00 PM to 06:30 AM. The assessment dated [DATE] did not have any 15-minute check fields completed for 10:00 PM to 06:00 AM. The assessment dated [DATE] did not have any 15-minutes checks for the midnight shift. A physician progress note revealed that R40 was seen by Physician W on 01/16/2023. This note read, in part, Resident is seen today in follow-up to a second recent episode of inappropriate behaviors directed towards another female resident .as this is a second event in a short time, an order was given for sertraline (an antidepressant) daily with psych to follow-up regarding sexually inappropriate behaviors .Plan: Resident is off of hospice as of 01/12/2023 so psych assessment/management plan can now be put in place .further POC (plan of care) pending psych. A progress note dated 01/17/2023 read, Referred to [psychology]. To be seen on 1/18/23. Behavior packet and notes in SW (Social Worker) office. Note that this referral was placed seven days after Physician W initially indicated on 01/11/2023 that R40 should be seen by psychology and five days after R40 was discharged from hospice service on 01/12/2023. Review of a psychology consult date 01/18/2023 found the following recommendations: continuation of sertraline, a structured routine, divisional activities, and mood and behavior monitoring. Review of another FRI read, in part, Incident Summary: [R40] was observed by a staff member in the dining room, sitting in a chair next to [R4] sitting in [their] wheelchair. [R40] had one hand on the underside of [R4's] knee area and one hand up [their] blouse .[R40] placed on observations . Note that the type of observation was not provided. Review of R40's clinical record revealed a progress note dated 03/04/2023 which read, in part, [R40] was observed on this date in the dining room at 1830, engaged in physical touch with [R4], using [their] hand to touch [R4] under [their] shirt on the chest area .Increased visual surveillance checks initiated by the staff and remain ongoing. The type of visual surveillance was not reported, and additional review of progress notes did not reveal details as to what was provided. On 03/08/2023 at 04:59 PM, the Administrator reported that CNA M witnessed the incident. Review of the clinical record revealed that R4 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, and category five blindness in right eye (blindness with no light perception), and that R4 was receiving hospice services. Review of the Admission MDS assessment (dated 02/06/2023) found that R4 required limited, one-person physical assistance for bed mobility, transfers, and toileting, and extensive one-person assistance for dressing. Per this assessment, R4 was severely cognitively impaired. Review of R4's care plan found the following: .AMBULATION: 1PA (a person assistance) with walker .Date Initiated: 01/30/2023 .LOCOMOTION: Independent in wheelchair .Date Initiated: 01/30/2023 . On 03/07/2023 at 11:07 AM, R4 was observed in their room, sitting up in a wheelchair. They presented as confused and very hard of hearing. On 03/08/2023 at 09:02 AM, a phone interview was conducted with R4's medical power of attorney-Family Member J. When asked about the what happened on 03/04/2023, Family Member J stated, I guess [R4] was fondled in the cafeteria by a male resident. Family Member J indicated that they were out of state at the time of the incident, and only just return the evening prior to the interview. When asked what the facility said they are doing to keep R4 safe, Family Member J stated that they were told that staff were monitoring [R40] every 15 minutes. Family Member J shared during the interview that R4's husband was physically abusive, and R4 was very leery of men. When asked, Family Member J stated that they shared this with the facility. Family Member J gave permission for Family Member K to be interviewed. On 03/08/2020 at 09:11 AM, Family Member K was interviewed. When asked what happened on 03/04/2023, Family Member K stated that they received a call from Family Member J and was told that R4 had been molested. Family Member K went to the facility to visit R4, and they spoke with an unknown staff member about how hard it is to get someone settled into a facility. Family Member K expressed to the staff member that every time they visit, R4 wants to leave, and per Family Member K, this staff member said, So do you want to transfer [R4] to another facility. Family Member K told the staff member that they thought R40 was on 15-minute checks before this incident, and the staff member said yes. Family Member K then asked, How did this happen? Family Member K stated that the staff member did not offer a response. On 03/08/2023 at 05:41 PM, a message was left for CNA M. CNA M did not call back by the end of the survey. No documentation of one-to-one supervision of R40 following the incident on 03/04/2023 was provided. Resident Visual Observation assessment dated [DATE] to 03/06/2023 were review. For the assessment dated [DATE], illegible text was written over the checks for approximately 11:00 PM to 1:15 AM-individual 15-mintue check fields were not completed. Fields from 12:30 AM to 5:45 AM were blank, as were fields from 07:15 AM to 05:45 PM. For the assessment dated [DATE], the 15-minute check fields from 10:00 PM to 06:45 AM were blank, as were the fields from 07:15 PM to 09:45 PM. No additional documentation of 15-minute checks was provided. Review of a psychology consult note dated 03/6/2023 read, in part, .Psych visit was requested as [R40] continues to exhibit inappropriate behavior problems .Plan/Monitoring outcomes/future sessions/review of Treatment Plan/Discharge from treatment/additional recommendations: Continue to meet with patient to work on goals . No interventions regarding R40's continued behaviors were recommended. Review of R40's progress notes revealed the following note dated 03/07/2023 that read, in part, Met with [R40's family member (Family Member H)] today and offered a room change to Emerald, near the Emerald lounge and in a high traffic area for supervision .[Family Member H] wants to think about it .[Family Member H] is considering moving [R40] back to the AFC (adult foster care) setting in the community . On 03/08/2023 at 11:05 AM, Family Member H was interviewed regarding the three incidents. When asked what interventions the facility provided for R40, Family Member H reported that the facility checked for a bladder infection, started sertraline, and provided more activities and supervision. Family Member H indicated that R40's mood was better when they had one-on-one observation. Family Member H stated that they were approached about moving R40 to another room, but they stated that switching rooms is not the answer. Repeatedly during this interview, Family Member H indicated that the issue is they need for more supervision. Family Member H referenced the attempt to move R40 to an out of state psychotic hospital, which Family Member H did not want to do as they would not be able to visit R40. Family Member H also stated that they do not want to move R40 to another setting as they were in very poor health before admitting to the facility and their health has greatly improved. On 03/08/2023 at 10:22 AM, an interview was conducted with Nurse E. When asked about R40's interactions with other residents, Nurse E reported that R40 has been inappropriate with women. When asked how many times this happened, Nurse E indicated that they knew of three, but could not be sure. Nurse E could not recall the incidents in January, and they indicated that they were not working during the incident on 03/04/2023. Nurse E reported that R40 was on one-on-one observation for a very long time. When asked, Nurse E could not recall a timeframe, but that R40 had been on one-to-one observation a lot. When asked about what interventions were put in place since the incident on 03/04/2023, they indicated 15 minutes checks over the weekend, though possibly one to one observation at night. Nurse E indicated that staff are doing eyes on now-meaning no one-to-one observation or 15 minutes checks. Nurse E reported that she told staff the morning of this interview to not leave R40 alone with female residents. When told about the multiple observations made of R40 being alone in the dining room with multiple female residents, Nurse E was not aware. During this interview, R4-the resident involved in the incident on 03/04/2023-attempted to enter R40's room. R40 was not in the room at the time, and Nurse E redirected R4. Nurse E indicated that they did not know the details as to which resident R40 inappropriately touched on 03/04/2023 until told by this writer. On 03/08/2023 at 11:41 AM, CNA O was interviewed. When asked about R40's contact with female residents, CNA O stated that R40 can get friendly. When asked for clarification, CNA O indicated hand holding, and that they had seen R40 try to kiss female residents. CNA O indicated that R40 had been good for a while until last weekend. When asked how many times R40 had had inappropriate contact with female residents, CNA O thought there were two, but was unsure. When asked about the incidents in January, CNA O indicated that R40 was put on one-to-one observation for a long time. They indicated that R40 had been behaving well, and was switch to 15-minute checks, then just eyes on. When asked about what interventions were in place since the incident on 03/04/2023, CNA O was not sure, but suggested one-to-one observation over the weekend, then 15-minute checks. CNA O indicated that R40 was currently eyes on for supervision. On 03/08/2023 at approximately 01:10 PM, the DON, who was also the facility's abuse coordinator, was approached to provide documentation on one-to-one observations and 15-minute checks for R40. DON mentioned the incident on 03/04/2023, and when asked why one-to-one observation was not put in place for R40, the DON reported that one-to-one observation could not be provided due to not having enough staff. When asked what interventions were put in place, the DON indicated that R40 was placed on 15-minute checks, and that these checks should still be in place. When told that the staff who were interviewed were not aware that R40 should have 15-minute checks, and that they thought he was just eyes on, the DON was not able to offer an explanation. When asked how staff were informed when residents are placed on 15-minute checks, the DON stated that they were informed verbally. On 03/08/2023 at approximately 12:25 PM, an interview was conducted with Social Services Q, who was contact/agency staff. When asked about R40's behavior, Social Services Q indicated that there had been a few instances of inappropriate behavior, two of which Social Services Q could not recall the exact dates for, indicating that they did not work at the facility at the time. Social Services Q indicated that the last incident was on 03/04/2023. When asked about interventions, Social Services Q indicated that R40 was put on one-to-one observations, though they did not know for how long. When asked about what was put in place when one-to-one supervision ended, Social Services Q indicated that staff were paying close attention to R40. Social Services Q went on to explain that she spoke with R40's family member about moving resident to an AFC. When asked what is being done differently since this last incident to ensure R40 does not have inappropriate contact with female residents, Social Services Q indicated that R40 is being closely supervised. When informed of multiple observations of R40 being unattended in a common room with multiple female residents, no explanation was offered. When asked how often psychology visits the facility, Social Services Q indicated every other week, and that psychology consults with Attending Physician W and Social Services Q. It was revealed

