Every finding on record at West Oaks Senior Care & Rehab Center

This citation pertains to intake 2680585 Based on interview and record review, the facility failed to provide adequate supervision for one vulnerable resident (R101) of five residents reviewed for supervision, resulting in a resident being left alone during an outside appointment and the potential for injury. Findings include: On 12/15/25 at 9am, record review of order dated 10/14/25 revealed R101 was to have an appointment on 11/19/25 at 12:30 pm with a pickup time at 11:30 am.On 12/15/25 at 2:30pm, R101 and Family Member G were interviewed regarding the incident at the facility. Family Member G explained that R101 has a traumatic brain injury and was taken to a medical appointment far away and left unsupervised for hours. Family Member G stated that the family would have accompanied R101 had they known about the appointment. On 12/16/25 at 9 am, record review revealed an admission date of 4/24/25 with diagnosis that included the following: acute respiratory failure, sepsis, staphylococcus aureus, acute embolism, thrombosis of unspecified femoral vein, anemia, Congestive Heart Failure, Anxiety Disorder, Adjustment Disorder, Dementia, Dysphasia, Quadriplegia. Record review of R101's care plans, last revised 10/6/25, revealed traumatic brain injury, Quadriplegia, incontinence, fall risk, two persons assist for transferring. Record review of a social services progress note dated 12/15/25 noted R101 is a 2 Person Assist- Hoyer lift and utilizes Geri chair when up. On 12/16/25 at 9:17 am Family Member F was interviewed and stated that R101 was sent to a neurology appointment alone. Family Member F stated on 11/19/2025.R101 was sent to a doctor's appointment for three hours unaccompanied by staff. Family Member F stated that she was not informed of this appointment and would have attended if made aware. Family member F stated that she usually rides the transportation van with R101 to all appointments and the facility should have confirmed her attendance or sent a staff person, when she was not at the facility on departure. On 12/16/25 at 12:40pm, Nurse D was interviewed and reported providing Family Member F with a copy of R101's upcoming appointments but admits not following up to ensure accompaniment to the appointment on 11/19/25. When asked what went wrong with this appointment, Nurse D stated, I assumed Family Member F would meet him at the appointment. Nurse D admitted that Family Member F usually met R101 at the facility before appointments. Nurse D stated again, I just assumed she was meeting him there. On 12/16/25 at 1:23pm, Nurse C was contacted by telephone with the DON (Director of Nursing) present. Nurse C stated, I dropped the ball on this one. I assumed his family member was going to meet R101 there. On 12/16/25 at 1:45pm, the transportation company Staff E was contacted and reported R101 was picked up from the facility around 12pm and rode alone on the van to the appointment on 11/19/25. On 12/16/25 at 3:18pm, a policy on supervision at medical appointments was requested. The administrator informed the survey team the facility did not have a policy regarding supervision on medical appointments, We follow physician orders. On 12/16/25 at approximately 3:30 pm, the Administrator and the Regional Clinical Director were queried regarding the incident involving R101. The Administrator and Regional Clinical Director acknowledged that R101 should not have been left without family or a staff member to supervise/accompany R101 and to ensure R101's needs were met while on the medical visit.

Based on interview and record review, the facility failed to ensure Physician/Physician Extender progress notes were entered into the clinical record in a timely manner for one resident (R35) of 19 resident's reviewed for Physician/Physician Extender progress notes. Findings include: On 6/24/25 at 8:42 AM, R35's Electronic Health Record (EHR) was reviewed for Physician/Physician Extender notes and revealed there were no Physician/Physician Extender notes found in the EHR since 12/2024. On 6/24/25 at 12:57 PM, Physician/Physician Extender practitioner notes were requested. Record review of the EHR revealed R35 was admitted to the facility on [DATE] with a diagnosis that included cerebral infarction (stroke) and attending physician listed as Medical Doctor (MD) F. On 6/24/25 at 3:25 PM, Nurse Practitioner (NP) E was interviewed and stated, I work with (MD F) and provided the care to (R35), but I did not provide notes in the medical chart. It was my mistake. The notes should be put in when the visit occurs. On 6/25/25 12:53 PM, the Director of Nursing (DON) was interviewed and said the expectation is for the Physician/Physician Extender to write a clinical note within 24 hours or performing the visit. The DON agreed there were no Physician/Physician Extender notes in the EHR for 2025 until the facility was made aware of the lack of physician notes in R35's EHR. Review of the facility's policy titled, Physician Services revised August 2006 revealed in part: Physician orders and progress notes shall be maintained in accordance with current Omnibus Budget Reconciliation Act (OBRA) regulations and facility policy.

Based on observation, interview and record review the facility failed to maintain infection control practices for two of five residents (R47 and R22) reviewed for respiratory care by not ensuring respiratory equipment was stored in a sanitary manner. This failure had the potential to expose residents to harmful microorganisms and increase the risk of infection. Findings include: On 6/23/25 at 2:00 PM, during an observation of R47's room, a nebulizer mask was noted on the bedside table uncovered and exposed to air. The mask was not stored in a protective covering. On 6/23/25 at 2:05 PM, Licensed Practical Nurse (LPN) A entered the room. When queried, about the storage of the nebulizer mask, LPN A said it should be in a plastic bag. Record review noted that R47 was admitted on [DATE] with a pertinent diagnosis of respiratory failure with hypoxia and dependence on supplemental oxygen. Record review revealed R47's Minimum Data Set assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating they were cognitively intact. On 6/23/25 at 2:30 PM, R22 was observed with a nasal canula oxygen mask attached to the back of their wheelchair, dangling and touching the floor. On 6/23/25 at 2:40, Registered Nurse (RN) B entered R22's room and observed the nasal canula mask touching the floor. RN B was interviewed and said the mask should have been in a plastic bag when not in use. Record review for R22 indicated they were admitted on [DATE] with a pertinent diagnosis of respiratory failure with hypoxia, emphysema, and malignant neoplasm of bronchus or lungs (lung cancer). Record review for R22 (MDS) dated [DATE] for (BIMS) score was 14 out of 15 indicating R22 was cognitively intact. On 6/25/25 at 10:25 AM, the Nursing Home Administrator (NHA) was interviewed and confirmed that nebulizer masks should be sanitized, and all masks should be stored appropriately when not in use. Review of facility policy titled Oxygen Administration and Safety with an effective date of 5/20/25 noted, the purpose of this policy is safe administration of oxygen therapy to the residents. Furthermore, the policy documented, .tubing will be store in a plastic bag or similar storage device when not in use.

This citation pertains to intakes MI00151575 and MI00151833. Based on interview and record review the facility failed to ensure proper positioning during care for one resident (R902) out of three residents reviewed for falls, resulting in R902 falling from bed and obtaining a large hematoma (blood filled bruise) with extensive bruising of the face. Findings include: The State Agency received an allegation that R902 had fell out of bed during care resulting in injuries. Review of R902's electronic medical records (EMR) revealed admission into the facility on [DATE] with a pertinent diagnosis of hemiplegia (paralysis) and hemiparesis (paralysis) following a cerebral infarction (stroke) affecting left non-dominant side. Review of R902's Minimum Data Set (MDS) dated [DATE], it was documented resident required partial/minimal assist with bed mobility. Review of R902's Brief Interview for Mental Status (BIMS) dated 2/20/25, R902 scored 12 out of 15 (moderate cognitive impairment). Review of ADL Care Plan dated 2/18/23, revealed Bed Mobility: 1 PA (person assist). Review of Progress Notes dated 3/24/25 at 3:53 AM, it was noted, Informed by nurse assistant that resident rolled out of bed while given care. Upon entering room, resident noted on the floor laying on her left side. Tennis ball size hematoma noted on residents left side of her forehead. No broken skin or lacerations noted. After getting resident back in bed resident stated, she told me to roll over and I fell . Review of hospital Discharge Summary dated 3/24/25 at 3:59 AM, it was noted ED (emergency department) Diagnoses- Fall and Traumatic hematoma of forehead. Interview conducted on 4/7/25 at 11:45 AM with Certified Nursing Assistant (CNA) A, It was reported that while changing the sheets on R902's bed the resident fell out of bed. CNA A was asked how R902 was able to fall out of the bed, CNA A reported standing on the side of the resident's bed and pulling on the fitted sheet toward herself so the resident would turn away from her, and when the sheet was pulled to turn the resident, the resident jumped and fell out of the bed. Interview conducted on 4/7/25 at 12:19 PM with Director of Nursing (DON), it was reported that if CNA A had followed proper procedures the fall with injury could have been prevented. Review of facility policy Turning a Resident on His/her Side Away from You (no date), documented the following: . 2. Unless otherwise instructed, lower the head and footrest of the bed. 3. Lower the side rails on the side of the bed you are working, if up. 4. Loosen the covers as necessary. Avoid unnecessary exposure of the resident's body. 5. Slide both your arms under the resident's back to his/her far shoulder. 6. Slide the resident's shoulders toward you on your arms. (Note: Keep your knees bent and your back straight as you slide the resident toward you.) 7. Slide both your arms (as far as you can) under the resident's buttocks. 8. Slide the resident's buttocks toward you. (Note: Keep your knees bent and your back straight as you slide the resident's buttocks toward you.) 9. Slide both arms under the resident's feet and ankles. 10. Slide the resident's feet toward you. (Note: Keep your knees bent and your back straight as you slide the resident's feet toward you.) 11. Cross the resident's arms over his/her chest. 12. Cross the resident's leg nearest you over the leg farthest from you. 13. Stand with your weight evenly distributed on both feet. (Note: Your feet should be approximately 12 inches apart.) 14. Keep your back straight. 15. Place one hand on the resident's shoulder nearest you. 16. Place your second hand under the resident's buttocks. 17. Gently turn the resident away from you. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Staff education on proper repositioning during care, audit of residents that could be affected from improper positioning, Director of Nursing randomly audited 10 residents per week, 1 on 1 education provided to staff present during incident, QAPI and IDT meeting held to discuss plan of correction. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00147802. Based on interview and record review, the facility failed to prevent an elopement for one resident (R301) out of four residents reviewed for elopement, resulting in R301 exiting from the facility without staff knowledge and the potential for injury for the resident. Findings include: On 12/05/2024 at 10:00 a.m., an investigation was conducted regarding a facility reported incident dated 10/20/2024. The facility's investigation report revealed in part: .on 10/20/2024 At about 8:00 p.m., R301's assigned nurse (Licensed Practical Nurse (LPN) A went to provide the resident with his evening medication and medication could not be administered because she could not locate the resident. R301's room was checked and all surrounding common areas. Nursing staff immediately called security and code [NAME] alert for missing person protocol was initiated. A total head count of all residents was conducted and only R301 was not accounted for . The resident traveled approximately twelve mile as reported by multiple sighting by family and friends. Resident traveled to the areas that he was familiar with to get a loosie (which is another name for a cigarette out of the pack). Resident also visited his maternal Grandmother's house in the morning and took a nap. Since family member had no knowledge of resident exiting facility without completing his Leave of Absence (LOA) paperwork due to his calm demeanor she left for an appointment and when she returned, he was gone. Resident also was spotted on his uncle's ring camera knocking on his door. The individual who saw resident did not notify facility nor police because they had no knowledge of the resident residing at the facility. The resident was found at 1:30 p.m. by R301's son's girlfriend on 10/21/2024. Resident was transported to (Hospital). Resident had no obvious or visible injuries .Conclusion: Resident chose not to return to the facility and is being discharged to stay with family from the hospital. Plan of Action: 6. Security Guard was suspended pending investigation. One-on-One education was provided to security staff and facility staff on Missing Person and Elopement Policy was reviewed. Employee (Security Guard (SG B) Corrective Action documented, Describe Situation and/or concerns as following: -SG B was unaware of resident whereabouts, she failed to follow front desk safety protocol during shift. Front desk staff must be alert and at tentative to all entering and exiting the building. SG B will be suspended and placed on a final corrective action. Continued violation of company policies will result in further corrective action, up to and including termination. On 12/05/2024 at 1:34 p.m. SG B was called and was not available for an interview. According to the electronic health record (EHR), R301's was admitted to the facility on [DATE] with diagnoses of congestive heart failure, diabetes mellitus type two, chronic kidney disease stage 3A, alcohol dependence with withdrawal and tobacco use. R301's Minimum Data Set (MDS) with a reference date of 10/16/2024 indicated R301 had moderately impaired cognition with a BIMS (brief interview for mental status) score of 09/15. A care plan with a review date of 7/10/2024 documented, Transfer status: one person assists with ambulation: wheelchair when out of bed. On 12/05/2024 at 1:01 p.m. during an interview, the administrator said after reviewing the facility's camera, R301 left out of the front door after SG B buzzed R301 out. The camera also showed that SG B allowed R301 to exit the facility without being accompanied by someone and without making sure the resident had LOA paperwork. The Administrator said the LOA paperwork is to be fully completed by the resident's assigned nurse on the unit before the resident gets to the security guard desk. The LOA paperwork is given to the security guard and kept until the resident return. Then the resident is buzzed out of the door to leave the facility. The Administrator also said R301 does not go out of the facility on a LOA without accompanied by family who is in the facility to sign the LOA papers. Multiple LOA paperwork with family signatures and return dates and times was presented and reviewed. The Administrator said SG B was in-serviced on checking completed LOA paperwork before letting a resident out of the building. SG B was suspended during the investigation but later resigned. The administration said after requesting a LOA policy that the facility did not have a LOA policy but presented a Elopement policy. R301's assigned Nurse A was called on 10/20/2024 at approximately 1:50 p.m. but the number was a non-working number. According to the facility's revision date 10/23/2024 elopement and/or exit -seeking management policy: Elopement: When a resident leaves a safe or secure area, for an unsafe area without assistance or supervision.