Based on observation, interview and record reviews the facility failed to consistently determine the causes that contributed to multiple falls and failed to revise the care plan with effective interventions to help prevent further falls for two (R61 who had a diagnosis of dementia, and R68) of four residents reviewed for falls, resulting in R61 to have continued falls which required two transfers to the hospital and surgical intervention for an acute right intertrochanteric fracture with varus angulation. Findings include: R61 On 3/8/23 at 12:03 PM, R61 was observed sitting in their wheelchair eating lunch. On 3/9/23 at 8:42 AM, R61 was observed sitting in their wheelchair in their bathroom with two staff members by their side. Review of the medical record revealed R61 was admitted to the facility on [DATE] with diagnoses that included: dementia, weakness, muscle wasting/atrophy and repeated falls. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5, which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a referral documentation dated 10/19/22 which was provided to the facility upon R61's admission documented in part, . Fall Risk . pt (patient) is a fall risk and family is unable to provide needed required care . On 3/7/23 at 10:20 AM, all fall incident reports from October 2022 to March 2023 was requested from the Administrator for review. Review of a Nursing note dated 11/16/22 at 2:16 PM, documented in part . observed sitting on the floor in . dining room . explained she tried to move a stationary chair to sit down and when she sat, missed the chair . Review of the incident reports provided by the facility revealed no incident report completed or provided for the date of 11/16/22. Review of a care plan titled Potential risk for fall or injury . dated initiated 10/23/22 (three days after admission into the facility) documented the following interventions, . Assess orthostatic hypotension prn (as needed) . Resident cannot use call light consistently for assistance anticipate and intervene for needs, Evaluate side effects of thromboprophylaxis therapy . Examine internal and external risk factors upon admission and post fall as noted on the fall risk assessment tool . Examine the residents diagnosis and orders and assess the ability to ambulate and bear weight- provide direction to staff via care card . review of the relationship of fall risk and medication side effects prn . Post - Fall review room for environmental factors/re-enact situations prn to assist with development of cause specific interventions ,neurological check prn . Review and modify environmental factors as indication . Review medication with potential side effects that could contribute to gait disturbance- care plan risk vs benefit prn . See ADL (activties of daily living) plan of care for fall risk interventions . Review of the fall care plan revealed no modifications, revisions or new interventions implemented since 10/23/22. Review of the ADL care plan documented on 11/18/22 an intervention was added to Consult PT (physical therapy)/OT (occupational therapy) for falls. Review of a Nursing note dated 1/3/23 at 7:32 AM, documented in part, . observed on knees on window side of bed . She tells me she was trying to push my feet into my slippers . UA (urinalysis) was ordered but delayed due to holiday weekend . PT and OT to eval and treat . Review of an incident report dated 1/3/23 at 5:08 AM, documented in part . Unwitnessed fall . observed on the window side of bed, on her knees with top of her body on bed . Resident Description . Well, I was trying push my feet into my slippers, I didn't fall or hurt myself. She told me she was on her knees, I just went down . Her roommate activated the light to alert staff . Therapy notified . Review of a Nursing note dated 1/3/23 at 8:20 PM, documented in part . Resident observed on floor next to bed. Resident assessed for immediate injuries . Hematoma to back of head observed with small amount of bleeding . Resident stated, I was trying to put my slippers on. I'm glad I hit my head and not my hip because my head is thick. Resident is on Apixaban 2.5 mg (milligram) BID (twice a day) . 911 called by writer . and being sent to (hospital name) . Review of an incident report dated 1/3/23 at 8:14 PM, documented in part . Un-witnessed . Resident observed on floor next to her bed . noted to have pain in head and hematoma . 911 called . Root cause (R61) is pleasantly confused d/t (due to) dementia and fell hitting her head . still awaiting results on urine C&S (Culture and Sensitivity) to start antibiotics . Review of the hospital documentation dated 1/3/23, documented in part . Patient presents for chief complaint of head injury on Eliquis. Reportedly tripped while making food in her kitchen at the nursing home . recently diagnosed with a UTI (Urinary Tract Infection) but not started on antibiotics yet . they (facility) are awaiting urine culture . when she arrived in the ER (emergency room ) she was found to be in atrial fibrillation with RVR (Rapid Ventricular Response) with ventricular rate at 146, and she was started on Cardizem drip . The resident was transferred back to the facility on [DATE]. Review of the ADL care plan documented on 1/4/23 and intervention was added which documented . UA (urinalysis) was ordered awaiting results, PT and OT eval and treat. Tylenol 500 mg scheduled 3 x daily x 7 days . This indicated the facility was awaiting to rule out a urinary tract infection, however failed to implement an effective intervention in attempt to prevent future falls. Review of a Nursing note dated 1/26/23 at 2:50 AM, documented in part . Resident was observed on the floor near the side of the bedside . Review of an incident report dated 1/26/23 at 2:15 AM, documented in part . Un-witnessed . Writer was notified by staff members (R61) is on the floor next to the bedside with non-grip socks on . Resident Description: I was trying to get the water off the floor then I slid out of bed . The medication was reviewed by the clinician and the pain medication was noted to possibly contributing to the falls. The pain medication times were changed, and lab work was ordered to r/o (rule out) hyponatremia . results came back this morning Sodium is WNL (Within Normal Limits) . Review of the ADL care plan documented on 1/26/23 and intervention was added to order a BNP <sic> Basic Metabolic Panel and a medication review was completed. Review of a Interdisciplinary Documentation note dated 2/1/23 at 7:19 PM, documented in part . witnessed fall (fall from 1/31/23). Resident did not verbalize any c/o (complaints of) pain or discomfort throughout shift . Review of an incident report dated 1/31/23 at 3:38 AM, documented in part . Staff noted to writer that resident stood up from her wheelchair in the sunshine room and started walking with a noticeable unsteady gait. Staff stated that she rushed up to prevent resident from falling but before she reached near the resident. Resident <sic> already slide <sic> down on the floor on her butt grabbing her wheelchair with her right hand. Writer came in and observed resident lying on the floor on her back stating I fell again, thank goodness it is not as bad as the last time I went to the hospital . Resident stated I just like falling, but it was not bad this time. Help me off this floor . Conclusion . dipped urine and it was clean . This indicated the facility failed to review, modify or revise the implemented interventions to prevent further falls. Review of a Nursing note dated 2/3/23 at 2:51 PM, documented in part . Resident was seen trying to walk from bathroom to bed and fell . Review of a Nursing note dated 2/3/23 at 10:42 PM, documented in part . Resident continue to display extreme anxiety and agitation. Poor safety precautions. Since 640pm resident had multiple falls. Resident continue to get up out of her w/c (wheelchair) or bed. 1 on 1 placed per order. Observed 5 falls in a 4 hr. (hour) period. Notified on call Team Health MD (medical doctor) and DON (director of nursing). Day shift nurse stated urine dip was negative. MD ordered hydroxyzine 25mg (milligram) x1 . Review of a Nursing note dated 2/4/23 at 12:04 AM, documented in part . Observed resident on the floor on her buttocks. Brief and pants pulled down to her ankles. Resident also stated I used the bathroom . Roommate stated she never made to the bathroom . Alert with extreme, anxiety and confusion. Hydroxyzine ordered . in w/c 1on1 observation initiated . This indicated the resident had three falls on the date of 2/3/23. Review of an incident report dated 2/3/23 at 2:45 PM, documented in part . Resident was seen by (aide name) trying to walk from bathroom and fell . Resident Description: I don't know what I was doing . Placed resident on toilet, changed brief, placed resident back in bed . seen by (aide name) trying to walk from bathroom and fell . Thought about UTI (Urinary Tract Infection) when speaking with doc (doctor). She have a UA (urinalysis) on 2/2 which was negative . Added a fall mat next to bed . Review of an incident report dated 2/3/23 at 6:52 PM, documented in part . Observed resident lying on the floor sitting on her buttocks . Resident Description . I was trying to get the broom to sweep up . (aide name) stated she seen resident lose her footing and slip onto the floor hitting her buttocks . It is preferred that she receives 1 PA (physical assistance) for transfers and ambulation but R61 has impaired cognition and is unable to recall that information . Intervention: Urinalysis completed and repeated with no acute infection indications . Review of an incident report dated 2/3/23 at 11:00 PM, documented in part . Observed resident sitting on the floor in her room near her bed . Resident Description: resident confuse stating she in the room with me . Notified MD ordered Hydroxyzine 25 mg x1 as well as neuro-checks 1on1 observation . was displaying increased confusion and impaired balance. It is preferred that she utilize staff assistance with transfers, ambulation and toileting but R61 has impaired cognition and is unable to recall this. A dipstick ua was collected and negative for acute infection . was placed with 1:1 staffing. A medication review was completed by the PCP (primary care physician) on call. Bowel review completed for constipation risks-none noted, footwear inventory completed and options all in place and in good repair. PT/OT screen and tx as indicated . Intervention: 1:1 care x 8 hours, medication review completed by PCP . This indicated multiple repetitive interventions documented (ex). Medication review and PT/OT screening. The intervention for a one-on-one staff supervision was implemented for 8 hours and removed. Increased supervision for eight hours for a resident who has a history of falls, confusion, a diagnosis of dementia and who continued to have multiple falls without effective interventions implemented, was not an effective intervention. Review of the ADL care plan documented on 2/3/23, a fall matt at beside was implemented, on 2/4/23 the bowel pattern was reviewed to rule out constipation, PT/OT eval and Tx as indicated, UA to rule out infection (no infection was identified) and the footwear inventory was completed and ensured all foot wear was in good condition, however no interventions were implemented to prevent further falls for R61 who had dementia with ongoing multiple falls. Review of an incident report dated 2/18/23 at 12:46 PM, documented in part . Resident observed sitting on her bottom on the floor in the dining room . Resident was unable to give an accurate description of what occurred leading up to the fall . She was assisted into wc post assessment for injury and placed note in maintenance logbook to apply anti-rollback brakes for residents wc . Assisted resident back to her room and to her bed. Upon transfer to her bed, resident c/o pain in her R (right) hip. Resident stated there was pain with rotation of R hip and avoided applying weight onto Hip with transfer. Resident was assisted into bed with 2PA (two person assist) . obtained verbal order for 2 View STAT (immediate) R hip X-ray. Applied ice to R hip for 15-minute intervals and gave scheduled Tramadol which was effective for controlling pain . Review of a Nursing note dated 2/18/23 at 7:48 PM, documented in part . Received res (resident) x-ray results revealing R hip fracture . order to transfer to ER (emergency room ) . Review of the hospital discharge paperwork provided to the facility documented in part . Emergency Department (ED) Arrival Date 2/18/23 . HR (heart rate) 104 . SBP (systolic blood pressure) 202 . DBP (diastolic blood pressure) 103 . Chief Compliant - Mild hip pain . present as a Trauma Consult to the ED via EMS (emergency medical services) after falling earlier in the day at her Living Facility (facility name). Daughter at bedside reports patient fell out of her wheelchair after lunch in the main room after people were leaving. Patient was not seen falling. Per daughter on Sunday 2/12 patient fell at least 5 times out of her chair. Patient has been falling daily per daughter . Family is concerned about the multiple falls the patient has been having recently. Daughter states she would like to talk to Ortho (orthopedic) before making a decision about surgery. Patient is presently confused and very pleasant in her confusion. She does not clearly recall the fall or the other falls. Patient is alert and oriented x1 . Work up was significant for Acute right intertrochanteric fracture with varus angulation . Further review if the hospital paperwork revealed R61 underwent an Open Reduction and Internal Fixation (ORIF) surgical procedure on 2/20/23 and was discharged back to the facility on [DATE] under hospice care. On 3/9/23 at 11:43 AM, the Director of Nursing (DON) was interviewed and asked about the concerns of the facility's interdisciplinary team to have consistently identified the root cause analysis of R61 falls and modified, revised and implemented effective interventions in attempts to prevent further falls and the DON stated the notes documented in the note section on every incident report is what the interdisciplinary team discussed, however will review the record in attempts to provide additional documentation and/or explanation. Upon the end of survey, the DON provided additional information that was reviewed offsite. Review of the additional information provided included a handwritten note that documented the following in part, . 1/26/23 . attempting to get water from floor and slid out of bed. Intervention: BMP r/o hyponatremia /med review. 1/31/23 . got up from chair to walk self-determining. Intervention: wedge cushion for w/c. 2/3/23 (2:45 PM) Independent use of restroom. Intervention: mat next to bed after assisting with restroom. 2/3/23 (6:52 PM) . resident reports she was looking for a broom to sweep. Intervention: UA completed. 2/3/23 at 11:00 PM, increased confusion. Intervention: urine dip. 2/18/23 added antiroll back (on wheelchair) . Review of a facility policy titled Accident/Incident Report Fall Management Revised: 10/00 documented in part, . To establish a standard for accident / incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action . It is recognized that not all falls can be prevented, the facility will utilize applicable elements of the systematic process of assessment, intervention and monitoring to minimize fall risk and injury including . Fall risk screening . Care plan interventions . Evaluation of the response to interventions and balancing risk with the residents right to self-determination and independence . Comfort Rounds and promotion of a culture of safety . Assessment of sensory contributors . Medication Review . Orthostatic Hypotension . Behavioral and Diagnosis risk factors . History of falls with root cause analysis . Pain management . 38271 Resident #68 On 3/07/23 at approximately 9:32 a.m., R68 was observed in their room, laying in their bed. R68 was observed to have a fall mat next to their bed. R68's call button (an electronic device used to notify facility staff of an assistance request) was observed on the ground behind their bed, out of reach. A second call button that was a touch pad was observed on a table out of reach. On 3/08/23 at approximately 3:30 p.m., R68 was observed in their room, laying in their bed. R68 was still observed to have their call button on the floor and behind their bed. A touch pad call button was still observed on the table out of reach of R68. R68's wheelchair was observed to not contain any anti-rollback bars (adaptive bars used to prevent wheelchairs from rolling back) or anti-tipper devices (adaptive equipment used to prevent wheelchairs from tipping over) equipped to it. On 3/9/23 at approximately 8:25 a.m., R68 was observed in their room, up in their wheelchair. R68 was still not observed to have any call buttons within reach of their person. R68's wheelchair was still observed without any anti-tipper or anti-rollback bars equipped on their wheelchair. On 3/9/25 at approximately 10:06 a.m., R68 was observed up in wheelchair with Nurse Manager A (NM A). R68 was still observed without anti tippers or anti-rollback devices on their wheelchair. NM A was queried as they inspected R68's wheelchair regarding the lack of anti-tipper or anti-rollback devices and they stated they did not see them on it. NM A was queried if R68 should have their call button within reach of them incase R68 needed to use it and they indicated they should and was observed putting the call putting within reach of R68. NM A was queried if R68 was at risk of falling and they indicated they were. NM A was queried why R68 did not have the anti-rollback or anti-tipper devices on their wheelchair and they reported they did not know but that R68 may have to reassessed for them. On 3/8/23 the medical record for R68 was reviewed and revealed the following:R68 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. R68 had diagnoses including Repeated falls, Muscle weakness and Abnormal Posture. A review of R68's Minimum Data Set (MDS with an ARD (Assessment Reference Date) of 1/23/23 revealed R68 needed extensive assistance with most of their activities of daily living. R68 was documented as having severely impaired cognition. An incident/accident form dated 2/4/23 revealed the following: Incident Description: .Nursing Description: Writer was notified by staff members resident was on the floor next to the wheelchair with non-grip socks on. Writer and staff members assisted the resident back to bed. Resident Description: Resident unable to give description .Notes: 2/6/23-Completed follow up assessment with resident. Care plan review completed for progression of interventions .Review of her environment reveals interventions are noted at the bedside including: Provided no back slipper, anti-rollback brakes, and anti-tip bars provided fall mat added to left side of bed and right side against wall for comfort. No walker at bedside, touch pad and call light at bedside . A review of R68's comprehensive plan of care revealed the following: Focus-[R68] has altered functional mobility and ADL's (activities of daily living) related to her recent hospitalization related to a UTI's (Urinary tract infections) that contributed to increased weakness and debility. She is being transferred from another facility and her UTI has resolved. She has COPD (Chronic obstructive pulmonary disease) with increased SOB (shortness of breath). She is very hard of hearing. Blind in the right eye. She is self determined to complete tasks independently without recognizing her limitations .Interventions: Fall-Risk Management: Encourage Non-skid Footwear, Maintain personal items within reach . 7-21-22: Anti-rollback bar; anti-tip bars 8/10/22-Fall mat added to left side of bed. Right side against wall for comfort. 8/22/22- No walker at bedside, PT (Physical Therapy) screen; touch pad call light .

This citation pertains to Intake Number(s): MI00133117 and MI00132321. Based on observation, interview, and record review the facility failed to respond to an alarming door after one (R801) of three residents reviewed for elopement who had exit seeking behaviors and severely impaired cognition, exited the front door, held open by a visitor, without staff knowledge. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when R801 was found by an off-duty staff member crossing a heavily trafficked road with no sidewalks and was eventually found walking on the side of the road toward oncoming traffic approximately a quarter mile away from the facility. This had the likelihood to cause serious harm, serious injury, and/or death. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency on 11/26/22 and a complaint received on 11/30/22 revealed R801 eloped from the facility. An unannounced, onsite investigation was conducted from 12/14/22 through 12/20/22. On 12/14/22, an observation of the outside of the facility revealed the facility was located on the corner of two heavily trafficked roads that intersected, one going east and west that the front of the facility faced, and one that went north and south that the side of the facility faced. There were no sidewalks on either side of both roads. There were no crosswalks at the intersections of the roads. A narrow shoulder was observed on both sides of each road. To the side of the road that ran east and west, a ditch was observed on the south side of the road and uneven ground sloping on an incline was observed on the north side of the road. A wooded area with tall trees was observed alongside the road that ran east to west. The speed limit of both roads was fifty miles per hour (MPH). On 12/14/22 at 2:32 PM, R801 was not in his room. It was explained by staff that R801 was on a leave of absence with his family member. On 12/15/22 at 8:18 AM, R801 was not in his room. At 9:12 AM, the Director of Nursing (DON) assisted with finding R801. After searching for R801, it was discovered that R801 was with the dentist. On 12/15/22 at approximately 3:30 PM, Nurse 'E' was asked where R801 was located as he was not in his room. Nurse 'E' reported R801 wandered throughout the facility, visited with certain residents in their room, used the bathroom on another unit, and was rarely in his room. After approximately five minutes, R801 was observed pushing another resident in a wheelchair. R801 was observed to be independently ambulatory. Review of R801's clinical record revealed R801 was admitted into the facility on [DATE] with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition and was independent with no assistance needed for transfers and walking. Review of R801's Wandering Risk Assessment Scale forms dated 6/1/22, 6/13/22 and 9/12/22 revealed R801 was at high risk for wandering. Review of R801's care plans revealed a care plan initiated on 6/3/22 and revised on 6/27/22 that documented, He (R801) will often wander throughout the facility looking for exit doors .he finds comfort in going outside with staff . Review of a psychosocial care plan initiated on 6/8/22 and revised on 9/9/22 revealed, Family report exit seeking but easily redirectable .Behavior monitoring utilize log for patterning and intervention revision as indicated . Review of R801's progress notes revealed a note dated 11/26/22, written by Nurse 'E', that documented, Writer received phone call from staff member (Certified Nursing Assistant - CNA 'M') who was calling from her car but still at the facility after having finished her shift. (CNA 'M') informed this writer that (R801) was walking down (street name that facility was located on) Resident stated, 'I thought my wife would be home by then but evidently she was not done grocery shopping. I waited around then I wanted to give myself some time to think.' When writer asked resident how he was able to get out of the facility, resident stated, 'Actually, there were quite a few people walking out and they were holding the door, so I went for a walk to do some thinking.' Staff immediately retrieved (R801) and returned him to this facility .Writer checked resident's exit seeking transmitter device for proper functioning; device on his ankle is properly functioning but the bracelet was loose, so writer replaced the bracelet with a new one. Resident was immediately placed on 1:1 direct supervision with a staff member .This writer tested all exit doors in this facility for proper functioning of alarm system with a new exit seeking transmitter device that was verified to be working by using a (wander alert device) tester. All exit doors tested positive for proper alarm sounding when triggered by properly functioning (wander alert device) within range of exit doors . Further review of R801's progress notes revealed R801 was assigned one to one supervision in June 2022 due to wandering. Review of a progress note dated 8/5/22 revealed, Patient attempted to exit the building without assistance. (Wander alert device) in place and alarm sounded. Staff followed the patient outside and he was retuned within one minute . Review of a progress note dated 11/19/22 revealed, (R801) has been exit seeking this evening, going from the exit