This citation pertains to intake MI00143663. Based on observation, interview, and record review, the facility failed to properly assess bilateral heel wounds for one resident (R404) of three residents reviewed for pressure ulcer prevention/intervention, resulting in the potential for the worsening of wounds. Findings include: On 5/7/24 at 11:58 AM R404 was observed lying in bed with loosely wrapped bandages on both feet. R404's heels were not completely covered revealing black dried scabs on both heels. R404's feet were observed to be dry, cracked, and dead skin was seen flaking off their feet onto the mattress. R404's feet were positioned directly on the mattress, there were no pressure relieving devices observed. On 5/7/24 at 12:01 PM Certified Nursing Assistant (CNA) A was asked if the bandages could be observed. CNA A lifted R404's heels. R404's bandages began to unravel onto the mattress and there was no date found on the bandaging. On 5/7/24 at 1:11 PM Wound Care Nurse (WCN) B was interviewed regarding R404's wounds. WCN B said R404 was admitted with the wounds on 2/22/24. During the interview, WCN B was queried about the documentation in the medical record regarding the wounds that were documented on 5/7/24. WCN B said this was the first time that the wounds were assessed by him (WCN B). WCN B said the care plan was revised to include the heel wounds (5/7/24). Initially the care plan did not mention R404's the heel wounds. Orders were placed for wound care (5/7/24) and the wounds were assessed, measured, and documented in the Electronic Medical Record (EMR) (5/7/24). On 5/7/24, upon surveyor query, was the first-time orders were placed for R404's heel wounds. On 5/7/24 at 1:36 PM MDS (Minimum Data Set) Coordinator E was interviewed regarding the MDS reviewed and revised on 2/28/24. MDS Coordinator E said the skin condition section the MDS was documented that R404 had the potential to develop pressure ulcer because she did not see any documentation that supported that R404 developed pressure ulcers. MDS Coordinator E said she looks at the resident's orders for wound care and the wound care assessments to get an idea if the resident had developed pressure ulcers. On 5/7/24 at 3:56 PM Wound Care Physician (WCP) C was interviewed regarding R404's heel wounds. According to WCP C, the wounds were assessed. WCP C said the findings revealed R404's heels had dried eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) on both heels, which were considered unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). WCP C said typically wounds such as the wounds R404 had would be treated with either alcohol or betadine and wrapped with a dry dressing. On 5/17/24 at 1:47 PM the Director of Nursing (DON) was interviewed regarding the expectation of when a wound is assessed upon admission. The DON said it is the expectation that the WCN assess the wound and then call the primary care physician to get orders for treatment. A review R404's EMR revealed R404 was admitted to the facility initially on 9/22/22 and readmitted on [DATE]. R404 had the following pertinent medical diagnoses: Severe Protein-Calorie Malnutrition, Bacteremia (Bacterial Infection of the blood), and Dementia. A review of R404's Minimum Data Set (MDS) dated [DATE] revealed R404 had a Brief Interview of Mental Status (BIMS) score of 0/15 (severely cognitively impaired). According to the MDS, R404 was dependent and required maximal assistance with bed mobility and transfers. Also, there was no mention of active pressure ulcers for R404, only the potential for pressure ulcers. On 5/7/24, at the time of record review, the skin management care plan revealed no mention of the bilateral unstageable heel pressure ulcers. A review of R404's orders revealed the following wound treatment orders and order date and time: Cleanse right heel unstageable pressure wound with dermal wound cleanser and pat dry, apply Betadine daily. Cover with Abdominal Pad (ABD) and wrap with Kerlix and as needed every evening shift for wound healing AND as needed when dislodged or soiled. Ordered 5/7/24 at 12:37 PM. Cleanse left heel unstageable pressure wound with dermal wound cleanser and pat dry, apply Betadine daily Cover with ABD and wrap with Kerlix and as needed every evening shift for wound healing AND as needed when dislodged or soiled. Ordered 5/7/24 at 12:35 PM. Review of R404's hospital notes dated 2/20/24 revealed R404's heels were staged as deep tissue injuries (Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). A review of R404's admission progress note dated 2/22/24 revealed, Received patient by stretcher from local hospital. Alert at moment no signs or symptoms of respiratory distress or discomfort. Diagnosis at the time of admission shortness of breath, Cerebrovascular Accident (Stroke). Upon skin assessment wounds on right side of leg, right side of knee, left and right side of heel old wound on coccyx pink color. Nurse Practitioner D notified of admission. A review of R404's admission assessment, dated 2/22/24, revealed documentation under the skin tab that R404 had wounds on bilateral heels. There was no description of the staging of the wounds on the either of R404's heels.

This citation pertains to #MI00140569. Based on interview and record review, the facility failed to ensure two residents (R107 amd R108) out of four residents reviewed for infection control, received proper COVID-19 testing following a COVID-19 outbreak in the facility, resulting in the potential for spread of COVID-19 throughout the building. Findings include: It was reported to the State Agency that staff were not following proper infection control/prevention guidelines. On 12/5/23 beginning at 11:03 AM, Infection Preventionist (IP) G was queried about COVID-19 testing conducted in the facility following a recent COVID outbreak. IP G said the recent COVID-19 outbreak began on 10/6/23 when Resident #105 (R105) tested positive. IP G said they tested residents complaining of COVID symptoms and residents who were exposed to COVID-19. IP G indicated they did COVID testing on the first day, third day, and fifth day. The IP G said he was off on 10/6/23 and did not return to work until the following week. On 12/5/23 beginning at 11:37 AM, the Director of Nursing (DON) acknowledged that the outbreak began on 10/6/23 and the first person that tested positive participated in a group activity on 10/6/23. The DON said testing of residents began on 10/6/23 and for an outbreak, they test according to contact tracing. The DON stated, We only test people that have been exposed. We don't test the whole building. On 12/5/23 at 4:46 PM, medical record reviews were conducted with the Regional Clinical Director for two residents (R107 and R108) that participated in the group activity with R105 on 10/6/23. Additional COVID-19 testing documents were also reviewed. Both residents tested negative for COVID-19 on 10/6/23. Subsequent COVID-19 testing occurred as indicated: Resident #107 was tested [DATE] but not again until 10/19/23. Resident #108 was not tested again until 10/19/23. On 12/5/23 at approximately 2:48 PM, Unit Manager Licensed Practical Nurse (UM/LPN) F was observed filling out a COVID-19 testing document, which she dated 10/9/23. This document indicated R108 was tested on that date for COVID-19. UM/LPN F said she was not the person that performed the testing on 10/9/23. On 12/5/23 beginning at 5:20 PM, the Nursing Home Administrator (NHA) and DON said residents exposed and/or with COVID symptoms should have been tested on day 1, day 3, and day 5. They indicated they considered day 1 as 10/6/23, day 3 as 10/9/23, and day 5 as 10/11/23 and that testing should happen according to the guidelines to ensure resident and staff safety. A review of the facility policy titled, Testing Requirements for Staff and Residents, dated 5/10/23, documented in part the following: - The facility will test residents and staff based on parameters and a frequency set forth by the HHS Secretary and in a manner that is consistent with current standards of practice for conducting COVID-19 tests. - Purpose: To establish a testing process to rapidly inform infection prevention initiatives to prevent and limit transmission of COVID-19 within the facility. - Outbreak testing and response for COVID-19 A single new case of COVID-19 infection in any staff or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and staff identified as close contacts or higher risk exposures (during the exposure window) or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. o Testing should occur day 1 (where day of exposure is day 0), day 3, and day 5. o If additional positive cases are identified on day 1, day 3 or day 5, the facility should continue testing using a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach every 3-7 days until 14 days of no new positives. A broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. On 12/5/23 at 5:30 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this concern when asked.

This citation pertains to MI00140144. Based on interview and record review, the facility failed to submit documentation of a completed investigation of an alleged incident of resident-to-resident abuse in a timely manner to the State Agency for two residents (R101 and R102), out of three residents reviewed for abuse, resulting in the potential delay for opportunities to implement corrective measures and interventions. Findings include: A facility self-reported incident (FRI) was received by the State Agency (SA) on 8/20/23 at 3:59 PM. The FRI documented that on 8/20/23 at approximately 1:30 PM, a nurse heard shouting coming from the [NAME] Hall. The shouting was coming from Room XX. Upon further investigation, Resident #101 (R101) was hollering at Resident #102 (R102) to get out of his house. R102 was observed standing over R101. R102 was escorted out of the room by the nurse to calm him down. Both residents were interviewed. R101 alleged that R102 hit him in the chest, however the nurse observed R102 holding R101's arm. Both residents were involved in an alleged, unwitnessed altercation. Nursing staff on duty did not witness any signs of altercation of physical contact. R102 denied hitting R101. R102 has a long history of inappropriate social behavior and poor impulse control. Residents were immediately separated and no further behaviors were noted, reported, or observed. On 12/5/23 at 4:12 PM, the Nursing Home Administrator (NHA) provided documentation that the completed investigation regarding the resident-to-resident allegation of abuse was submitted to the SA on 9/7/23. The NHA was unable to provide a reason for the late submission of the FRI. A review of the facility policy titled, Abuse, Neglect and/or Misappropriation of Resident Funds or Property, dated 3/15/2023, documented in part the following: - Reporting/Response. i) For the alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency, local authorities as appropriate, and adult protective services where state law provides for jurisdiction in long term care facilities), in accordance to the state law, and within 5 working days of the incident with the conclusion. On 12/5/23 at 5:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information regarding this concern when asked.

This citation pertains to intake MI00139131, Based on interview and record review the facility failed to inform the resident's representative of a change in condition for three (R601, R602, and R605) of five residents reviewed for change in condition, resulting in the resident's representative not being informed of the resident's physical and psychosocial well-being. Findings include: R601 Review of R601's medical record revealed admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (weakness) affecting the right dominant side, hemiplegia and hemiparesis affecting non dominant side and diabetes mellitus. Responsible party power of attorney care conference person and emergency contact #1 listed as Family Member B. On 9/18/23 at 9:10 AM, during an interview Family Member B stated that R601 had multiple falls in the facility and that R601's care was not adequate. Family Member B reported that upon visiting R601 on 8/16/23 R601 complained of right leg pain and observed a bruise on R601's waist. Family Member B immediately talked to the nurse and reported R601's complaints. An X-Ray was done at the facility and later showed a fracture. Family Member B stated that she was never called about the fall R601 had on 8/15/23 resulting in a broken leg which required hospitalization and surgery. Review of the Nursing Progress Note dated 8/15/23 stated Pt was observed sitting on the floor at shift change, next to bed. No c/o pain, bruising, or discomfort. No lumps bleeding or bumps. Review of the fall report dated 8/15/23 revealed, Writer observed pt sitting on floor mat next to bed, sitting up during shift change. Writer placed In bed assessment complete, vitals signs taken, ROM completed . Contraction on Right arm and leg no bruising, bleeding or lumps observed. No injuries observed at time of incident. Physician contacted at 8/15/23 at 5:27. There is no reference to contacting Family Member B in either note. Review of the facility provided Change in Condition Note dated 8/17/23 at 5:02 revealed that the documentation for Family Member B notified of change in condition occurred on 8/16/23 at 5:00 and was completed late after the fact of the fall on 8/15/23 with injury. R605 Review of R605's medical record revealed admitted to the facility on [DATE] with pertinent diagnoses of dementia, schizophrenia and dysphasia. Responsible party power of attorney care conference person and emergency contact #1 listed as Family Member C. Review of the nursing progress note dated 6/18/23 revealed Resident was observed on the floor in the hallway , No injuries noted. Resident denies any pain . Vss (vital signs stable), denies any pain Dr. notified . No new orders given . Neuro to be started. Review of the Fall Report dated 6/18/23 revealed Resident observed on floor in the hallway no injuries noted, resident unable to give description. Certified Nursing Assistant (CNA)s picked resident up off the floor and sat her in her WC (wheel chair). VSS checked and were stable Dr. was notified. There is no documentation of contacting Family Member C. In an interview on 9/18/23 at 1:18 PM with Licensed Practical Nurse (LPN) A when asked the expectation of reporting a fall LPN A stated we assess the resident, check vitals, call the doctor, call the family, and complete the fall report. In an interview on 9/18/23 at 1:25 PM with the Director of Nursing (DON) when asked what the expectation is of reporting a fall the DON stated assess the resident, call the doctor, call the family, perform change in condition report. 39958 R602 Review of an Admission Record revealed, R602 admitted to the facility on [DATE] with pertinent diagnosis which included Morbid Obesity, Muscle Weakness, and Heart Failure. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/17/23 revealed R602 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. R602 required extensive assistance of one staff with bed mobility, transfers, or toilet use. Review of an incident report with a date of 6/13/23 revealed R602 had a fall. The Physician was notified at 3:50 p.m. R602's emergency contacts were not notified. Review of a progress note with a date of 6/13/23 at 4:01 p.m. revealed, Patient slid from bed to the floor while transferring to the wheelchair. CNA was present during fall. All Vitals normal and no injury reported . Review of a progress note with a date of 6/14/23 at 6:45 a.m. revealed, Pt (patient) in w/c (wheelchair) at bedside AO (alert and orientated) x4. Previous nurse reported fall to writer . Pt also had a critical PT INR (test for blood clotting). Pain and critical lab reported to MD (Doctor). PRN (as needed) pain med administered. MD ordered xray and a hold for Anticoagulant . The facility did not notify R602's family or emergency contact. Review of a progress note with a date of 6/17/23 at 2:27 p.m., revealed, NP called back, stated to send pt to hospital. Writer notified DON 911 called by writer, awaiting arrival. In an interview on 9/18/23 at 1:18 p.m. Registered Nurse (RN) reported when a resident falls the nurse must, assess the resident, call the Dr., notify DON, and call the family. In an interview on 9/18/23 at 1:50 p.m. the NHA reported resident's emergency contacts should be called when there is a fall or change in condition. Review of a Change of Condition-Resident Family/Responsible Part Notification policy with a revised date of 4/12/2016 revealed, Family and/or responsible party are notified anytime there is a change in the resident's condition or plan of care . Procedure: 1. Notification of any change in the resident's condition will be done in a timely manner . Review of a Falls Reduction Program with a revised date of 9/25/16 revealed, . 3. If fall occurs Charge Nurse to complete the following: Physical assessment of resident and observation of environment. Immediate interventions as identified by physical assessment and environmental observation. Incident Report. Notify physician. Notify resident responsible party/family member .