door on Sapphire to the exit door on Ruby and opening the exit door in the Sunshine dining room. He was quickly diverted after opening the Sunshine dining room by staff. The door did alarm, however the door opened easily for him . On 12/15/22 at 8:34 AM, an interview was conducted with CNA 'M'. When queried about the day (11/26/22) R801 got out of the facility, CNA 'M' reported she left her shift around 3:00 PM and noticed she left her purse at the facility. CNA 'M' returned to the facility and left again at approximately 3:20 PM. CNA 'M' explained as she approached the corner in her vehicle, she observed R801 waiting to cross the intersection. At that time, CNA 'M' turned left, pulled into the back parking lot of the facility, parked her car, and contacted Nurse 'E' who was R801's assigned nurse at that time. CNA 'M' stated, By the time I got to him, he crossed the street. CNA 'M' reported she initially could not see R801 and thought he entered the wooded area on the side of the road, but found him approximately a quarter mile away, walking on the side of the road (there was a small gravel strip on the side of the road) toward oncoming traffic. CNA 'M' further reported at that time, Nurse 'E' and Nurse 'B' caught up to R801 and all three assisted R801 back to the facility. CNA 'M' reported it took approximately 10 minutes from the time she parked the car and walked back to the facility with R801. When queried about whether R801 exhibited any exit seeking behaviors during her shift, CNA 'M' reported R801 was ripping at the alarm on his ankle and tried to remove it. CNA 'M' reported she reported the behavior to Nurse 'L', but the ankle bracelet remained on R801's ankle when she left her shift at 3:00 PM. On 12/15/22 at 1:08 PM, an interview was conducted with Nurse 'E'. When queried about the day (11/26/22) R801 eloped from the facility, Nurse 'E' reported she was seated at the nurses' station located between the Sapphire and Ruby hallways. Nurse 'E' received a phone call from CNA 'M' who recently left the facility when her shift was over. Nurse 'E' explained that CNA 'M' told her she saw R801 walking down (the street the facility was located on). Nurse 'E' explained she notified Nurse 'B' who was assigned to the Ruby hallway, and they ran out of the break room door and down the road until they caught up to R801 and CNA 'M'. Nurse 'E' reported R801 had crossed the road at the intersection and was walking on the gravel strip on the side of the road going toward oncoming traffic when herself and Nurse 'B' caught up to the resident. Nurse 'E' explained she found out R801 was missing from CNA 'M' and left the building to get the resident due to the phone call. Nurse 'E' explained she was not responding to a door alarm and stated, I don't even know if I heard an alarm, but when we returned to the building an alarm was going off and (CNA 'C') had to let us in. On 12/15/22 at 10:07 AM, a telephone interview was conducted with Nurse 'B'. Nurse 'B' was asked to explain the facility's protocol for responding to an alarming door. Nurse 'B' explained if an alarm was sounding, you would go to the nearest exit to respond to the door. Nurse 'B' further explained if you noticed a resident was missing, you would announce it on the overhead speaker and conduct a head count of residents. Nurse 'B' explained that residents who were at risk of elopement generally had a wander alert device which would alarm if they attempted to leave through one of the doors. When queried about the incident of R801 eloping from the facility on 11/26/22, Nurse 'B' reported he was assigned to the Ruby hallway and was passing medications when Nurse 'E' summoned him to help find R801 who was outside of the building. Nurse 'B' explained that himself and Nurse 'E' immediately ran out of the break room door and saw R801 across the road that ran north and south alongside the building. Nurse 'B' reported that CNA 'M' had already caught up to R801 and they all brought the resident back to the facility. When queried about whether there was an alarm sounding at the time he was alerted of R801's elopement, Nurse 'B' reported he could not remember and that he might not have heard it if he was at the end of the Ruby hallway. Nurse 'B' explained he responded to R801 being outside because Nurse 'E' notified him, not because he responded to a door alarm. On 12/15/22 at 10:09 AM, a phone interview was conducted with CNA 'C'. When queried about what happened the day R801 eloped from the facility on 11/26/22, CNA 'C' reported she worked second shift from 2:30 PM until 11:00 PM on that date. CNA 'C' explained that she thought R801's wife came to the facility and was going to take him out but ended up staying at the facility and R801 received a shower. CNA 'C' stated, I honestly did not know he left the building until I let him and the nurses and aide back into the building. CNA 'C' reported she had to let them in because the alarm needed to be disengaged. CNA 'C' further explained that she saw him at some point prior to finding out he left but did not know he left. CNA 'C' explained there was a monitor at the nurses' station that had view of the front door of the facility and the monitor would also show which door was alarming if it was set off. CNA 'C' stated, From what I recall, the door was alarming but there was a group of family leaving so she did not notice the resident. On 12/15/22 at approximately 9:15 AM, an observation was made of the front door wander alert system with the DON, as the Maintenance Director was not working that day. The front door required a code to be entered on a keypad to exit that door. When the wander alert device was at a close distance from the front door, the lock engaged, and the door could not be opened. If the wander alert bracelet device was further back from the door, the code allowed the door to open. If the door was held open after the code was entered and the wander alert device was passed through the doorway, an alarm sounded and could clearly be heard at each nurses' station and faintly in the hallways in between. The alarm could only be disengaged by entering the code at the door that was alarming. On 12/15/22 at approximately 10:20 AM, review of the video footage of the facility's front door on 11/26/22 was conducted with the Administrator. Review of the video footage revealed on 11/26/22 at 3:23 PM, R801 exited the front door to the outside of the building while an unknown person held the first door open and then the second door. R801 is observed going to the left. The Administrator pointed to the light on the key code box and reported the light meant the alarm was engaged and sounding. A visitor is observed in the lobby near the front door. No staff are observed coming to the front door. At approximately 3:26 PM, two people (identified as Nurse 'B' and Nurse 'E' by the Administrator) are observed running past the front door of the facility on the outside. At 3:31 PM, Nurse 'B', Nurse 'E', and CNA 'M' are observed with R801. They entered the first door from the outside of the building and CNA 'C' disengaged the alarm using the code box to let them into the facility. At that time, the Administrator was asked what the facility did because of R801's elopement on 11/26/22. The Administrator reported they checked all the wander alert devices for placement and functioning, checked the door alarms, conducted a missing resident drill, and posted a sign on the door to alert visitors not to let residents out. When queried about what was done about the lack of staff response to the alarming door, the Administrator reported Nurse 'B' and Nurse 'E' responded to the alarm and that was why they were running outside. It should be noted that during surveyor interviews, staff indicated they did not respond to an alarm on 11/26/22 and they either were unsure if an alarm was sounding or did not respond to the alarm. Nurse 'E' indicated they went outside after alerting Nurse 'B' because they were alerted by CNA 'M' who happened to come back to the facility to get her purse and left again and saw R801. On 12/15/22 at 1:27 PM, a telephone interview was conducted with CNA 'A' who worked on 11/26/22 on a different unit than where R801 resided. When queried about whether she was aware of R801's elopement on 11/26/22, CNA 'A' reported she worked that day, but did not hear about it until the following day. When queried about the facility's protocol for responding to door alarms, CNA 'A' explained the alarms went off quite a bit when visitors leave and they leave the door open, so we are always running up to shut off the alarm. CNA 'A' further reported that R801's wife took him out of the building often and did not always sign him out or left staff know. On 12/15/22 at 1:55 PM, an interview was conducted with Nurse 'I' who was assigned to the Emerald Unit on 11/26/22. The Emerald Unit was located to the right of the front lobby. When queried about their response to the door alarm on 11/26/22, Nurse 'I' reported she did not recall an alarm going off and stated, If the front door alarm goes off, usually someone gets it. Nurse 'I' then reported that she thought she heard an alarm but it is such a common occurrence for it to go off and I was passing medications so I just figured someone would do their job and turn off the alarm. Nurse 'I' reported she did not respond to the alarm and assumed someone else did because it was eventually cleared. Nurse 'I' explained she was not aware of R801's elopement until the following Monday when Administration called her for an interview. On 12/15/22 at 2:04 PM, an interview was conducted with the Administrator. When queried about the required timeframe to respond to a door alarm, the Administrator reported it should be addressed immediately. When queried about who was responsible to respond, the Administrator reported all staff are responsible to respond. Review of the facility's Elopement Drill Log forms for 2022 revealed a minimum of one drill on each shift was conducted on a quarterly basis. The log revealed drills were conducted on all three shifts in March 2022 and September 2022. Review of an Elopement Drill Record dated 3/24/22 at 12:56 PM (first shift) revealed, Nursing leadership to receive additional training. Temp. (temporary) staff needs additional training. Review of an Elopement Drill Record dated 3/30/22 at 3:38 PM (second shift) revealed, Additional Training needed. Review of an Elopement Drill Record dated 3/31/22 at 6:12 AM (third shift) revealed, Additional Training needed. Review of an Elopement Drill Record form dated 9/14/22 at 4:54 PM (second shift), revealed, Poor response - Ended with a round-table discussion of responsibilities. More drills needed. There was no evidence provided by the facility of any additional drills conducted after the poor response to the 9/14/22 elopement drill. The next documented drill was conducted after R801 eloped from the facility. Review of the investigation conducted by the facility into R801's elopement on 11/26/22 revealed CNA 'C' heard the front door alarm on 11/26/22 but could not respond right away because she was transferring another resident. Additional statements from witnesses did not indicate the staff responded to the door alarm but responded to the call from the off-duty CNA (CNA 'M') who found R801 outside. There was no indication in the facility's investigation that addressed the lack of response to the door alarm until nine minutes later when CNA 'C' let Nurse 'B', Nurse 'E', and CNA 'M' back into the facility with R801. Review of a facility policy titled, Wandering Residents Exit Seeking Management revised 2/2021, revealed, in part, the following: .RESPONSE TO A SOUNDING DOOR ALARM .Check the alarm panel to determine which door has been triggered. DO NOT ASSUME someone else has already done this .Check the exit door for any exiting resident by means of a visual check .If an exit door alarm is triggered, the cause is evaluated and re-set after the resident is re-directed, and their safety is assured . The IJ began on 11/26/22, it was identified by the survey team on 12/15/22 and the facility was notified of the IJ on 12/15/22, and a removal plan was requested. On 12/17/22, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 12/15/22, however the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency.

This citation pertains to Intake Number(s): MI00129826. Based on interview and record review, the facility failed to ensure medications were administered to the correct resident for one (R806) of one resident reviewed for medication errors, resulting in a significant medication error when R805's medication was administered to one (R806) of one resident reviewed for medication errors. Due to the significant medication error, R806 required administration of an opioid reversal agent and was transferred to the hospital. Findings include: Review of a complaint submitted to the State Agency revealed R806 was admitted to the hospital on 7/15/22. The complaint intake documented, Today, the daughter found the patient nonresponsive at her ECF (extended care facility). As per daughter, the nursing staff had given the patient 60 mg (milligrams) morphine ER (extended release). This was said to have been on accident (she was given another resident's medication by mistake .In the ED (emergency department), the patient was noted to be hypotensive (low blood pressure) and received a total of 3.5 L (liters) IVF (intravenous fluids) . Review of R806's clinical record revealed R806 was admitted into the facility on [DATE], transferred to the hospital on 7/15/22, and readmitted on [DATE] with diagnoses that included: metabolic encephalopathy, alcohol dependence, and dementia. Review of a Minimum Data Set (MDS) assessment revealed R806 had severely impaired cognition. Review of an Interdisciplinary Documentation progress note dated 7/15/22, written by Nurse 'G', revealed the following documentation: 1030 medication error, N.P (Nurse Practitioner) in building, she evaluated and ordered V.S. (vital signs) to be done and close watching. 1030 (AM) B/P (blood pressure) 86/58 HR (heart rate) 83 1100 (AM) B/P 92/57 HR 84 1130 (AM) B/P 93/63 HR 87 1200 (AM) B/P 94/64 HR 86 1230 (AM) B/P 93/65 HR 85 1300 (1:00 PM) B/P 96/62 HR 84 With each of these interactions, she was responsive, alert, eyes open and talking. Daughter came to visit and at 1400 (2:00 PM) noted she was not talking, vs remain stable 110/57, HR 74. Call placed to (Physician 'S'), and orders obtained for Narcan (opioid reversal agent used for suspected or known overdose of opiates) .04mg/ml (milligram per milliliter). This was given at about 1435(1:35 PM) and send to hospital. 911 called information given over the phone and they arrived at 2:45 (PM). At this time she lethargic, but responsive and talking . On 12/19/22 at 4:16 PM, the Administrator and Director of Nursing (DON) were asked to provide any incident reports, including any medication error reports for R806. Review of a Medication Discrepancy form for R806 revealed on 7/15/22 at 10:00 AM Nurse went into resident room used MAR (medication administration record) asked pt (patient) is she was (R805) she said 'Yes I am'. Nurse gave meds (medications). The form documented the discrepancy could not have endangered the life or welfare of the resident because Pt has hx (history) of substance abuse. The actual discrepancy was gave meds to wrong pt. It was documented that Nurse 'G' walked out and realized I was in wrong room. It was documented Nurse 'G' notified the physician but the medication discrepancy form did not document which medications R806 received. At the time the Administrator provided that form, it was explained this was all the facility had on that incident. On 12/20/22 at 8:47 AM, an interview was conducted with the DON. When queried about the facility's policy for ensuring residents received the correct medications, the DON reported nurses double checked in the computer with the patient identifier. When queried about why it was determined no harm could occur for R806 due to a history of substance abuse, the DON reported it was decided along with the NP that R806 was not at risk due to her history. When queried about whether there was any investigation into the incident that explained the risk to R806, evaluated whether any other residents were affected, and explained what medications were given to R806, the DON reported she had a soft file in her office and would provide it. On 12/20/22 at 9:15 AM, the DON reported she could not find the soft file. On 12/20/22 at 9:25 AM, the DON provided a typed, undated document titled, REPORT ON (R805) and explained it was her investigation. Review of the document revealed the following: .On 1/15/22 @ 1000 (10:00 AM) (staff) made a med error when asked (R806) if she was (R805), she replied yes. Was given Celexa 40 mgs (a medication used to treat depression) Ativan 1mg tab (a medication used to treat anxiety) and Morphine 60 mg ER (a medication used to treat pain) po (by mouth). (Nurse 'G') realized when she came out of the room, she was in the wrong room. Then realized she gave the wrong resident the wrong medication . The rest of the report was quoted from the progress note mentioned above. Review of R806's Physicians Orders revealed R806 was not prescribed any opioid medications and was prescribed Celexa 20 mg in the morning for depression. There was an order dated 7/15/22 for Narcan. Review of a progress note written by the NP on 7/15/22 revealed, Patient seen due to the fact that she received the incorrect medications this morning. She did receive some opioids that were not intended for her and given in error .she is sleeping and more lethargic .Patient was a prior opioid user, so is not naive. (It should not noted that R806 was not currently prescribed any opioid medications). A policy pertaining to medication administration was requested from the Administrator. Review of a policy provided by the facility titled, Medication Administration by the Various Routes, revised March 2022, revealed, in part, the following: It is the policy of this facility to administer medication in agreement with standards of practice .Medications supplied for one resident are not administered to another resident .To ensure accuracy of the administration of medications, staff administering the medication are responsible for checking to see if the drug and dosage schedule on the residents' administration record matches the label on the medication container .Double check the label with the Medication Administration Record .Identify unfamiliar residents using the photo ID .

Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and monitoring for weight loss per plan of care for one resident (R23), of four residents reviewed for nutrition, resulting in severe weight loss (10.8% in less than one month) and the potential for further clinical compromise. Findings include: On 11/16/21 at 10:00 AM, R23 was observed lying in bed, naked from the waist up. The resident's body frame was noted to be very thin. On 11/16/21 at 12:06 PM, R23 was observed lying in bed wearing a hospital gown with a lunch meal that had been placed on an overbed table which was pushed further down towards the resident's knees. The meal (chicken and broccoli pie with a side of green beans and carrots) was untouched. There was no staff in the room. The resident was attempting to eat a small portion of vanilla ice cream that was on their finger and was observed having difficulty bringing their finger to their mouth. There was only one small scoop of ice cream missing from the container. According to the meal ticket on the tray, the resident was on a regular diet with regular liquids. On 11/16/21 at 12:12 PM, Registered Nurse (RN 'X') entered the room and began to assist R23's roommate with eating their lunch meal. When asked about whether R23 required any assistance, RN 'X' reported, He's a feeder. We got six feeders on this hall. Sometimes if we get him started, he will do it. On 11/17/21 at 8:00 AM, R23 was observed lying in bed on their left side with their knees curled towards their chest. There was no breakfast tray in the room at this time. R23 was observed to have dried food debris on their upper and lower lip. On 11/17/21 at 8:03 AM, RN 'X' was asked to about whether the meal trays had arrived yet and reported No'. When asked to observe R23's mouth, RN 'X' confirmed the dried debris and stated, Yeah that's bad. RN 'X' then obtained a wet cloth and cleaned the resident's mouth. RN 'X' further reported, He hasn't eaten yet today. He's a feeder. Don't think any of the trays have been pass here. When asked if they could identify the substance on the resident's lips, RN 'X' reported it could've been from medicine from the previous shift. When asked regardless of what it was, should staff have ensured appropriate oral care, RN 'X' reported Yes. On 11/17/21 at 8:07 AM, RN 'X' asked Certified Nursing Assistant (CNA 'T') who was assigned to R23 if the resident had eaten yet today, and CNA 'T' reported No. On 11/17/21 at 8:21 AM, R23 was observed lying in bed with the breakfast meal untouched (biscuits and sausage gravy, sliced hardboiled egg and cranberry juice). On 11/17/21 at 8:24 AM, the interim Director of Nursing (DON), CNA 'T' and CNA 'W' were observed at the nursing desk. CNA 'W' was observed holding R23's meal tray and when asked about the uneaten meal, CNA 'W' reported R23 didn't want to eat. The interim DON reported the resident had been having difficulty with eating and He hasn't been wanting to drink that or eat much at all. CNA 'T' reported the resident had been spitting out the food and gnawing on blanket too. The interim DON was asked if the interdisciplinary team had implemented any interventions to determine if decline in or difficulty in chewing/swallowing and they reported they thought they had. The DON was requested to provide any recent therapy evaluations. Review of the clinical record revealed R23 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R23 had severe cognitive impairment, required supervision with setup help for eating, weighed 111 pounds (lbs.), had recent weight loss of 5% or more in the last month or loss of 10% or more in last 6 months