Based on record review and interview the facility failed to consistently ensure the services of a Registered Nurse (RN) for eight consecutive hours per day, seven days per week, resulting in the potential for unmet care needs for all residents who reside in the facility. Findings include: Review of master schedules provided for Registered Nurse (RN) coverage for the past 60 days revealed, the facility did not have eight consecutive hours of RN coverage on the following days: Saturday: 6/10/23 Saturday: 6/24/23 Sunday: 6/25/23 Saturday: 7/1/23 Sunday: 7/2/23 Monday: 7/4/23 Sunday: 7/9/23 In an interview on 7/27/23 at 12:51 p.m., the Director of Nursing (DON) reported they did not have an RN everyday. The DON was unsure of why the facility did not have eight hour consecutive RN coverage. Regional Clinical Director (RCD) RN A reported the former Assistant Director of Nursing (ADON) was employed as the RN five days a week from 5/22/23 - 7/7/23. In an interview on 7/27/23 at 2:21 p.m., RCD A and MDS Nurse B acknowledged that there was not 8 hour RN coverage on 6/10, 6/24, 6/25, 7/1, 7/2, 7/4, and 7/9/23.

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility reach-in freezer which had the potential to affect all residents that eat from the kitchen. Findings include: During the initial tour of the kitchen on 7/24/2023 beginning at 8:54 AM with Dietary Manager (DM) F the internal temperature of the reach-in freezer was observed to be 20 F (Fahrenheit). A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. DM F said the temperature of the freezer should be zero or below. A review of a facility policy titled, Food Storage, received during the survey, documented in part the following, Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid . A review of the 2013 FDA Food Code revealed the following: - Section 3-501.11. Stored frozen foods shall be maintained frozen. - Section 4-501.11. Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. On 7/27/2023 at 3:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to follow-up with dental recommendation for one resident with Medicaid benefits (R34) reviewed for dental services resulting in R34 not having several broken/decayed teeth extracted and the potential for tooth pain, tooth abscess, and difficulty eating. Findings include: On 7/24/23 at 10:11 AM R34 was observed in a room seated on the bed with several visible broken and decayed teeth. During interview R34 pointed to the left side of his mouth and said he gets tooth pain now and again, but not at this time. R34 said he saw a dentist and, was supposed to get some teeth pulled, but don't know what happened with that. According to the Electronic Health Record (EHR) R34 was admitted to the facility with medicaid benefits and had multiple diagnoses that included impaired coordination after a hemorrhage of the brain and vascular dementia. The Minimum Data Set (MDS) dated [DATE] indicated R34 had intact cognition with a BIMS (brief interview for mental status) score of 13/15. R34 was identified to require supervision and set up assistance for personal hygiene. According to a Dental Summary Report on 12/2/22; Resident (R34) complained of tooth pain on left upper side. Several missing and broken teeth. Leaving a referral for extraction of root tips and broken teeth, then in the future, partial dentures. There was no further documentation to indicate that R34 had a follow up dental visit or tooth extractions. During an interview on 7/26/23 at 10:34 AM Social Worker (SW) H reviewed R34's EHR including the Dental Summary report and acknowledged that there was no follow up for R34's teeth extractions. SW H said she uploaded the Dental Summary but did not recall the Dentist telling her about the referral for R34's teeth extraction. They usually come in my office and tell me what outside referrals need to be made. SW H said she would set-up the dental referral for R34 today. On 7/26/23 at 11:03 AM the Director of Nursing (DON) said that R34 should have been followed up with a dental referral for extractions at this time. The Social Worker should have made the referral and followed up with the Dentist. According to the facility's Dental Services Policy (undated) in part, documented the following: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation 1. Oral health services are available to meet the resident's needs. 2. Routine and emergency dental services are provided to our residents through: ^ a. A contract agreement with a local dentist. b. Referral to the resident's personal dentist. c. Referral to community dentists; or d. Referral to other health care organizations that provide Dental Services. 13. Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview, and record review, the facility failed to ensure hypertensive medication (Carvedilol) was properly administered for one resident (R4), resulting in a medication being left at the bedside. Findings include: During an observation and interview on 7/24/2023 at 9:58 AM, Resident #4 (R4) was observed awake and in his room. A clear plastic medication cup containing a white pill was observed on R4's overbed table. R4 said he did not know what the pill was for but was waiting on breakfast to be served so that he would have some liquid available to take the pill. During an observation and interview on 7/24/2023 at 10:00 AM, Licensed Practical Nurse (LPN) G was shown the pill in R4's room and stated, He should not have it at his bedside. LPN G identified the pill as Carvedilol. A review of the Admission Record for R4 documented an admitted [DATE] with diagnoses that included end stage renal disease, diabetes mellitus-type 2, and hypertensive heart disease with heart failure. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of physician orders documented R4 was prescribed Carvedilol 25 mg, one tablet by mouth two times a day for hypertension. The prescribed times were 8:00 AM and 5:00 PM. A review of the facility's Admission Contract signed by R4 on 6/9/2023 revealed in the section titled, Self-Administration of Drugs, that R4 declined to self-administer his own medication(s). During an interview on 7/27/2023 at 12:37 PM, the Director of Nursing (DON) said nurses are supposed to stay with the resident until the resident swallows the medication. The nurse should have provided the resident with fluids for medication administration. On 7/27/2023 at 3:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to provide appropriate tracheostomy (surgical opening through the neck to help oxygen reach the lungs) care or have emergency supplies readily available for one resident (R57) reviewed for tracheostomy care resulting in the potential for inadequate oxygenation and respiratory infection. Findings include: On 7/24/23 at 9:33 AM, R57 was observed in bed with a tracheostomy (trach) collar (soft plastic mask that fits over and around the tracheostomy tube) secured around the neck with a T-bar (T- shaped) connecter attached to the trach. One end of the T-bar connector had corrugated tubing directly attached to an oxygen machine with humidification. The other end of the T- bar connecter had a blue cap over it. The trach collar indicated the inner canula was a size 6.5 mm (millimeter). A trach kit/box identification #6UN75H was taped on the wall inside a clear plastic bag with 'emergency trach' written on it. The 'emergency trach' box was opened and did not contain an inner canula tube. R57 was unable to be interviewed due to severe cognition impairment and did not display any signs of respiratory distress. At this time Licensed Practical Nurse (LPN) D entered the room and was asked about R57's tracheostomy. LPN D said she did not know what size R57's trach was. LPN D observed the opened 'emergency trach' kit and said there was another trach kit in the respiratory cart located next to the resident's bed. Upon inspection of the respiratory cart there was no additional trach kit with identification #6UN75H. There were several individual inner canula tracheostomy with identification #6IC75. LPN D said, I don't do trach care. Midnight shift does. I don't really know what type or size her R57's) trach is. I will notify the nurse manager and she can order more trach kits. On 7/25/23 at 8:57 AM R57 was observed in bed with a trach collar secured around the neck with the T-bar connected to the trach. One of end of T-bar was connected to an oxygen machine with humidification. The other end of the T-bar was open to air and did not have a blue cap over it. The resident coughed, and a small amount of white sputum came directly out of the opening that was not covered with a cap. An open suctioning kit with used equipment including gloves was sitting on the resident's over-bed table. R57 did not have signs of respiratory distress but was coughing intermittently. Licensed Practical Nurse (LPN) E was outside the room and was asked about the trach being directly open to air. LPN E said she was unsure how the trach and T-bar should look because midnight shift did trach care. At this time the Regional Clinical Director, Registered Nurse (RN) A came into the room and was asked about the trach tubing being directly open to air and used equipment being left out. RN A said there should be a cap covering the end of the T- bar. Observation of the respiratory cart did not reveal any caps to cover the end of the T-bar. RN A said she would ask the unit nurse manager. At 9:10 AM Nurse Manager, Licensed Practical Nurse (LPN) C and LPN E entered the resident's room along with RN A and a new trach tubing kit that contained a cap to cover the end of the T-bar. LPN C said that staff need to be trained on replenishing the respiratory cart and trach care. LPN C proceeded to remove the used suction kit and said, This should not have been left out like this. R57 started to cough at this time with a moderate amount of sputum coming into the trach tubing. LPN E opened a suctioning kit and proceeded to start suctioning R57. LPN E donned clean gloves placed a towel over the resident's chest and removed the inner canula of the trach. LPN E did not wash her hands, change gloves, or apply additional PPE (personal protective equipment) before she attempted to suction the resident. LPN E picked up the sterile suction catheter with dirty gloves and dragged it across the towel on the resident's chest preparing to insert the catheter into the resident's trach. RN A stopped LPN E from inserting the suction catheter and proceeded to explain infection control practices with suctioning a resident with a tracheostomy. According to R57's Electronic Health Record (EHR) R57 admitted to the facility with respiratory failure that required a tracheostomy for oxygenation. R57 had severely impaired cognition function and required total assistance for all Activities of Daily Living from staff. The physician's orders for R57 included a Shiley disposable trach with inner canula size 6.5 mm and trach care every shift as needed. On 7/26/23 at 1:52 PM R57 was observed up in a recliner chair with the trach collar secured around the neck with the T-bar connected to the trach. One of end of T-bar was connected to an oxygen machine with humidification. The other end of the T-bar was open to air with a blue cap over it. The resident had small amount of sputum in her trach tubing. RN A entered the room at this time and went through the respiratory cart to obtain a suction kit, to suction the resident. There were no suction kits in R57's respiratory cart. RN A asked unit manager LPN C about the suction kits. LPN C went through the respiratory cart and confirmed there were no suction kits. LPN C said she would obtain the suction kits from Central Supply and restock the respiratory cart. According to the facility's Tracheostomy Care policy last revised on 7/1/2008: Definition: Artificial opening into the trachea for the insertion of a tube to facilitate passage of air into the lungs or to evacuate secretions. Purpose: 1. To maintain a patent airway. 2. To evacuate secretions. 3. To prevent and/or reduce infection. Equipment: NOTE: TRACH KITS VARY FROM VENDOR TO VENDOR SO BECOME FAMILIAR WITH CONTENTS OF KIT PRIOR TO STARTING PROCEDURE TO ENSURE ALL SUPPLIES ARE AT THE BEDSIDE. 1. Suction machine or wall mounted suction. 2. Sterile suction catheter. 3. Connecting tubing. 4. Hydrogen Peroxide and Sterile Water may or may not be included in your kit 5. Sterile Gloves. 6. Scissors. 7. Plastic bag for waste. 8. Protective Equipment Disposable Face Shield, Gown NOTE: EMERGENCY TRACHEOSTOMY TUBE AND REINSERTION SUPPLIES, INCLUDING HEMOSTATS SHOULD BE AT BEDSIDE. RESUSCITATION BAG SHOULD BE AVAILABLE. Procedure: 3. Apply protective equipment 4. Open sterile catheter using aseptic technique. Suction tracheostomy tube using sterile technique if suctioning is indicated. 6. Wash hands and put on gloves