that was not on a physician prescribed weight-loss regimen, was not on a therapeutic diet and had no oral concerns or difficulty with chewing. Review of R23's nutrition care plans identified the resident was at risk for altered nutritional status related to low body mass index with significant weight loss in the past 180 days and currently had a pressure ulcer on their bilateral buttocks. This care plan had been initiated on 9/2/21 and last revised on 10/26/21. The interventions from 9/2/21 to 10/26/21 included: Evaluate significant weight change with routine weights. Date Initiated: 09/02/2021. Record Intakes on FAR (Food Acceptance Record). Date Initiated: 10/26/2021. Registered Dietician evaluation prn. Date Initiated: 09/02/2021. A review of R23's weights as of 11/17/21 revealed there had been no weight obtained since 11/3/21. The weight before 11/3/21 was last obtained on 10/16/21. There were no re-weights noted as well in the available documentation. R23's weights since admission (9/1/21) were documented as: 11/3/21 = 112 10/16/21 = 116 10/9/21 = 114.2 10/1/21 = 110 9/22/21 = 110.6 9/4/21 = 111.4 Review of the FAR documentation which directed staff to document the percentage of food accepted at each meal (minimum of three times a day/each shift) revealed multiple missed opportunities of R23's food intake. As of this review on 11/18/21, the last documented food intake was on 11/15/21. Further review of the clinical record revealed the last documented nutrition note was from RD 'Z on 10/26/21 which documented, .Initiated FAR to start this evening. Staff to record intakes of meals and supplements and encourage P.O. (oral intake) of same. RD to continue to follow. There was no further documentation that RD 'Z' had evaluated R23 since this entry. On 11/17/21 at 9:54 AM, an interview was conducted with the interim DON who reported they had spoken with the Therapy Manager and reported speech therapy had not evaluated or provided therapy to R23. The interim DON reported there had been recent medication changes by the physician but in regard to nutritional management, would have to speak directly with RD 'Z'. When asked about what the facility's policy was for obtaining weights upon admission and if concerns with nutritional status or weight loss, the interim DON reported weights were done once a week unless they were a new admission, then would be the first three days whether they were a new or readmission. The interim DON was informed of concerns regarding staff obtaining consistent and timely weights, as well as consistent documentation of the resident's food intake. During an observation on 11/17/21 at 11:50 AM, R23's weight was obtained via two staff (Therapy Manager 'BB' and CNA 'T') using a scale built into the mechanical lift. R23's weight was reported as 103.4 lbs. (a weight loss of 8.32% since the previous weight obtained on 11/3/21 and 10.8% since 10/16/21). On 11/17/21 at 12:41 PM, an interview was conducted with RD 'Z' who reported they began working at the facility as the full-time RD about a month ago. When asked who was in place prior to that, RD 'Z' reported Corporate RD 'Y' had been the person responsible. When asked about the facility's process for reviewing concerns regarding resident's nutritional status such as poor intake, change in intake or chewing status, or weight loss, RD 'Z' reported if it was a clinical issue, staff would go directly to the Clinical Care Coordinator or the DON. When asked if they had been notified of any concerns for R23 since their last assessment on 10/26/21, RD 'Z' reported No. When asked about the facility's process for monitoring weight changes, or oversight to identify if weights were not being obtained, or if their food intake was poor, RD 'Z' reported they had concerns with obtaining weights and documentation of food intake was a battle. When asked if they participated in an interdisciplinary team (IDT) review to identify changes in clinical status such as weights, nutrition, etc., RD 'Z' reported they had Stand-up meetings once a week but usually did not discuss clinical issues. On 11/17/21 at 12:52 PM, Corporate RD 'Y' joined the interview with RD 'Z'. Corporate RD 'Y' reported they covered multiple facilities but was at this facility usually once a week. When asked how nutritional concerns were communicated given the limited time at the facility, Corporate RD 'Y' reported they communicated by email. When asked what the process was for obtaining and monitoring weights for residents with nutritional concerns, Corporate RD 'Y' reported the standard was weekly but if concerns with intake or weight, they should've been contacted. When asked if they had been notified of any changes for R23's nutritional status, poor intake, or weights not being obtained, Corporate RD 'Y' reported they had not been notified. When asked how they were able to monitor the resident's actual food intake if documentation was not available, and who was overseeing that to ensure that occurred, neither offered a response. At that time, both RD 'Z' and Corporate RD 'Y' were informed of the weight obtained earlier and they indicated they would follow up. A request was made for a facility policy for nutritional and weight management. On 11/18/21 at 2:51 PM, review of an additional weight obtained by the facility documented a current weight of 100.6 lbs. (10.18% loss since 11/3/21). Review of the facility's policy titled, Weight Management dated April 2015 documented, in part: .It is the policy of this facility that resident's weight will be monitored by the IDT team in coordination with the nutritional plan of care .The recording of the resident's weight will be maintained in the clinical record .The nutritional plan of care is evaluated .as indicated to determine if current interventions are being followed and if they are effective in attaining nutritional and weight goals.

This citation pertains to intake #MI 515. Based on observation, interview and record review, the facility failed to ensure two residents (R#904 and R#905) were free from verbal and physical abuse of three residents reviewed for abuse, resulting in R#905 using profanity towards R#904 and R#904 responding by throwing R#905 out of their bed and onto the floor with R#905 sustaining a left humerus fracture with overlapping bone. Findings include: R#904 On 6/5/19 at approximately 1:05 p.m., R#904 was observed in their room sitting on their bed. R#904 was queried if they had been involved in a fight with another resident in the facility and they indicated that they had. R#904 was queried what happened that led to the fight and they stated, He called me a fu**** and called my mom a son of a bi*** so I went over to him and threw him on the floor. What would you have done if someone said that to you? R#904 was queried if they had said anything to R#905 to make R#905 call them those things and they stated, I might have said something to him, I don't remember. On 6/5/19 the medical record for R#904 was reviewed and revealed the following: R#904 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#904's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/21/19 revealed R#904 was independent with most of their activities of daily living. R#904's BIMS score (Brief Interview of Mental Status) was 8 indicating moderately impaired cognition. A review of R#904's careplans revealed the following: Problem: (Name and nicknames of R#904) has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness, anger, empty feeling over lost roles and status, and adjusting to a new environment. (R#904) is being followed by psych services, he is prescribed [MEDICATION NAME] for s/.s (signs/symptoms) of depression . (R#904) is also prescribed [MEDICATION NAME] 0.25 2 x (two times) a day. He is being seen by psych services. 5/13/2019. Date Initiated: 03/15/2018. Revision on: 06/03/2019 .Goals: Adjustment to nursing home placement as evidenced by participation in daily routine and socialization with peers and stable BIMS and PHQ-9 scores Date Initiated: 03/15/2018. Revision on: 05/21/2019. Target Date: 09/10/2019 . Change in mood and usual psychosocial functioning will be identified desired therapeutic effect of psychoactive medication will be achieved: Date Initiated: 03/15/2018. Revision on: 05/21/2019. Target Date: 09/10/2019 Reduction in behavioral episodes < 3-5 times per week; with no evidence of creation of a danger to self or others. Date Initiated: 03/15/2018 Revision on: 05/21/2019 Target Date: 09/10/2019 .The highest practicable level of communication, memory, judgment and orientation will be achieved with psychosocial needs met. Date Initiated: 03/15/2018 Revision on: 05/21/2019 Target Date: 09/10/2019 .Interventions: Acknowledge residents mood and behavior; conveying acceptance toward the resident while rejecting negative behavior Date Initiated: 03/15/2018, Allow time and opportunities to express feelings, Date Initiated: 03/15/2018, Assess feelings or behaviors that could present a danger to self or others and intervene accordingly. Date Initiated: 03/15/2018, Behavior monitoring as identified on the individualized log; utilize log for patterning and intervention revision as indicated. Date Initiated: 03/15/2018, Evaluate changes in mood and socialization Date Initiated: 03/15/2018, Identify behavioral precipitants if possible to assist with further defining effective dementia care Date Initiated: 03/15/2018, Maintain a calm environment as able Date Initiated: 03/15/2018, PASRR (Pre-Admission screening) screening completed annually and with significant changes Date Initiated: 03/15/2018, With presentation of behavioral and psychological symptoms of dementia, attempt use of social interventions such as tactile stimulation, sorting objects, appropriate touch, music and sounds, etc., to increase stimulation of the senses and to decrease negative behaviors. Date Initiated: 03/15/2018. A