Based on observation, interview, and record review, the facility failed to ensure food items listed as always available were on hand to ensure resident food preferences were honored for one resident (R67) of one resident reviewed for food preferences, resulting in resident dissatisfaction with the dining experience. Findings include: During an interview on 7/25/2023 at 9:31 AM, Resident #67 (R67) was awake and sitting in his room. R67 stated, The food could be a whole lot better. I ordered a hot dog and chicken noodle soup, and they told me they didn't have any. A review of a document posted on an informational bulletin board on R67's housing unit during the survey was titled, Always Available Menu. The always available menu items included in part the following: hot dog, chicken tenders, chicken noodle soup, and tater tots. During an observation and interview on 7/25/2023 at 3:35 PM with Dietary Manager (DM) F, the following items were not in stock in the kitchen: chicken tenders, tater tots, and hot dogs. DM F stated the purpose of the always available menu items was so that if the residents don't want what's on the regular menu they can pick something up off the always available menu. These food items should always be available. A review of the Admission Record for R67 documented an initial admitted [DATE] and readmitted [DATE]. R67's diagnoses included atherosclerotic heart disease and hypertension. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment and supervision with set-up help only for eating. A review of physician's orders documented R67 was prescribed a regular diet of regular texture. On 7/27/2023 at 3:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to intake MI00130169. Based on interview and record review the facility failed to ensure a resident's picture was not posted on social media (sharing of information, ideas, interest, communication through use of technology) for one resident (R801) of six residents reviewed for abuse, resulting in the violation of privacy. Findings include: On 1/18/2023 at 9:30 A.M. review of the Facility Reported Incident (FRI) documented, On July 7, 2022, at 5:00 P.M. the Administrator received an anonymous call regarding a picture posted on Facebook of a resident's lower extremities, after having a large bowel movement. The anonymous caller identified an Agency staff employee, (Certified Nurse Aide [CNA] L) as the individual who took the picture and posted the picture on Facebook. The Administrator of the facility contacted the Director of the Staffing Agency and informed the Director of the information reported and the agency employee identified CNA L. The Director of the staffing agency interviewed CNA L (date and time unknown) concerning the posting of the resident's picture on Facebook. Initially CNA L denied posting the resident's picture. After a continuous conversation, CNA L admitted she shared this Facebook page with someone else. CNA L told the Agency Director the resident had been given a laxative and had a bowel movement. CNA L stated she immediately cleaned the resident up quickly and the picture did not show the resident's face. CNA L stated she did not mean any harm and took the posting down shortly after posting the picture. In a subsequent interview conducted by the Facility's Administrator, CNA L was asked, if she took a picture of one of the residents of the facility and put it on Facebook. CNA L responded yes. CNA L denied knowing the resident's name, room number and the time the picture was taken. When asked by the Administrator how long the picture was up CNA L replied not long, 2 minutes or so. CNA L was asked why, she would do something like that and replied, I do not know . On 1/18/23 at 11:00 A.M. review of CNA L (Inservice) Contractor Agreement signed 2/23/22, indicated the employee (had attended or read educational-in-service training) in the form of meeting or handouts for the following policies/procedures; HIPAA training, Abuse and neglect, Elder Justice Act, Caregiver Best practices in the Workplace. On 1/18/23 at 1:00 P.M. review of the Admission Record documented R801 was admitted to the facility on [DATE], with diagnoses that included: dementia w/o behavioral disturbance, non-traumatic intracranial hemorrhage, adjustment disorder with anxiety, acute embolism and thrombosis of the lower extremities and gastrostomy (tube inserted in stomach for providing nutrition). According to the Minimum Data Set, dated dated dated [DATE], R801 was moderately impaired in cognitive skills for daily decision making and required extensive assistance with Activities of Daily Living (ADLs). Review of the facility's policy titled, Cell Phone/Camera Equipment Devices, revised 7/20/15, documented in part; 1). Employee's personal camera-equipped, cell phones, smartphones and related devices are not permitted in resident care areas . No camera-equipped devices are to be taken into any restroom, exercise area, or shower facility at any time. 3). Any employee who takes pictures of resident/patients or employee without written consent will be terminated.

This citation pertains to Intake MI00129614. Based on interview and record review the facility failed to consistently monitor residents' Arteriovenous fistula (AV) {connection made with an artery and vein for dialysis access} for two residents (R810 and R811) of three residents reviewed for assessment and monitoring of dialysis access points, resulting in the potential of missed opportunities to assess dialysis access points for infection, bleeding, and functioning. Findings include: R810 Record review revealed R810 was admitted into the facility on [DATE] and readmitted on [DATE] with a pertinent diagnosis of end stage renal disease. Record review of Medication Administration Records dated December 2022 and January 2023 revealed no orders to monitor and assess R810's AV fistula in left arm. Record review of Physicians Orders dated December 2022 and January 2023 revealed no orders to monitor and assess R810's AV Fistula. Record review Clinical Assessment- Dialysis Communication Form ll dated from 12/01/22-1/10/23 revealed assessment and monitoring by nursing staff of R810's AV fistula only before visit to outside dialysis provider. Resident received dialysis on Mondays, Wednesdays, and Fridays. Record review of care plan Renal Insufficiency documented the following interventions: 1.Evaluate thrill and bruit (rumbling sound and sensation made by AV fistula that indicates proper functioning) every shift. Notify dialysis if absent. (Initiated 10/8/21). 2.Follow dialysis center direction for maintenance of fistula. (Initiated 10/8/21). R811 Record review revealed R811 was admitted into the facility on [DATE] and readmitted on [DATE] with a pertinent diagnosis of end stage renal disease. Record review of Medication Administration Records dated December 2022 and January 2023 revealed no orders to monitor and assess R811's AV fistula in left arm. Record review of Physicians Orders dated December 2022 and January 2023 revealed no orders to monitor and assess R811's AV Fistula. Record review of R811's Clinical Assessment- Dialysis Communication Form ll dated from 12/18/22-1/16/23 revealed assessment and monitoring by nursing staff of R811's AV fistula only before visit to outside dialysis provider. Resident received dialysis on Mondays, Wednesdays, and Fridays. Record review of care plan Renal Insufficiency documented the following interventions: 1.Monitor dialysis access for signs and symptoms of bleeding/infection. Notify doctor if present every shift Date Initiated: 04/06/2021 Revision on: 01/18/2023. During interview on 01/18/2023 at 2:56 PM with the Director of Nursing (DON) when asked, how often should residents with AV fistulas, AV grafts (artificial fistula) and dialysis catheters (device inserted to make a temporary dialysis access point) should be assessed and monitored by nursing, DON said, Residents should be monitored every shift. When asked the purpose of the assessment and monitoring of dialysis access points, DON said, They should be assessed and monitored to make sure there is no signs of infection or bleeding. When asked if AV fistulas and grafts should be assessed for thrill and bruit, DON said, Yes. After reviewing documents for R810 and R811, DON was asked if these residents were assessed and monitored daily, DON said, No. Record review of policy Dialysis/Hemodialysis (last revised 9/23/19) documented the following: 1.If Fistula Present- Assess daily for the thrill/bruit and monitor for s/s of infection. Document 2.If Perma-Cath (temporary access point) or other access device- Follow physician order for monitoring and-assessment.

Based on observation, interview, and record review, the facility failed to ensure food preparation and service equipment were adequately cleaned and allowed to air dry. This deficient practice had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During a return observation of the kitchen on 5/24/2022 at 2:45 PM, Dietary Aide (DA) M was observed using a cloth towel to hand dry cleaned and sanitized meal trays in the dish tank area and DA N was observed using a cloth towel to hand dry cleaned and sanitized pots and pans near the three-compartment sink. During an observation and interview on 5/24/2022 at 2:50 PM, Dietary Director (DD) I stated, I told them not to use (cloth) towels because of cross contamination. The cloth towel DA M used to hand dry the cleaned and sanitized meal trays was visibly stained. The cloth towel DA N used to hand dry cleaned and sanitized pots and pans was extremely soiled. DD I stated, Cross contamination occurs when dirty towels are used to wipe cleaned dishes. DD I acknowledged that the soiled towels were evidence the meal trays, pots, and pans had not been properly cleaned in the first place. During an interview on 5/26/2022 at 10:46 AM, Nutritionist Q stated, pots and pans always air dry. The (cloth) towel can cause bacteria to transfer from one pan to another. You want to avoid cross contamination, so you always air dry. A review of the facility policy titled, Sanitation, undated, was reviewed and documented, Food preparation equipment and utensils that are manually washed will be allowed to air dry. The 2013 FDA Food Code was reviewed and revealed the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and (b) may not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination, potentially affecting all residents in the facility consuming ice from the kitchen ice machine. Findings include: During the initial tour of the kitchen on 5/24/2022 at 9:00 AM with Dietary Director (DD) I, the drain line from the ice machine was observed lying on the floor drain. The ice machine was not equipped with the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line of the ice machine and the flood rim of the floor drain). When queried about the ice machine drain, DD I stated, That's how it was when I got here. During an interview on 5/26/2022 at 10:46 AM, Nutritionist Q stated, An air gap can prevent the contamination of water from the drain. The space is really important. During an interview on 5/26/2022 at 2:30 PM, DD I said the ice from the kitchen ice machine was used for ice carts and hydration stations for all the resident floors. The 2013 FDA Food Code was reviewed and revealed the following in Section 5-202.13 Backflow Prevention, Air Gap: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

This citation pertains to intakes: MI 3. Based on interview and record review, the facility failed to ensure that an allegation of staff to resident abuse (verbal and physical) was reported to the State Agency timely for one resident (R#277) resulting in the potential for additional abuse allegations to go unreported to the State Agency. Findings include: On 5/24/22 10:54 a.m., the facility reported investigation and other pertinent documentation regarding the reported incident that occurred on 9/29/21 at approximately 10 p.m. was reviewed. It was documented that on 9/30/21, R#277 reported to Social Worker S a staff member had cursed him out and called him 'a nasty mother****** after having a bowel movement. The Administrator was also contacted on 9/30/21 and informed of the allegation R#277 made. The Administrator also had a conversation with R#277 via telephone and reiterated the allegation. Nurse X provided a witness statement that documented going into the resident's room on 9/30/21 when the resident reported a nurse aide cursed at him, twisted his arm, and threatened him. The facility submitted the Incident Summary to the State Agency on 10/1/21 at 3:21 p.m. Review of the facility's face sheet documented R#277 was admitted into the facility on [DATE] and discharged from the facility on 1/23/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission Minimum Data Set assessment dated [DATE], R#277 had moderately impaired cognition (BIMS=9) and required total assistance with two persons with most activities of daily living. On 5/26/22 at 4:16 p.m. the Administrator was referred to the State Operating Manual, F-609 and to the facility's policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property dated 12/10/18 which documented: For the alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on interview and record review the facility failed to provide timely care and services ([MEDICATION NAME]-narcotic pain patch for the treatment of [REDACTED].#603) resulting in delayed treatment for [REDACTED]. Finding include: Record review revealed that R#603 was originally admitted into the facility on [DATE] and re-admitted on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was severely impaired and required total staff assistance for all activities of daily living. Review of the (MONTH) 2 and (MONTH) 3rd, 2019 nurses notes documented, Resident alert, non-verbal .alert, responds to verbal and tactile stimuli . Review of the clinical record documented the following: -Care Plan titled, I am at risk for pain related to multiple severe contractures of upper and lower extremities dated 5/21/19 with an intervention of Assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered meds .Medications as ordered. -physician's orders [REDACTED]. Apply one patch [MEDICATION NAME] (on the skin) one time a day every 3 days for pain and remove per schedule. -Medication Administration Record [REDACTED]. R#603 did not receive the ordered [MEDICATION NAME] Patch on 7/4/19, 7/7/19, 7/10/19 or 7/13/19 (missing a total of 4 doses). -Nurses Note dated 7/3/19 ( 2 days after last [MEDICATION NAME] Patch was applied) documented, Pharmacy recommendations .need C2 (written valid prescription for a controlled substance medication before it can be dispensed by the pharmacy) for [MEDICATION NAME] (alternate name for [MEDICATION NAME]) Patch . -An entry on the (MONTH) 2019 MAR indicated [REDACTED]. Review of the day, evening and night shifts 7/4/19 through 7/16/19 documented nurses signatures that a pain assessment was done, but there were no documented results of the performed pain assessments (for example: pain intensity, numeric rating scale, location, duration, aggravating factors, alleviating factors, facial expression, breathing patterns, moaning, non-verbal sounds, protective body moments, teeth clenching, etc.). -Physician's Note dated 7/11/19 (10 days after the last [MEDICATION NAME] Patch was applied) documented, .Patient appears to be in pain as assessed by staff nurse. She is started on [MEDICATION NAME](narcotic pain medication)/5-325 milligram (mg) 1 tablet every 4 hours for pain. She is non-verbal but non-verbal clues are used for pain assessment .Assessment: general pain, pain med's started/scheduled . -July 14, 2019 entry's on MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 7/18/19 at 2:56 PM, during an interview with the facility's Director of Nursing (DON) she was asked about the delay in pain medications for R#603. The DON explained that nursing staff were indicating on the MAR indicated [REDACTED]. The DON went on to say that the pharmacy need additional information on the C2 prescription, therefore the reason for not sending the medication. The DON stated, The nurses should have contacted the attending physician to get a 'bridge' medication (interim pain medication) put into place while awaiting for a corrected C2 form. The DON could not explain how a non-verbal resident was documented to have a documented pain level at a 5 and 8. Review of the facility's policy titled, Controlled Substance Medication Orders dated 5/16 documented, Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them .if unable to provide the written prescription in an emergency situation, the prescriber verbally communicates the order directly to the pharmacist for a limited quantity. Review of the facility's Pain Management policy dated 8/17/17 documented, Improve the quality of life for our residents by ensuring timely pain identification and interventions.

This citation pertains to Intake number MI 07. Based on observation, interview and record review the facility failed to ensure proper and safe transfer for one sampled resident (R#603) resulting in a displaced spiral fracture of shaft of right tibia (lower leg bone). Findings include: On 6/26/19 at 1:20 PM, R#603 was observed in bed with right lower extremity immobilized with a bandage wrap and elevated on a pillow. The resident stated, She broke my leg. She picked me up and and turned me from my wheelchair into the bed. She should have had help, but she did it herself. Record review revealed that R#603 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact and required extensive two person staff assistance with all transfers. Review of the Certified Nurse Assistant (CENA) care guide (a guide that helped the CENA provide individualized resident care) and a care plan titled, History of [MEDICAL CONDITIONS] with [MEDICAL CONDITION] dated 8/25/14 had an intervention of , I required Mechanical lift with 2 person assistance for all transfers. Review of the electronic progress notes documented the following: -6/6/19 Resident complained of (c/o) pain to right leg. Resident states when CENA was transferring her to bed she hit her right leg on the bed. Nurse Practitioner (NP) was in the building and venous doppler to lower extremity was ordered and Tylenol was given for pain. -6/7/19 Received doppler result, no [MEDICAL CONDITIONS] noted. -6/10/19 Resident continues to c/o pain to right leg, refused to be changed due to pain .new order for x-ray. -6/10/19 Nurse Practitioner note: Patient seen in bed c/o right leg pain .patient would not come out of bed due to the pain the nurse said .patient was assessed in bed and denied knee or ankle pain but was pointing to her calf which was warm and tender to touch. Patient appears to be in mild distress due to pain, at the time I was not aware of possible trauma to the leg. Doppler was ordered at that time to rule out [MEDICAL CONDITION]. -6/12/19 (6 days after initial complaint of pain) Nurse Practitioner note: Saw, examined and evaluated the patient today .c/o right leg pain. Stated that someone put her in bed that evening and it started hurting since. Right leg is tender to touch, warm with discoloration. She stated that her pain was 10/10. Patient would not get out of bed due to the pain .an x-ray was ordered which shows oblique [MEDICAL CONDITION] tibia. Patient was sent out to the hospital for further evaluation. On 6/26/19 at 2:00 PM, during an interview with the facility's Director of Nursing (DON) she was asked about the incident with R#603. The DON said The resident was assessed to require two staff assistance with transfers and the CENA assigned to her that night did the transfer alone. My expectation is that if another CENA is not available to help, then the nurse can help. Review of the facility's policy titled, Transfer Techniques dated 7/1/08 documented, Purpose: To transfer a resident from bed to chair, toilet or tub safely . General Instructions: 4. Obtain help when necessary, or as identified on care plan/care guide.

This citation has two deficient practices. Deficient practice number one: Based on observation, interview and record review the facility failed to ensure that adequate supervision and interventions to prevent falls were consistently implemented for one sampled resident (#708) of five residents whose falls were reviewed in a total sample of 19 resulting in a subdural hematoma when falling sideways off the toilet. Findings include: On 06/26/17 at 8:15 a.m., Resident #708 was observed seated behind the counter of the nursing station. A horizontal row of stitches were observed on the resident's forehead. Resident #708 moved the actively and pulled their arms inside their clothing. Resident #708 was confused on query and repeated statements on follow up questions. The CCC (clinical care coordinator) Nurse H for the floor was queried as the why the resident was behind the nursing station and why the stitches were placed and indicated the resident had a fall. The CCC also indicated on query Resident #708 had been declining but was staring more since the fall. On 06/27/17 at 9:29 a.m., the left brake of Resident #708's wheelchair was observed to be unlocked. Staff H was queried if both should be locked and stated, Yes. On 06/27/17 at 12:30 p.m., the clinical record for Resident #708 was and revealed: Resident #708 was admitted into the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated a decline in cognition since the MDS dated [DATE] with a BIM'S (brief interview of mental status) score of six out of 15 compared to seven out of 15 for the 11/25/16 MDS. A score of 0-7 indicates resident is severely impaired. Either MDS indicated the need for the extensive assist of one person for bed mobility, transfer, locomotion, hygiene, bathing and bowel and bladder needs. Each MDS also indicated Resident #708 was not steady on and off the toilet, not steady for surface to surface transfers nor from a seated to standing position and was not able to stabilize during these activities without human assistance. A I have been falling several times r/t Unaware of safety needs, gait balance problems, incontinence, Glaucoma, Hx (history) of falls. Please note that I do not use call light and think I can walk to BR (bathroom) on my own. I recently rolled out of bed, while asleep and sustained a laceration on my forehead. initiated on 05/31/16 and revised last on 06/27/17. The intervention were noted as bilateral floor mats initiated 06/23/17; Ensure I am wearing non skid foot wear when OOB (out of bed) initiated 05/31/16, revised but not changed 02/03/17 and 04/19/17; Offer toileting every two hours to avoid unassisted ambulation. Please do not leave me unsupervised when I am in the bathroom initiated 09/01/16 and revised 03/15/17, 03/30/17 and 04/19/17 (Please do not leave me unsupervised when I am in the bathroom was added 03/15/17); Offer toileting upon awakening, before/after meals and HS to avoid unassisted ambulation initiated 09/01/16 revised 03/30/17 to offer every two hours); Please keep me in a highly visible area while awake, initiated 02/03/17 and revised but not changed 6/06/17. On 06/28/17 at 1:30 p.m., a review of the identified fall reports for Resident #708 was completed and revealed the following falls for Resident #708: On 09/03/16 4:13 p.m., observed resident on floor on side of bed, resident stated she was trying to get in her bed, no injury. Predisposing situation factors: Footwear not in place. No witness found On 11/14/16 12:45 p.m., told that resident was observed on floor (in room), no injury. Predisposing situation factors: call light not used. No witness found On 12/14/17 8:54 p.m., resident on floor in front of bed, noted that there was a small cut in the resident's lateral side of the right eye brow, order to send to hospital. Predisposing situation factors: call light not used, ambulating without assistance. No witnesses found. On 02/22/17 6:50 a.m., notified that resident had just been observed on floor (in room), resident had loose stools and was attempting to clean self. No injuries. Predisposing situation factors: ambulating without assist. No witnesses found. On 03/07/17 3:26 p.m., Incident Location: Resident's Bathroom, resident was observed on floor, CNA (nurse aide) stated went to get towels and when came back resident was observed on floor. Resident stated 'I was trying to get off the couch.' No injuries noted. No witnesses found. On 03/29/17 11:48 p.m., (Resident #708) is on the floor. Resident stated, 'I slid down from the bed and my buttocks got in to floor.' No injuries noted. No witnesses found. On 04/10/17 8:17 a.m., observed on floor in bathroom by the toilet on her buttocks. Resident states, 'I was trying to go to the bathroom.' No injuries observed. No witnesses found. On 04/13/17 8:15 p.m., Observed lying on back on floor up against CNA (certified nursing assistant). 2 cm opening below right eyebrow. Actively bleeding. Blood stained bathroom floor. (CNA statement): ' .sat her on the toilet. As she was toileting I turned on the hot water to warm it up so I could complete care. I walked over to the bed (outside of bathroom) to grab the wash cloths, towel and gown also her brief I sat aside earlier. As I headed back into the bathroom pt (patient) fell to the floor sideways.' All CNA's on floor and available for assistance at time of incident. Nurse at station doing documentation. On 06/23/17 3:29 a.m., rolled OOB onto floor leaving a frontal lobe laceration approximately 1.5 inches long. Resident taken to hospital? Y(yes). No witnesses found. On 06/28/17 at 2:30 p.m. and 4:43 p.m., the DON (Director of Nursing) was queried about the falls for Resident #708 and in particular the falls on 03/07/17 and 04/13/17 were reviewed. The Falls assessment for the 03/07/17 fall indicated No new interventions at this time. The nurse progress note dated 04/13/17 8:43 p.m., was reviewed and revealed: At 7:25 p.m. nurse summoned to room by CNA. Observed pt lying on floor on her back up against CNA actively bleeding from a 2 cm laceration above eyebrow and 2 cm laceration below eyebrow unconscious. CNA states pt was being toileted and slid off toilet onto floor and hit her head. States pt was conscious before fall .called for transfer to hospital. The physician progress notes [REDACTED].#708) was readmitted to the facility after being hospitalized for [REDACTED]. The DON was queried if the expectation of the aide would be to provide care according to the care plan and stated, Yes. The DON was queried if the current intervention for the fall on 04/13/17, was not to leave Resident #708 in the bathroom unsupervised and stated, Yes. Correct. The DON noted Inservice related to the 04/13/17 incident was on Leaving resident unattended in the bathroom. The DON was asked if the aide should have put the call light on for assistance instead of going out of the bathroom and stated, Yes. The DON was also queried if leaving the bathroom and going to get towels from the bed (not with the resident in the bathroom) and turning ones back on the resident was considered leaving the resident unsupervised and stated, That's true. On 06/28/17 at 3:45 p.m., the facility policy titled, Falls Reduction Program with revised date of 09/25/26 revealed, Purpose: To provide a safe environment for residents, modify risk factors and reduce risk of fall related injury. 2. Implement and indicate individualized interventions on Care Plan/Kardex. Based on interview and record the facility failed to properly secure a bed bolster to the resident's bed for one sampled resident (#704) of 5 sampled residents reviewed for falls, in of a total sample of 19, resulting in the potential of an avoidable accident and injury from falls. Findings include: Review of the clinical record revealed that Resident #704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #601 severely impaired cognition and required extensive assistance with most activities of daily living. On 6/27/17 at 10:07 a.m., Resident #704 was observed in the bed lying down with the head of the bed elevated. Resident #704's bed was observed with a left and right bed bolster and fall mats. The right side bolster appeared to not be attached to the bed mattress. The bolster was hanging off the bed and the buckle was observed to not be fastened together. Further review of Resident #704 clinical record revealed the following Incident reports: 6/24/17, Incident Description: . upon entry observed resident laying on Right side on top of bolster next to bed. 6/9/17, Incident Description: . resident on right side of bed on floor mat sitting up, knees bent . 3/26/17, Incident Description: . observed resident lying on her left side on floor next to her bed with her right side bed bolster slightly off bed . On 6/27/17 at 10:15 a.m., during an interview, the Unit manager (UM) A was asked to observe the bed bolster and assess if the bolster was attached correctly. UM A said, No it's not on here correctly. It also should be down the mattress some. UM A was observed grabbing the bed bolster to adjust it, while doing that the bolster came off the bed. The straps of the bolster were observed to not be locked in place with the mattress. UM A said, They probably just finished feeding her and did not lock it back. On 6/27/17 at 11:26 a.m., during an interview, the Director of Nursing (DON) explained that the facility would be looking into it and doing an in-service. On 6/27/17 at 3:00 p.m., a review of the Manufactory Instructions titled Skill-Care Corporation Roll Control Bolster, Purpose: Roll Control Bolsters are designed to be used as positioning devices to support a resident on his/her side and to reduce the likelihood that resident will off the bed.