progress note dated 5/11/19 revealed the following: Resident approached and stated 'the new guy called me a son of a bi***. I went up to him and said are you calling my mother a bi***? And then I threw him on the floor!' I ran into room and noticed that his roommate's bed was empty. His roommate, (R#905), that was in bed (R#905's bed number) was on the floor. The roommate stated that (R#904) went over and hit him and pushed him onto the floor. Did assessments on each resident. Called 911, and Administrator, Sent (R#905) to (name of local hospital). Police took this resident to (name of local hospital) for mental evaluation. Spoke to Physician on call to notify of this information. Spoke to Director of Nursing , Left message for residents son to return phone call to facility. Left message for (name of R#905's legal guardian) to return phone call. A progress note dated 5/14/19 revealed the following: I asked (R#904) to join me in my office this morning. I asked him if he remembered what happened. He states big guy, new guy, called me a mother f*****, that means I f***** my mother, so I pushed him off the bed. I explained to (R#904) that he caused that man to have a broken arm, he is adamant that he had to defend his mother. I tried to explain that it is just words and words cannot harm someone and that if someone says something unkind, he should get a nurse right away and not put his hands on another person. He shrugged his shoulders, if someone says something about your mother what would you do. I told him I would say that's not nice and walk away. Reminded him of the old saying sticks and stones can break your bones but words will never hurt you, or your mother or your wife. He just shrugged his shoulders. I explained that this behavior is unacceptable and reminded him the police took him away. An incident report dated 5/10/19 for R#904 was reviewed and revealed the following: Incident Description: Resident approached and stated, 'the new guy called me a son of a bi***. I went up to him and said are you calling my mother a bi***? and then I threw him on the floor!' Nurse ran into room and noticed that his roommate's bed was empty. His roommate (R#905) that was in bed (R#905's bed number) was on the floor between his bed and the dresser. The roommate stated that (R#904) 'went over and hit him and pushed him onto the floor.' R#905 On 6/5/19 at approximately 1:13 p.m., R#905 was observed in their room lying in their bed. R#905 was observed to have a sling on their left arm. R#905 was queried regarding the altercation between him and R#904 and R#905 stated, we were arguing about something, I called him a mother f***** and told him he was a bi***. He came over and threw me off the bed and started pounding me. R#905 was queried how the argument got started and why he swore at R#904 and he indicated that he could not remember. On 6/5/19 the medical record for R#905 was reviewed and revealed the following: R#905 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#905's MDS with an ARD of 5/28/19 revealed R#905 needed total assistance from facility staff with most of their activities of daily living. R#905's BIMS score was 9 indicating moderately impaired cognition. A progress note dated 5/11/19 revealed the following: Resident (R#904). approached and stated the new guy called me a son of a bi***. I went up to him and said are you calling my mother a bi***? And then I threw him on the floor! This writer ran into room and noticed that this resident's bed was empty. This resident was on the floor next to the bed towards the window. The resident stated that (R#904) went over and hit him and pushed him onto the floor. Did assessments on each resident. Called 911, and Administrator, Sent (R#905)to (name of local hospital). Police took (R#904) to (name of local hospital) for mental evaluation. Spoke to Physician on call to notify of this information. Spoke to Director of Nursing , Left message for residents son to return phone call to facility. Left message for (R#905's legal guardian) to return phone call. An incident report dated 5/10/19 for R#905 revealed the following: Incident Description: Observed (R#905) on the floor on left side of bed semi-prone toward left with left arm up against the bedside dresser. His head was turned to his right and on the floor Immediate Action Taken: Body assessment completed to level of ability without moving him. Bed side stand slid along the wall to move it away from him to make him comfortable. Pillow and linens applied, 911 call with EMS response. 6 person blanket transfer off the floor by EMS to gurney Mental Status: Notes-EMS transported resident to (name of local hospital). No second assessment completed. Upon return to facility at 0545, from hospital, per discharge paperwork, (R#905) has a left fractured humerus. He has some kind of splint and ACE wrap from shoulder to hand with a sling. None of the dressings were removed for evaluation. He is to be followed by (name of ortho doctor) No x-rays were sent back with him. He has c/o (complaints of) pain, verbalized 'it feels like somebody is pulling on it.' A hospital brief incident note dated 5/17/19 revealed the following: (R#905) .presents with left humerus fx (fracture) the patient currently states that he broke his arm in a fight at the nursing home. He will not reply to other questions answered. On 6/5/19 at approximately 2:31 p.m. staff member A was queried regarding the altercation between R#904 and R#905. Staff member A indicated that they arrived to the room and saw R#905 on the floor. Staff member A indicated that R#904 told her that he threw R#905 on the floor because R#905 called him a son of a bi***. Staff member A indicated that they assessed R#905 for injury and they ended up sending them to the hospital. On 6/5/19 a facility summary of the altercation was reviewed and revealed the following: .(Staff member A) reports (R#905) arrived at the facility around 4:15 PM. (Staff member A) reported that around 9:15 PM (R#904) approached her at the med cart. (A) states that (R#904) told her 'the new guy called me a son of a bi***. 'I went up to him and said are you calling my mother a bi***? and then I threw him on the floor!' (A) immediately went to the room with (staff member B) to room (R#905's room number). (A) reports (R#905) was in bed (another bed number) was on the floor between his bed and the dresser. (R#905) reported that (R#904) 'went over and hit him and pushed him onto the floor. (R#904) and (R#905) remained separated. (B) reported (R#905) verbalized, when she asked what happened (R#905) stated 'I called him a mother f***** and he threw me off the bed.' (A) assessed (R#905) for injury. (A) reports that left arm started to become red and swollen. No impairment of skin integrity noted. No bleeding. Due to position of resident on the floor, did not move resident unnecessarily. (R#905) was made comfortable on the floor and (B) stayed with the resident until EMS arrived. (R#905) was transported to hospital for evaluation .(R#905) returned to the facility at 5:45 AM on (MONTH) 12, 2019. Upon return, R#905 has an ACE wrap on left arm wrist to shoulder, there appears by feel to be some kind of splinting under the ace wrap and his arm is in a sling. X-ray done at the hospital revealed a left arm humerus fracture . On 6/5/19 at approximately 3:39 p.m., the facility Administrator was queried regarding the abuse incident. The Administrator was queried if it was their expectation that all residents be free from abuse in the facility and they indicated that it was. The Administrator further indicated that they called the police and the police petitioned R#904 for psychiatric care. The Administrator indicated that the incident was reported to the State of Michigan per abuse reporting guidelines. On 6/5/19 a facility documented titled Abuse Prevention Overview (last revised (MONTH) 2019) was reviewed and revealed the following: Policy- It is the policy of this facility to provide the highest quality of care possible and utilize policies that protect residents from acts of abuse, neglect or misappropriation of personal property .Purpose-To protect the residents right to be free from verbal, sexual, physical and psychological abuse, corporal punishment, and involuntary seclusion by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff or others serving the resident, family member or legal guardian, friends or other individuals .Mission Statement- To provide a facility system of abuse prevention, resident advocacy, and education enabling our residents to enjoy a safe dignified environment .