This Citation Pertains to MI 191 Based on record review, observation and interviews the facility failed to: 1) ensure adequate supervision and assistance to prevent falls in 1 of 3 sampled residents (#101) from a total sample of 7 residents reviewed for falls, resulting in a fractured hip to Resident #101, and 2) ensure sensor alarms were in working order for 4 of 7 residents (#104, #105, #106) resulting in one sampled resident #104 who had a history of [REDACTED].#105, and #106. Findings include: Resident #101 Resident #101 was admitted to the facility on [DATE], according to the facility face sheet with a medical history of [REDACTED]. According to the MDS (minimum data set) dated 2/24/12, Resident #101 was severely impaired for cognitive daily decision making skills, required extensive one person assistance with dressing, to transfer, walking in the hall and all activities of daily living, and was continent of both bowel and bladder. Resident #101 was observed and an interview was attempted on 6/6/12 at 9:45 AM. Present at the bedside of Resident #101 was the Psychologist who was making weekly rounds and not disturbed. Resident #101 was observed to be in a low bed, bilateral fall mats present and call light attached to her gown. Resident #101 appeared somewhat restless but stated "I'm OK". During an interview on 6/6/12 at 10:05 AM, Licensed Practical Nurse (LPN) #1 stated that she was working a double shift (3-11 p & 11-7 a) on 5/11/12 and Resident #101 fell prior to the end of the 3-11 p shift. LPN #1 stated that she had asked the 3-11 PM CNA (certified nursing assistant) to get Resident #101 ready and into bed prior to leaving at 11:30 PM. LPN #1 stated it was about 11:15 PM and she saw the CNA and Resident #101 go into the resident's room and heard the personal alarms go on and off while care was being given "I'm not sure if it was the wheelchair or bed alarm but the door was closed I knew someone was in there so I wasn't concerned at that time, it was 11:30 PM and I looked up and saw the afternoon CNA leaving and my midnight CNA coming off the elevator. CNA #11 began making rounds and immediately came and got me and told me Resident #101 was on the floor". LPN #1 added "I asked him later and he told me that she (Resident #101) didn't want me to do her so he placed Resident #101 fully clothed on the bed, with the nightgown unfolded to finish herself, I told him he had 3 choices 1: he was required to stay with the resident and observe or get a female to help him, 2: bring the resident back out to the nurses station and I would have had the midnight CNA put her to bed 3: he never told me she didn't want a male CNA to get her ready for bed. He did not communicate that in any way and just left without telling me anything. Also she had 2 alarms you stay with them to supervise and he didn't plain and simple plus he turned off the alarms, shut the door and left her alone, she was fully dressed the gown was unfolded still on the bed, she had to have been in the wheelchair when I went into the room that's where he left her not in bed, she was lying on the floor with her legs in a funny position under the wheel chair, I can't imagine how she could have done that without being in the wheelchair, she was complaining of pain and told me 'I think it's broke'". LPN #1 stated after assessing the resident she was placed in bed the physician was notified and x-ray done at the facility confirmed a fractured hip. Resident #101 was sent to the hospital for evaluation and treatment and returned to the facility on [DATE]. During a telephone interview on 6/7/12 at 7 PM, CNA #11 stated that when she arrived at 11:30 PM she immediately began making rounds and heard a noise and as she approached where it was coming from she got near Resident #101's door which was closed "I opened it and found Resident #101 on the floor banging the floor with her shoe, she was fully clothed telling me "my leg hurts I think it's broken". The alarms were not ringing and they were turned off, I was taught if they had alarms you stayed with them and she was not someone who could change clothes without help you had to be there". During an interview with Occupational Therapist #8 on 6/7/12 at 10:45 AM, she stated that Resident #101 last received therapy on 3/28/12 and was minimal assist meaning 1-25% of the work done has to be done for them. "For the CNA that would mean providing direction and assistance physically assisting the resident and not left alone to do it herself, yes she would need assistance". Review of the Facility fall risk assessment dated [DATE] for Resident #101 was classified at a score of 22 to be "moderate risk" for falls with score of 10 or more interventions should promptly be put in place. Review of the undated "Resident Care Guide" for Resident #104 revealed Oriented to person only, mental status varies, safety interventions: bed sensor and wheel chair sensor, personal hygiene assistance needs X 1. Attempts to reach the CNA involved were unsuccessful and no return call was received by the conclusion of this investigation. ( ) Resident #104 Resident #104 was admitted to the facility 12/9/2010 and according to the facility face sheet with a medical history of [REDACTED]. Resident #104 according to the facility MDS dated [DATE] was moderately impaired in cognitive daily decision making skills, required extensive one person assistance with ambulation, dressing, toileting and bathing. Balance during transition from moving from seated to standing position, walking, moving on and off the toilet and surface to surface transfers was not steady and only able to stabilize himself with staff assistance. Resident #104 was occasionally incontinent of both bowel and bladder. Review of the Facility Fall Risk assessment dated [DATE] Resident #104 was scored at 24 moderate risk "a score of 10 or more, interventions should be promptly be put in place". Review of the undated Facility "Resident Care Guide" revealed transfer assist X 1, safety interventions bed alarm, wheel chair alarm. Resident #104 was observed on 6/7/12 at 10:08 AM in his room working with the Speech Pathologist. While awaiting completion of the treatment session this Surveyor noted a wheel chair present with the alarm box light blinking. This surveyor sat in the wheel chair for 5 minutes prior to speaking with Resident #104 this surveyor stood from the wheel chair and the alarm did not ring. Lifting the wheel chair pad it was noted the wheel chair sensor pad was saturated in urine. Review of the Facility Nursing Notes dated 5/5/12 at 8 PM "resident up in wheel chair. Assisted resident from bed to wheel chair and resident was very weak in legs and could not stand on his own. Shortly after resident's wheel chair alarm sounded, CNA responded immediately resident was on floor has a cut on his left eye brow and scratch on top of his head, intervention is non skid foot wear". Review of Facility Nursing Notes dated 5/18/12 at 9 PM revealed: "resident observed on the floor by the entrance door to his room and hallway. New bed alarm pad obtained and installed on his bed". Review of Facility incident/accident reports for Resident #104 revealed two falls the first on 5/5/12 at 6:40 PM the only intervention initiated according to the report was non-skid foot wear. The section "items witnessed and in place at the time of event check all that apply" was blank. Supervisor/Manager's investigation dated 5/7/12 conclusion: "due to the resident's decreased muscle strength and tone to lower extremities Resident requires one person assistance with ambulation. Cognition diminishes his understanding of safety and physical limitation. Resident attempted to ambulate and was unsuccessful. IDT (interdisciplinary team) determined resident ambulating without non skid foot wear was a factor in the fall". Resident #104 sustained a cut above the left eye brow and cut on skull. Review of the facility "Investigation of Incident" dated 5/24/12 "in an interview with the nurse it was reported to writer that the resident's bed alarm had a crease in it and did not sound, although it was in position and indicator light was on". In the same investigative report with the PM Shift CNA "she also informed this writer that she checked the resident's bed alarm before he was assisted back to bed and observed a crease in the alarm pad. The alarm was on at the time but did not sound. She stated she removed the crease and the alarm sounded". Conclusion: Although the resident's alarm did not sound it is highly unlikely that the fall could have been prevented". Resident #104 suffered a fractured hip requiring surgical repair. Resident #105 Resident #105 was admitted to the facility on [DATE] and according to the facility face sheet with a medical history of [REDACTED]. According to the facility MDS dated [DATE] Resident #105 was severely impaired for cognitive daily decision making skills, rarely able to make herself understood or able to understand others, required extensive one person assistance to transfer, dress, toileting, personal hygiene and was totally dependent on staff to move about the unit. Review of the facility Nursing Notes dated 5/21/12 at 3:30 AM "resident observed on floor under bed with cover in hand on right side. Finding right side bruise on hip, back bilateral, right wrist swollen. Resident stated "call 911 I'm hurting". Sent resident to hospital to rule out fracture, bed alarm on and sounding". Review of facility Fall Risk assessment dated [DATE] Resident # 105 scored 18 "low risk "score of 10 or more, interventions should promptly be put in place". Review of the Facility "Unusual Occurrence" dated 5/21/12 at 3:30 AM "items witnessed and in place at time of event "bed alarm" was marked. Immediate interventions/prevention taken; bedside mat, low bed, bed bolsters. Review of the facility undated "Supervisor/manager's Investigation: Resident able to reposition and turn independently is unaware of spacial boundaries, IDT determined resident repositioned self in close proximity to the edge of the mattress. Distribution of resident's body weight resulted in resident being observed on the floor". Resident #105 was observed on 6/7/12 at 9:42 AM in a low bed with no gown lying on her right side in a fetal position both legs hanging off the bed feet touching bilateral fall mats. Noted hanging on the bed touching the floor was a sensor alarm box device. Noted on the alarm box were exposed wires with a blinking light and noted under the sheet was a visible sensor pad. The pad was wadded in a ball along side the resident, not under the resident. Staff Nurse LPN #6 was asked to check the sensor pad/alarm for function and lifted the resident off the mattress. No alarm rang when the resident was lifted off the mattress. Resident #106 Resident #106 was admitted to the facility 11/29/2007 and according to the facility face sheet with a medical history of [REDACTED]. Review of the Facility MDS dated [DATE] Resident # 106 was severely impaired in daily decision making skills, was usually able to understand others and to be understood, and required extensive assistance with all Activities of daily living. Review of the facility fall risk assessment dated [DATE] Resident # 106 scored 22 "moderate total score of 10 or more interventions should promptly be put in place". Review of the Facility Nursing Care Plan dated 8/3/11 "fall risk because of balance problems and poor coordination, poor posture. I lean forward in stooping position, have poor safety awareness, I rarely ask for assistance. Interventions: remind me about the wheel chair alarm are to be on at all times, low bed and bed bolsters dated 5/23/12". Resident #106 was randomly selected for wheel chair alarm function on 6/7/12 at 10:28 AM this surveyor was accompanied by Staff LPN #6 who stood Resident #106, no alarm rang when the resident was lifted off the seat. Noted on the alarm device box were exposed wires and the sensor pad was not located in close proximity to the resident's buttocks. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, IMPLEMENT, AND MONITOR INTERVENTIONS TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER FOR ONE (#505) AND PROMOTE HEALING FOR ONE (#504) RESIDENT OF FOUR RESIDENTS REVIEWED FOR PRESSURE ULCERS OF A TOTAL OF 19 SAMPLED RESIDENTS RESULTING IN THE DEVELOPMENT OF A PRESSURE ULCER CAUSED BY A FOLEY CATHETER (USED TO DRAIN URINE), AND AN INCREASE IN SIZE AND DEPTH OF A STAGE FOUR (IV) PRESSURE ULCER WITH A POTENTIAL FOR PAIN, INFECTION, AND PHYSICAL DECLINE. FINDINGS INCLUDE: ON 9/27/11 AT 10:40 A.M., RESIDENT #505 WAS OBSERVED IN BED ON HIS BACK WITH A FOLEY CATHETER INTACT AND DRAINING CLEAR, AMBER URINE. ON 9/28/11 AT 9:30 A.M., RESIDENT #505 WAS OBSERVED TO RECEIVE MORNING CARE FROM CERTIFIED NURSE ASSISTANTS (CNA) "D" AND "E". THE RESIDENT WAS POSITIONED ON HIS RIGHT SIDE WHEN CNA "D" BEGAN TO WIPE THE BACK OF RESIDENT #505'S RIGHT UPPER THIGH AND RIGHT GLUTEAL (BUTTOCK/FOLD) AREA. THE AREA WAS WIPED THREE TIMES. WITH EACH WIPE THE, THE RESIDENT STATED, "THAT HURTS". CNA "D" WAS QUERIED REGARDING THE AREA. OBSERVATION OF THE AREA REVEALED THE RESIDENT HAD A STAGE TWO( II) PRESSURE ULCER TO THE BACK OF HIS RIGHT THIGH SIMILAR IN SIZE AND SHAPE OF THE FOLEY CATHETER TUBING. THE CNA'S WERE ASKED IF THE RESIDENT RECEIVED THE OPENED AREA BECAUSE HE WAS LAYING ON THE CATHETER TUBING FOR A LONG PERIOD OF TIME, AND CNA "D" STATED, "YES, THAT IS WHAT HAPPENED". ON 9/28/11 AT 10:30 A.M., NURSE "C" OBSERVED RESIDENT #505'S RIGHT GLUTEAL FOLD AND UPPER THIGH AREA. NURSE "C" WAS QUERIED ABOUT THE PRESSURE ULCER AND STATED, "THEY (CNA') DID NOT TELL ME ANYTHING ABOUT IT." ON 9/28/11 AT 10:40 A.M., THE WOUND TREATMENT NURSE WAS QUERIED REGARDING ANY OPENED AREAS OR PRESSURE ULCERS ON RESIDENT #505. THE WOUND TREATMENT NURSE STATED THAT SHE WAS UNAWARE THAT RESIDENT #505 HAD ANY OPENED AREAS ON HIS BODY AND SHE COULD NOT EXPLAIN WHY NOTHING WAS NOTED ON THE "WEEKLY HYDRATION AND SKIN ASSESSMENT" SHEETS. AT 11:00 A.M., THE WOUND TREATMENT NURSE OBSERVED THE AREA ON RESIDENT #505 AND WAS QUERIED REGARDING THE AREA AND DESCRIBED IT AS BEING THE SAME SIZE AND SHAPE OF THE FOLEY CATHETER. ON 9/29/11 AT 2 P.M., THE WOUND CARE NURSE MEASURED THE OPENING AT THE RESIDENT'S RIGHT GLUTEAL FOLD AT FIVE CENTIMETERS (CM) IN LENGTH AND ONE CM IN WIDTH. THE DEPTH OF THE WOUND WAS CURVED AND SHALLOW. THE WOUND EDGES WERE PINK IN COLOR WITH RED IN THE MIDDLE. THE TREATMENT NURSE WAS QUERIED AND UNABLE TO EXPLAIN WHY THERE WAS NO DOCUMENTED EVIDENCE OF ANY SKIN CHANGES NOTED FOR RESIDENT #505. ON 9/27/11 AT 1:30 P.M., RESIDENT #505'S CLINICAL RECORD WAS REVIEWED AND REVEALED THE FOLLOWING: PER THE FACE SHEET THE RESIDENT WAS admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET ((MDS) dated [DATE], REVEALED THAT THE RESIDENT HAD MODERATELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S). THE INCONTINENCE ASSESSMENT, DATED 7/27/11, NOTED THAT RESIDENT #505 WAS admitted WITH A CATHETER. THE RESIDENT WAS assessed with [REDACTED]. PER THE ADMISSION CARE PLAN, DATED 7/27/11, INTERVENTIONS INCLUDED "CNA DAILY SKIN ASSESSMENT, NURSE WEEKLY SKIN ASSESSMENT". REVIEW OF THE CLINICAL RECORD REVEALED THAT THERE WERE NO NURSES NOTES TO REVIEW FOR THE MONTHS OF AUGUST THROUGH SEPTEMBER 27, 2011. REVIEW OF THE "WEEKLY HYDRATION AND SKIN ASSESSMENT" FOR THE MONTHS OF JULY, AUGUST AND SEPTEMBER 2011 REVEALED NO DOCUMENTATION REGARDING A PRESSURE ULCER OR ANY OPENED AREAS OR PRESSURE ULCERS TO THE RIGHT GLUTEAL FOLD FOR RESIDENT #505. PHYSICIAN ORDERS [REDACTED]. THE MOST RECENT SKIN assessment dated [DATE] REVEALED NO OPEN AREAS TO THE RIGHT GLUTEAL FOLD AND UPPER THIGH AREA. ON 9/29/11 AT 3:10 P.M., THE DIRECTOR OF NURSING (DON) WAS UNABLE TO EXPLAIN "HOW" THE RESIDENT DEVELOPED A PRESSURE ULCER AND "WHY" IT WAS NOT IDENTIFIED BY NURSING STAFF. THE DON WAS UNABLE TO EXPLAIN WHY THERE WERE NO PREVENTIVE MEASURES IN PLACE TO PREVENT PRESSURE ULCERS RELATED TO THE CATHETER TUBING. ON 9/30/11 AT 2:00 P.M. THE FACILITY POLICY ENTITLED, "WOUND MANAGEMENT PROGRAM" REVISED ON 6/3/10 WAS REVIEWED. THE POLICY DOCUMENTED THE FOLLOWING: "PURPOSE--TO ASSURE THAT THOSE RESIDENTS THAT ARE admitted WITH, OR ACQUIRE WOUNDS, RECEIVE THE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT COMPLICATIONS AND PREVENT NEW SKIN CONDITIONS FROM DEVELOPING". THE INTERVENTIONS INCLUDED, "CHARGE NURSES WILL COMPLETE A (FACILITY NAME) WEEKLY HYDRATION AND SKIN ASSESSMENT PER SCHEDULE". ON 9/27/11 AT 9:00 A.M., DURING THE INITIAL TOUR AND AT 12:25 P.M., 1:12 P.M., 2:15 P.M., AND 3;10 P.M., RESIDENT #504 WAS OBSERVED IN BED LAYING UPON A SPECIALTY MATTRESS THAT ALTERNATES THE AMOUNT OF AIR TO PERIODICALLY RELIEVE PRESSURE TO PARTS OF THE BODY AND WAS DESIGNED AS AN INTERVENTION TO TREAT INDIVIDUALS WITH PRESSURE ULCERS. THE SETTING ON THE MATTRESS INDICATED 165-199 LBS (POUNDS), WHICH REPRESENTED THE WEIGHT OF THE INDIVIDUAL USING THE SPECIALTY MATTRESS. ON 9/27/11 AT THE FOLLOWING TIMES; THE RESIDENT WAS LAYING IN BED WITH THE MATTRESS SETTING AT "165-199 LBS". ON 9/28/11 AT 8:45 A.M., RESIDENT #504 WAS OBSERVED IN BED WITH THE MATTRESS SETTING AT "165-199 LBS". ON 9/28/11 AT 11:08 A. M, THE WOUND CARE NURSE WAS QUERIED REGARDING THE CONDITION OF RESIDENT #504'S SACRAL PRESSURE ULCER. THE WOUND CARE NURSE SAID THE RESIDENT HAD BEEN USING THE ALTERING AIR LOSS MATTRESS FOR A NUMBER OF MONTHS, ADDING, "THE WOUNDS ARE BETTER... BUT HEALING REALLY SLOW". THE WOUND CARE NURSE WAS ASKED WHETHER THE SETTING OF THE MATTRESS INTERFERED WITH HEALING PROCESS AND SHE SAID, "YES. IT WON'T WORK LIKE IT SHOULD". THEN THE WOUND CARE NURSE OBSERVED THE MATTRESS SETTING FOR RESIDENT #504 TO BE ON 165-199 LBS AND WAS QUERIED IF IT WAS ON THE CORRECT SETTING. THE WOUND CARE NURSE STATED, "NO, IT SHOULD BE ON 120-164". THE WOUND CARE NURSE THEN CHANGED THE MATTRESS SETTING TO 120-164 LBS. WHEN ASKED THE WEIGHT OF THE RESIDENT, THE WOUND CARE NURSE REVIEWED THE CLINICAL RECORD. THE "WEIGHT RECORD" FOR THE YEAR 2011 DOCUMENTED RESIDENT #504'S WEIGHT FROM FEBRUARY 2011 THROUGH SEPTEMBER 2011 RANGED FROM 92.1 TO 96.2 LBS LBS. AT 11:15 A.M., THE WOUND TREATMENT NURSE RETURNED TO THE RESIDENT'S ROOM AND CHANGED THE MATTRESS SETTING TO 75-119 LBS. WHEN QUERIED IF THERE WAS A SYSTEM IN PLACE TO CHECK FOR THE CORRECT SETTING FOR MATTRESSES FOR THE RESIDENTS, THE WOUND CARE NURSE STATED, "NO, WE WILL HAVE TO PUT SOMETHING IN PLACE". ON 9/29/11 AT 10:15 A.M., THE WOUND TREATMENT NURSE PERFORMED A WOUND DRESSING CHANGE ON RESIDENT #504. CLEAR DRAINAGE WAS OBSERVED TO CONTINUOUSLY OOZE FROM THE WOUND SITE (SACRUM), MUSCLE WAS OBSERVED AS WELL AS SOME UNDERMINING. THE WOUND MEASURED AT 2.5 CM LONG, 1.8 CM IN WIDTH AND 1.0 CM IN DEPTH. THE WOUND WAS OBSERVED TO BE LARGER THAN WAS DOCUMENTED ON 7/18/11. RECORD REVIEW ON 9/29/11 AT 8:50 A.M., REVEALED RESIDENT #504 WAS REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE], DESCRIBED THE RESIDENT TO HAVE SEVERELY IMPAIRED COGNITION. THE RESIDENT REQUIRED TOTAL ASSISTANCE BY STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S). THE MDS DOCUMENTED THAT THE RESIDENT HAD A STAGE FOUR PRESSURE ULCER THAT MEASURED 3.0 CENTIMETERS (CM) IN LENGTH, 0.6 CM IN WIDTH AND 0.6 CM IN DEPTH. ON 9/29/11 AT 3:10 P.M., THE DIRECTOR OF NURSING (DON) OFFERED NO VERBAL EXPLANATION WHY THE SETTING OF THE MATTRESS WAS INCORRECT, OR AN EXPLANATION FOR THE INCREASE IN SIZE. ON 9/30/11 AT 2:00 P.M., THE FACILITY POLICY ENTITLED, "WOUND MANAGEMENT PROGRAM" REVISED ON 6/3/10 WAS REVIEWED. THE POLICY DOCUMENTED THE FOLLOWING: "PURPOSE: TO ASSURE THAT THOSE RESIDENTS THAT ARE admitted WITH, OR ACQUIRE WOUNDS, RECEIVE THE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT COMPLICATIONS AND PREVENT NEW SKIN CONDITIONS FROM DEVELOPING". ( )