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TIMELY ORAL SURGEON SERVICES FOR ONE (#113) OF ONE SAMPLED RESIDENTS REVIEWED WITH POOR DENTITION FROM A TOTAL OF 18 SAMPLED RESIDENTS, RESULTING IN MULTIPLE ORAL INFECTIONS, ABSCESSES, A DECLINE IN DENTAL HEALTH AND THE POTENTIAL FOR OVERALL DECLINE IN HEALTH STATUS DUE TO DEVELOPMENT OF A SYSTEMIC INFECTION. FINDINGS INCLUDE: ON 10/4/11 AT 10:00 A.M., DURING THE INITIAL TOUR OF THE "SAPPHIRE" NURSING UNIT, RESIDENT #113 WAS OBSERVED IN HIS ROOM. DURING AN INTERVIEW WITH RESIDENT #113 REGARDING HIS QUALITY OF LIFE IN THE FACILITY, RESIDENT #113 STATED "THINGS AREN'T GOOD, I CAN'T EAT. LAST NIGHT ONE OF MY TEETH BROKE WHILE I WAS TRYING TO EAT. I THINK I SWALLOWED A PIECE OF MY TOOTH TOO. LOOK AT MY TEETH IT'S TERRIBLE. MY MOUTH IS HURTING. I'M SUPPOSED TO SEE AN ORAL SURGEON. THEY GIVE ME ANTIBIOTICS AND SAY I AM GOING TO HAVE MY TEETH REMOVED THEN NOTHING HAPPENS. THEY SAY THEY ARE WAITING ON MY DAUGHTER TO GIVE THEM THE OK, BUT NOTHING IS HAPPENING. I HAVEN'T HEARD FROM MY DAUGHTER IN MONTHS." RESIDENT #113 OPENED HIS MOUTH, HE POINTED TO HIS LOWER LIP AND SAID "I BIT MY LIP TOO BECAUSE MY TEETH ARE BROKEN." RESIDENT #113'S MOUTH WAS OBSERVED. HIS LOWER FRONT JAW REVEALED THREE TEETH THAT WERE BLACKENED, DECAYED AND SOME WERE BROKEN DOWN TO THE ROOT. A SMALL TEAR WAS OBSERVED ON HIS LOWER LIP. IN ADDITION, HIS UPPER FRONT JAW HAD FOUR TEETH THAT WERE ALSO BLACKED, DECAYED AND BROKEN. ON 10/5/11 AT 2:30 PM., RECORD REVIEW REVEALED THAT RESIDENT #113 WAS ORIGINALLY admitted INto the facility on [DATE], AND readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. SPONDYLOSIS, [MEDICAL CONDITION] IN DIABETES, DIABETES WITH NEURO MANIFESTATIONS, BONE AND CARTILAGE DISORDER, HYPERTROPHY OF PROSTATE, [MEDICAL CONDITION] AND [MEDICAL CONDITION]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED RESIDENT #113'S WAS COGNITIVELY INDEPENDENT WITH DECISION MAKING SKILLS AND REQUIRED ASSISTANCE AND SET UP WITH PERSONAL HYGIENE. HOWEVER THE MDS DID WAS BLANK FOR THE RESIDENT'S ORAL DENTAL STATUS. REVIEW OF physician's orders [REDACTED]. 7/11/11-"[MEDICATION NAME] (ANTIBIOTIC) 100 MILLIGRAMS (MG) BY MOUTH TWICE PER DAY FOR 10 DAYS." 8/1/11- "[MEDICATION NAME] (ANTIBIOTIC) 500 MG BY MOUTH TWICE PER DAY FOR 10 DAYS- ORAL ABSCESS." 8/15/11-"[MEDICATION NAME] (ANTIBIOTIC) 500 MG BY MOUTH TWICE PER DAY FOR 14 DAYS- ORAL ABSCESS." REVIEW OF THE DENTIST CONSULT NOTES DOCUMENTED: ON 3/3/11 "..ORAL SURGEON HAS TO REMOVE TEETH..". 9/15/11 "PRESCRIPTION FOR ANTIBIOTICS FOR ORAL SURGEON VISIT IN FUTURE." REVIEW OF NURSE'S NOTES FOR RESIDENT #113 DOCUMENTED: 2/17/11 -ADMISSION ASSESSMENT ORAL "7 UPPER, 6 LOWER TEETH BLACKENED/EVIDENCE OF CARIES, BROKEN/CHIPPED TEETH." 7/22/11- ADMISSION ASSESSMENT ORAL "7 UPPER, 6 LOWER TEETH BLACKENED/EVIDENCE OF CARIES, BROKEN/CHIPPED TEETH." 7/28/11 10:40 AM, "RESIDENT SEEN BY DENTIST TODAY FOR COMPLAINTS OF TOOTH PAIN...FULL MOUTH XRAY'S TAKEN IN MAY, SUBMIT TO FAMILY HIS PLAN OF TREATMENT AS SOON AS POSSIBLE." 8/1/11 3:00 PM, "RESIDENT diagnosed with [REDACTED]." 8/15/11 3:30 PM, "NEW ORDERS FOR [MEDICATION NAME] FOR ORAL ABSCESS ALSO REFER TO ORAL SURGEON FOR POSSIBLE EXTRACTION." 9/15/11 10:50 AM, "RESIDENT SEEN BY DENTIST, PRESCRIPTION WROTE FOR ANTIBIOTIC FOR DENTAL INFECTION." 9/16/11 3:30 PM, " DPOA (DURABLE POWER OF ATTORNEY) CALLED IN REGARDS TO ANTIBIOTIC THERAPY AWAITING CALL BACK." 10/3/11 10:10 PM, "PLACED CALL TO DPOA REGARDING REFERRAL TO ORAL SURGEON,...MESSAGE LEFT TO CALL FACILITY TO SET UP APPOINTMENT." REVIEW OF THE PHYSICIAN'S PROGRESS NOTES DOCUMENTED: 7/1/11 "PATIENT SEEN TODAY IN REGARDS TO HAVING POOR DENTITION AND TEETH PAIN AGAIN. THE PAIN IN GENERAL IS WORSE. I RECOMMENDED THAT HE SEE A DENTIST/ORAL SURGEON FOR EVALUATION OF HIS POOR DENTITION." 7/11/11,"PATIENT SEEN TODAY IN REGARDS TO HAVING A SORE THROAT AND DENTAL PAIN. THE PATIENT HAS TERRIBLE DENTITION...I WILL TREAT HIM FOR PHARYNGITIS AS WELL FOR A SUPPOSED DENTAL ABSCESS., THE PATIENT HAS POSITIVE LEFT-SIDED LOWER JAW REDNESS AND TENDERNESS TO PALPATION INDICATIVE OF ABSCESSED GUMS, HAVE PATIENT EVALUATED BY A DENTIST AT THE NEXT ROUNDS". 7/18/11 "PATIENT SEEN TODAY IN REGARDS TO COMPLAINT OF EXTREME NAUSEA, HARDLY ABLE TO EAT ANYTHING OR TAKE ANY OF HIS PAIN MEDICATIONS." 7/29/11 "PATIENT STILL HAS TOOTH PAIN WITH POSSIBLE UPPER JAW ABSCESS..HAVE DENTIST FOLLOW UP WITH THE PATIENT." 8/15/11 "PATIENT SEEN TODAY IN REGARD TO HAVING TEETH PAIN/TOOTH ABSCESS. THE PATIENT NEEDS TO SEE AN ORAL SURGEON TO HAVE SOME OF HIS DECAYING TEETH REMOVED WHICH WILL HOPEFULLY END THIS PROCESS OF ABSCESSED GUMS AND JAW". PER PHYSICIAN HISTORY AND PHYSICAL ASSESSMENT FORM DATED 9/16/11 DOCUMENTED: "PATIENT SEEN AND EVALUATED TODAY." HOWEVER, THE SECTION FOR TEETH/GUMS ASSESSMENT WAS LEFT "BLANK". REVIEW OF A CARE PLAN DATED 5/23/11 TITLED "COMFORT": MONITOR FOR PAIN ASSOCIATE IN ORAL CAVITY REDNESS, SWELLING, NOTIFY PHYSICIAN AS SOON AS POSSIBLE (ASAP), DENTAL EVALUATION AND TREATMENT AS ORDERED." ON 10/6/11 AT 1:00 PM, DURING AN INTERVIEW AND RECORD REVIEW, THE DIRECTOR OF NURSING (DON) STATED, "THE FAMILY HAS TO ARRANGE FOR THE RESIDENT TO BE SEEN BY THE ORAL SURGEON WE'VE TRIED TO CONTACT HIS DAUGHTER SHE HAS POWER OF ATTORNEY. IT'S NOT OUR RESPONSIBILITY. THE RESIDENT CAN'T MAKE HIS OWN DECISIONS." HOWEVER, THE DON WAS UNABLE TO EXPLAIN WHY AN THE RESIDENT HAD NOT BEEN SEEN BY THE ORAL SURGEON AS RECOMMENDED BY THE DENTIST. ON 10/6/11 AT 1:30 PM DURING AN INTERVIEW THE FACILITY'S SOCIAL WORKER STATED, "I'VE ONLY BEEN HERE TWO WEEKS, I WAS NOT AWARE OR INVOLVED IN THE RESIDENT'S DENTAL CONCERNS." ON 10/7/11 AT 9:45 AM, DURING A PHONE INTERVIEW THE RESIDENT'S PHYSICIAN (O) STATED "I WAS AWARE OF THE RESIDENT'S POOR DENTITION AND CONSULTED THE DENTIST IN MARCH (2011)". PHYSICIAN (O) FURTHER STATED THE RESIDENT'S EVALUATION AND TREATMENT BY THE ORAL SURGEON HAD BEEN DELAYED SINCE MARCH DUE TO THE LACK OF THE RESIDENT'S FAMILY'S FOLLOW-UP. REVIEW OF THE FACILITY'S POLICY TITLED "RULES AND REGULATION' DATED JULY 2009 DOCUMENTED: "ANCILLARY SERVICES PHYSICIAN, PODIATRY, DENTAL....SERVICES ARE CONTRACTED BY THE FACILITY THOUGH ANCILLARY SERVICES." ( )

Based on observation, interviews and records review, the facility failed to provide adequate supervision and assistive devices for one (1) of four (4) sampled residents out of a total of ten (10) residents who were identified by the facility as having the potential of falling resulting in a transfer of a resident by one CNA instead of two CNAs without the use of a gait belt and resulting in a left femur fracture to a resident. Findings include: An unannounced on-site investigation was conducted by a Health Care Surveyor from the Department of Licensing and Regulatory Affairs ' Complaint Investigation Unit beginning on August 26, 2011. Resident #101 was an [AGE] year-old female who was admitted to the facility with the following Diagnoses: [REDACTED]. On 8/26/2011 at 10:45 AM, a record review of the investigation notes dated 8/4/2011 provided by the Administrator of the facility indicated that Resident #101 was transferred from the wheelchair to the bed by "one caregiver only, apparently without a gait belt. The therapeutic transfer is a two-person assist with gait belt". On 8/26/2011 at 11:00 AM, an interview was conducted with the medical director of the facility. He stated that resident #101 had poor circulation to her left leg with multiple open wounds to her ankle and shin. He also stated that resident #101 had bypass grafts in the left leg in an attempt to increase the circulation to that leg which were not successful. In the past, resident #101 was offered an amputation to the left leg which resident #101 declined to have done. On 8/26/2011 at 11:30 AM, a record review of the incident report dated 8/4/2011 for Resident #101 indicated that, on 8/2/2011 at 9:15 PM, CNA #4 assisted Resident #101 to transfer from the wheelchair into a standing position to pivot into the bed. Resident #101 lost her balance and was assisted by CNA #4 to the floor. Resident #101 complained of hip pain, the physician was notified and ordered x-rays. The x-ray results indicated a hip fracture. Resident #101 was transferred to a local hospital for medical care. On 8/26/2011 at 2:40 PM, CNA #4 was interviewed. According to CNA #4, resident #101 was a two (2) person transfer and CNA #4 thought resident #101 was a one (1) person transfer. CNA #4 said she did not check resident #101's care guide, which was located on the inside of the closet door in resident #101's room, before she transferred resident #101. According to CNA #4, she had to pivot resident #101 from the front of the wheelchair to the resident's bed on the resident's "bad leg". At this point, CNA #4 became confused about which leg was being used to pivot the resident and stated that resident #101 pivoted on her right leg, which did not have circulatory problems. She did not use a gait belt to move resident #101 from the wheelchair to the bed. On 8/26/2011, a record review of the disciplinary action for CNA #4 indicated that the nature of the discipline was "failure to meet standards of care" and "unsafe work". The immediate corrective action was noted as "final written warning" and was dated on 8/8/2011. In addition, CNA #4 said that she was suspended without pay for four (4) days before being allowed to return to work at the facility. On 8/29/2011 at 10:00 AM, LPN # 6 said that the CNAs should check the resident care guides daily at the beginning of the shift in order to ensure that they know what care needs to be provided. In addition, since the care guides are updated whenever changes occur, checking the care guides keeps the CNAs aware of how care should be rendered. On 8/29/2011 at 10:30 AM, RN #7 said that the CNAs should check the care guide every day and every time they are going to transfer a resident in case changes have been made to the care guides. On 8/29/2011 at 11:00 AM, CNA #8 said she checked resident care guides at the beginning of every shift because the information in the care guide changed often as care information was updated. On 8/29/2011 at 11:15 AM, resident #101 was observed sitting in a wheelchair in the facility hallway with her left leg elevated. When asked, she denied have any pain in her left leg. CNA #9 was interviewed on 8/29/2011 at 12:30 PM and stated that she always used a gait belt when transferring any resident in the facility. CNA #10, who was interviewed on 8/29/2011, said that she always used a gait belt when transferring residents as this helped to avoid any injury to her back. On 8/29/2011 at 1:25 PM, physical therapy assistant (PTA) #11 said that a gait belt should be used all the time when a resident is being transferred unless a Hoyer lift is being used instead. PTA #11 said that the use of a gait belt gives more support and leverage to the CNAs doing the transfer. On 9/6/2011 at 10:00 AM, the floor staff were observed moving resident #105 from the bathroom, using a geri-chair, and then transferring resident #105 to a wheelchair using a gait belt and the handrails in the hall. The transfer was completed following the facility's policy and procedure for resident transfers.