THIS CITATION PERTAINS TO INTAKE # MI 000. FINDINGS: BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THE RESIDENT ' S RIGHT TO BE FREE FROM PHYSICAL ABUSE, IN 1 OF 4 SAMPLED RESIDENTS (# 101); RESULTING IN RESIDENT # 101 BEING HELD IN PLACE AND FORCED TO TAKE A SHOWER AGAINST THE RESIDENTS WISHES AND THE POTENTIAL FOR FUTURE MISTREATMENT WITH ASSOCIATED INJURY, PAIN, SUFFERING AND/OR EMOTIONAL DISTRESS. RESIDENT # 101: ACCORDING TO THE FACESHEET DATED 3/24/2010, RESIDENT # 101 HAS LIVED IN THE FACILITY SINCE 1/27/2010. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 101 WAS AN [AGE] year OLD FEMALE THAT WAS DEPENDANT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. ON 3/8/2011 AT 11:14 AM RESIDENT # 101 SAID THAT ON THE EVENING OF 1/19/2011 SHE HAD EXPLAINED TO THE CERTIFIED NURSE ASSISTANTS (CNA) THAT SHE DID NOT WANT A SHOWER. RESIDENT # 101 SAID THAT TWO NURSES CAME INTO HER ROOM AND FORCED HER TO SHOWER. RESIDENT # 101 SAID " ...I KEPT TELLING THEM THAT I DIDN'T WANT A SHOWER, I YELLED AT THEM AND YELLED FOR THEM TO LEAVE ME ALONE, BUT THEY JUST DID WHAT THEY WANTED ... " RESIDENT # 101 SAID THAT SHE WAS FORCED INTO A WHEELCHAIR AND TAKEN, SCREAMING, TO THE SHOWER ROOM WHERE AGAINST HER WILL SHE WAS DISROBED AND SHOWERED. RESIDENT # 101 SAID " ...I TOLD THEM ALL DON'T TOUCH ME ...THEY NEVER SHOULD HAVE DONE THAT TO ME ... " ON 3/8/2011 AT 11:14 AM CNA #1 SAID THAT ON THE EVENING OF 1/19/2011 SHE GOT OFF ELEVATOR AND HEARD RESIDENT # 101 YELLING THAT SHE DIDN'T WANT A SHOWER. CNA #1 SAID SHE WENT INTO THE SHOWER ROOM AND SAW LICENSED PRACTICAL NURSE (LPN) # 2 HOLDING RESIDENT # 101 ' S HANDS DOWN SO SHE COULDN ' T RESIST. CNA #1 SAID LPN # 1 TOLD RESIDENT # 101 YOU KNOW YOU NEED A SHOWER, LOOK HOW DIRTY YOU ARE. CNA #1 SAID RESIDENT # 101 KEPT SAYING I TOLD YOU I DON'T WANT A SHOWER. CNA #1 SAID SHE WENT AND CALLED THE ADMINISTRATOR TO HELP STOP THE ABUSE, BEFORE IT GOT WORSE. CNA #1 SAID " ...YOU CAN'T FORCE THEM (RESIDENTS) TO DO ANYTHING THEY DON'T WANT TO, THAT'S ABUSE, THEY SHOULDN'T HAVE ABUSED THAT LADY ... " ON 3/8/2011 AT 12:48 PM CNA # 3 SAID THAT ON THE EVENING OF 1/19/2011 SHE OFFERED RESIDENT # 101 A SHOWER SEVERAL TIMES. CNA #3 SAID THAT RESIDENT # 101 SAID THAT SHE DIDN'T WANT A SHOWER. CNA #3 SAID SHE THEN TOLD THE NURSE, LPN # 2. CNA # 3 SAID THAT LPN # 2 WENT INTO RESIDENT # 101 ' S ROOM. CNA #3 SAID THAT RESIDENT # 101 YELLED AT LPN # 2 AND TOLD HER THAT SHE DIDN'T WANT A SHOWER. CNA #3 SAID THAT LPN #2 THEN CALLED THE SUPERVISOR INTO THE ROOM. CNA #3 SAID THAT RESIDENT # 101 YELLED AT THE SUPERVISOR AND TOLD HER THAT SHE DIDN'T WANT A SHOWER. CNA #3 SAID SHE THEN WENT INTO ANOTHER RESIDENT'S ROOM TO HELP THEM. CNA #3 SAID THAT WHILE IN THE OTHER RESIDENT ' S ROOM SHE HEARD RESIDENT # 101 YELLING AND CURSING AT THE NURSES, BUT SHE COULDN'T LEAVE THE RESIDENT SHE WAS WITH TO HELP RESIDENT # 101. CNA #3 SAID RESIDENT # 101 TOLD THEM TO LEAVE HER ALONE. " ...SHE (RESIDENT # 101) WAS SCREAMING, THEY SHOULD NEVER HAVE TOUCHED HER. CNA #3 SAID RESIDENT # 101 WAS VERY UPSET AT THE TIME, AFTER THE SHOWER HER ARMS WERE RED AND THE NURSES WERE OUT OF BREATH. CNA #3 SAID RESIDENT # 101 SAID " ...YOU DON'T MAKE AN ADULT DO ANYTHING THEY DON'T WANT TO, YOU TREAT A DOG LIKE THAT NOT A PERSON ... " CNA #3 SAID RESIDENT # 101 STILL LOOKS AT STAFF LIKE SHE DOESN'T TRUST THEM. ON 3/8/2011 AT 12:12 PM LPN # 2 SAID SHE WAS NURSE IN CHARGE AND RESIDENT # 101 ON 1/19/2011 WHEN SHE REFUSED A SHOWER. LPN # 2 SAID RESIDENT # 101 HAD NOT HAD A SHOWER FOR SOME TIME. LPN # 2 SAID SHE TALKED TO RESIDENT # 101 AND EXPLAINED THE NEED FOR A SHOWER, SHE SAID SHE DID NOT WANT A SHOWER. LPN # 2 SAID RESIDENT # 101 TOLD HER " ...LEAVE ME ALONE, WHY ARE YOU PICKING ON ME ..." LPN # 2 SAID SHE CALLED HER SUPERVISOR, LPN 1. LPN # 2 SAID SHE SAW LPN # 1 PHYSICALLY MOVE RESIDENT # 101 INTO THE WHEELCHAIR. LPN # 2 SAID LPN # 1 INSTRUCTED HER TO HELP GIVE RESIDENT # 101 A SHOWER EVEN THOUGH SHE HAD REFUSED. LPN # 2 SAID RESIDENT # 101 WAS VERY UPSET AND AGAIN SAID SHE DID NOT WANT A SHOWER. LPN # 2 SAID RESIDENT # 101 WAS TAKEN TO THE SHOWER ROOM. LPN # 2 SAID RESIDENT # 101 WAS YELLING ALL THE WAY DOWN THE HALL AND INTO THE SHOWER. LPN # 2 SAID RESIDENT # 101 KEPT SAYING SHE DID NOT WANT A SHOWER, BUT THAT SHE AND LPN #1 HELD RESIDENT # 101 AND SHOWERED HER AGAINST HER WILL. LPN # 2 SAID RESIDENT # 101 WAS OBVIOUSLY " ...NOT HAPPY ... " LPN # 2 SAID LOOKING BACK SHE WOULD NEVER DO IT AGAIN, " ...I WOULD NEVER WANT TO ABUSE A RESIDENT ...I KNOW THE RESIDENTS HAVE THE RIGHT TO REFUSE CARE, BUT I WAS JUST DOING WHAT MY SUPERVISOR SAID ... " LPN # 2 SAID SHE KNEW THEY SHOULD HAVE NEVER HELD HER HANDS AND FORCIBLY CLEANED HER. LPN # 2 SAID SHE KNOWS THERE WERE OTHER OPTIONS THAT WE SHOULD HAVE CONSIDERED RATHER THAN FORCING THE RESIDENT TO SHOWER, BUT DID NOT. ON 3/8/2011 AT 11:35 AM THE ADMINISTRATOR SAID THAT ACCORDING TO HER INVESTIGATION, TWO NURSES IGNORED RESIDENT # 101 ' S RIGHT TO REFUSE CARE AND RESIDENT # 101 WAS FORCED INTO A SHOWER ROOM, HELD DOWN, OR HELD IN PLACE, FORCIBLY DISROBED AND FORCED TO BE SHOWERED. THE ADMINISTRATOR SAID THE ACTIONS OF THE TWO LPNS WAS WITNESSED BY FOUR OTHER STAFF MEMBERS. THE ADMINISTRATOR SAID " ...I WOULD SAY THAT HOLDING THE RESIDENT REACHES THE DEFINITION OF ABUSE ... " THE ADMINISTRATOR SAID RESIDENT # 101 SHOULD NOT HAVE BEEN HELD, OR FORCED TO HAVE A SHOWER, " ...WAITING ONE MORE DAY WOULD NOT HAVE HURT ANYTHING ... " ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 741 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#501) OF FOUR SAMPLED RESIDENTS, WHO WAS AT RISK FOR ABUSE, WAS FREE FROM PHYSICAL AND EMOTIONAL ABUSE BY STAFF RESULTING IN, RESIDENT #501 BEING PUSHED INTO THE WALL WHILE LYING IN BED WHICH FURTHER RESULTED IN INJURY TO RESIDENT #501'S RIGHT SHOULDER WITH SUBSEQUENT COMPLAINTS OF PAIN. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION SHEET, RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #501 HAD MODIFIED INDEPENDENCE WITH SOME DIFFICULTY IN NEW SITUATIONS ONLY. THE MDS FURTHER INDICATED THAT RESIDENT #501 HAD SHORT TERM MEMORY PROBLEMS, AND REQUIRED SUPERVISION TO LIMITED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, PERSONAL HYGIENE, BATHING AND TOILETING. A COMPLAINT ON FILE ALLEGED THAT A STAFF MEMBER THREW HIM (#501) INTO THE WALL WHEN PROVIDING CARE. THE FACILITY'S WRITTEN INVESTIGATION OF THIS MATTER, DATED 9/20/10, DOCUMENTED THAT APPROXIMATELY TWO WEEKS PRIOR, CNA #1 PUSHED RESIDENT #501 INTO THE WALL WHEN PROVIDING CARE. THE REPORT FURTHER DOCUMENTED THAT CNA #1 ASKED RESIDENT #501 TO TURN ON HIS RIGHT SIDE AS SHE WAS PROVIDING INCONTINENCE CARE. RESIDENT #501 COMPLIED. "...WHEN PROVIDING CARE, CNA #1 HIT HIS (#501) TESTICLES AND THIS WAS VERY PAINFUL. RESIDENT #501 FURTHER STATED THAT HE REACTED AND YELLED, "DON'T DO THAT". ACCORDING TO THE RESIDENT (#501), HE WAS THEN PUSHED AGAINST THE WALL. THE RESIDENT (#501) COMPLAINED OF PAIN IN THE RIGHT SHOULDER. X-RAYS WERE ORDERED..." A REVIEW OF CNA #1'S STATEMENT TAKEN AT THE TIME OF THE INVESTIGATION DOCUMENTED THE FOLLOWING: "...CNA #1 DID NOT RECALL ANY INCIDENT OF THE ONE DESCRIBED..." "...CNA #1 FURTHER STATED SHE DID RECALL HIM (#501) COMPLAINING ON ONE OCCASION THAT HIS TESTICLES WERE TENDER WHEN PROVIDING CARE ..." THE INVESTIGATION REPORT DOCUMENTED THAT RESIDENT #501 "...STATED TO WRITER THAT HE REPORTED THE INCIDENTS SHORTLY AFTER THEY OCCURRED BUT COULD NOT STATE WHO HE REPORTED THE OCCURRENCES TO..." "...RESIDENT #501 VERBALIZED THAT HE IS AFRAID FOR HIS SAFETY AND WELL-BEING..." ACCORDING TO THE FACILITY'S INVESTIGATION REPORT CONDUCTED WITH THE DIRECTOR OF SOCIAL SERVICES, DATED 9/20/10, "...RESIDENT #501 STATED THAT CNA #1 BECAME PHYSICAL TOWARD HIM, PUSHING HIM UP AGAINST THE WALL, NOW HIS SHOULDER HURTS ON THAT SIDE..." "...CNA #1 WIPED HIM FROM BEHIND AS HE LEANED TOWARD THE WALL SHE WIPED HIM ROUGH HURTING HIS TESTICLES AND HE SNATCHED BACK AND SAID "DON'T DO THAT ANY MORE AND SHE SHOULD HAVE KNOWN THAT THE WAY SHE WIPED ME HURT MY TESTICLES." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 9/20/10 REVEALED "...THERE IS NO EVIDENCE OF A FRACTURE..." ON 10/11/10 AT 12:27 P.M., DURING AN INTERVIEW WITH CNA #1, SHE REPORTED THAT RESIDENT #501'S BED IS DIRECTLY AGAINST THE WALL. WHEN QUERIED ABOUT RESIDENT #501 ALLEGEDLY BEING PUSHED AGAINST THE WALL AND INCONTINENT CARE WAS RENDERED, CNA #1 SAID "...I DID RUB HIS TESTICLES..." "...I WASN'T AWARE THAT THEY WERE SORE..." "...THERE IS A BIG POSSIBILITY THAT HE MADE CONTACT WITH THE WALL..." "...I DIDN'T USE ANY FORCE BUT IT'S POSSIBLE THAT I COULD'VE PUSHED HIM BUT I WASN'T AWARE IF I DID BECAUSE HE DIDN'T COMPLAIN..." ON 10/11/10 AT 2:57 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF SOCIAL SERVICES (STAFF #1), SHE REPORTED THAT SHE WAS INFORMED OF A "ROBE AND GOWN ISSUE BY THE DON". WHEN ASKED IF SHE ADDRESSED THE ALLEGATION OF ABUSE WITH RESIDENT #501, STAFF #1 SAID SHE WAS INSTRUCTED TO SPEAK WITH RESIDENT #501 IN ORDER TO SEE IF HIS STORY WOULD CHANGE FROM WHAT HE INITIALLY REPORTED. "...I ONLY SPOKE TO HIM (#501) ABOUT THE THINGS THE DON HAD TOLD ME..." "...I WASN'T AWARE OF ANY ABUSE..." ALTHOUGH THE DIRECTOR OF SOCIAL SERVICES (STAFF #1) DENIED ANY AWARENESS OF RESIDENT #501'S ALLEGATION OF ABUSE, (STAFF #1), THE FACILITY'S INVESTIGATION REPORT, DATED 9/20/10, REVEALED THAT RESIDENT #501 HAD REPORTED THIS ALLEGATION TO HER (STAFF #1) AND SHE IN TURN, ORDERED A PSYCHIATRIC EVALUATION. THE RESULTS OF THAT EVALUATION WERE OBSERVED IN RESIDENT 501'S CLINICAL RECORD. ON 10/11/10 AT 3:52 P.M., DURING AN INTERVIEW, NURSE #1 STATED: "...ABOUT TWO WEEKS AGO, CNA #1 INFORMED ME THAT HE (#501) DIDN'T WANT HER TO CARE FOR HIM ANYMORE..." NURSE #1 FURTHER STATED: "...I WENT IN HIS ROOM TO TALK TO HIM (#501) AND HE SAID THAT CNA #1 IS TOO ROUGH AND SHE HURT MY TESTICLES AND THREW ME AGAINST THE WALL..." "...HE SAID HE TOLD THE SOCIAL WORKER..." WHEN ASKED IF SHE REPORTED THIS INCIDENT, NURSE #1 SAID "...I WROTE A STATEMENT AND SLIPPED IT UNDER THE DOOR OF THE DIRECTOR OF NURSING'S (DON) DOOR..." WHEN ASKED IF SHE DOCUMENTED ANYTHING IN RESIDENT #501'S CLINICAL RECORD, NURSE #1 SAID "I JUST WROTE A NOTE TO THE DON BUT I DIDN'T DOCUMENT ANYTHING IN HIS (#501) CHART..." WHEN ASKED IF THE DOCTOR WAS NOTIFIED OF RESIDENT #501'S ALLEGATION OF ABUSE, NURSE #1 SAID "NO". THERE WAS NO DOCUMENTATION OF THIS EVENT IN RESIDENT #501'S CLINICAL RECORD AND THERE WAS NO DOCUMENTED EVIDENCE THAT THE DOCTOR HAD BEEN NOTIFIED OF THIS INCIDENT TO COME IN AND ASSESS RESIDENT #501 FOR COMPLAINTS OF TESTICLE OR RIGHT SHOULDER PAIN. ADDITIONALLY, THERE WAS NO CARE PLAN THAT ADDRESSED RESIDENT #501'S RIGHT SHOULDER PAIN IN ORDER TO DIRECT STAFF ON THE CARE TO BE PROVIDED FOR RESIDENT #501. REVIEW OF THE FACILITY'S ABUSE POLICY, UNDATED, DOCUMENTED THE FOLLOWING: "...IT IS THE POLICY OF THE FACILITY TO MAINTAIN AN ENVIRONMENT FREE OF ABUSE AND NEGLECT. THE RESIDENT HAD THE RIGHT TO BE FREE FROM VERBAL, SEXUAL, PHYSICAL AND MENTAL ABUSE, CORPORAL PUNISHMENT, AND INVOLUNTARY SECLUSION. RESIDENTS WILL NOT BE SUBJECTED TO ABUSE BY ANYONE INCLUDING, BUT NOT LIMITED TO, FACILITY STAFF, OTHER RESIDENTS, CONSULTANTS OR VOLUNTEERS, STAFF OR OTHER AGENCIES SERVING THE RESIDENT, FAMILY MEMBERS OR LEGAL GUARDIANS, FRIENDS OR OTHER INDIVIDUALS..."