Every finding on record at Westwood Nursing Center

This citation is based on Intake#2993239. Based on interview and record review, the facility failed to thoroughly investigate and elopement for one Resident (R304) of three reviewed for accidents. Findings include: A review of the medical record revealed that R304 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type; Delusional Disorder; and Post-Traumatic Stress Disorder (PTSD). The resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.Further review revealed that an Elopement Risk Assessment completed upon admission on [DATE] identified R304 as being at risk for elopement, with a score of five. Despite the identified risk, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk.A review of the facility's incident report revealed on 4/6/26 at approximately 12:00 a.m., R304 exited the facility through a second-story window and landed on the ground. The resident sustained injuries requiring emergency medical treatment and hospitalization. The report also revealed that staff reported to emergency services.The investigation did not document findings in regard to the resident's ability to exit through the second-story window without supervision and the window safety mechanisms and functionality.The investigation did not include documentation of interviews with all staff involved, an evaluation of environmental factors, or a determination of whether facility policies and procedures regarding elopement prevention were followed.During an interview on 5/26/26, the Assistant Director of Nursing (ADON) stated that an incident investigation was completed following the event. However, the ADON was unable to provide evidence that the investigation included an assessment of why interventions were not implemented despite the resident being identified as at risk for elopement upon admission.During an interview on 5/26/26, the Administrator stated that upon notification of the incident, he came to the facility and initiated the reporting process. The Administrator acknowledged that the focus of the investigation was primarily on documenting the occurrence and reporting requirements. Record review failed to identify evidence that the facility conducted a comprehensive root cause analysis to determine system failures that contributed to the incident or to identify measures necessary to prevent a similar occurrence in the future.Further review of the facility's investigation failed to identify corrective actions addressing the lack of a care plan, absence of elopement interventions, staff monitoring practices, environmental safety concerns, or accountability measures related to the resident's ability to exit through a second-story window.There was no additional information provided by the exit of survey

This citation pertains to intake #2993239. Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate safety interventions for one Resident (R304) of three residents reviewed for accidents, resulting in the resident to have jumped out of a two-story window, fracturing (breaking) their leg and required hospitalization. Findings include:Record review revealed the facility submitted an incident report to the State Agency (SA) which stated, in part, that at approximately midnight, Nurse C heard a noise and entered R304's room. Upon entering, Nurse C observed the resident climbing out of the window. Nurse C attempted to intervene; however, the resident jumped from the window and landed on his feet in the yard below. Nurse C instructed a Certified Nursing Assistant (CNA) to call for assistance while additional nursing staff responded to the scene. Emergency Medical Services (EMS) were contacted, and the resident was assessed. Pain and skin assessments were completed, neurological checks were initiated, and the physician and legal guardian were notified.A review of the medical record revealed that R304 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type; Delusional Disorder; and Post-Traumatic Stress Disorder (PTSD). The resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.Further record review revealed that an Elopement Risk Assessment completed upon admission on [DATE] identified R304 as being at risk for elopement, with a score of five. Despite the identified risk, the facility did not develop a care plan or implement interventions to address the resident's elopement risk.During an interview conducted on 5/26/26 at 1:21 p.m., the Assistant Director of Nursing (ADON) explained that upon admission, nursing staff complete an elopement assessment. The ADON stated that residents identified as high risk for elopement are typically placed on the memory care unit, which is a secured unit. The ADON further stated that social services and security personnel are notified of residents at risk for elopement and that a care plan with interventions should be developed and implemented. When asked about their involvement in the incident involving R304, the ADON stated that they were informed of the event by nursing staff and documented a progress note but did not have direct involvement in the incident itself.On 5/26/26 at 2:48 p.m., an interview was conducted with Nurse C. Nurse C reported that the shift had been uneventful and that R304 had been calm and cooperative throughout the evening. Nurse C stated that the resident was alert, oriented, cognitively intact, ambulatory, and able to move throughout the facility independently. According to Nurse C, the last direct observation of the resident occurred at approximately 10:00 p.m. during medication administration. At that time, the resident displayed no signs of distress and did not indicate any desire to leave the facility.Nurse C reported hearing glass break and immediately proceeded to the resident's room, where she observed the resident's foot at the window. She stated that the resident climbed out of the window and jumped, landing on his feet and sustaining injuries that required hospitalization. Nurse C reported that she immediately called for assistance from other staff members.When asked why she was unable to redirect or physically intervene before the resident jumped, despite observing the resident at the window, Nurse C stated that the incident occurred too quickly for her to prevent it.On 5/26/26 at 3:23 p.m., an interview was conducted with the Administrator and the ADON. The Administrator stated that he arrived at the facility after being notified that a resident had jumped from a window. Upon arrival, the resident had already been transported to the hospital. The Administrator stated that he initiated the facility's investigation and completed the required reporting to the State Agency. The Administrator further reported that, during a follow-up discussion with the physician several days later, he was informed that R304 had sustained fractures in three separate locations of the leg but was otherwise stable.When asked what interventions had been implemented for R304 following the admission assessment that identified the resident as being at risk for elopement, both the Administrator and ADON acknowledged that no care plan or interventions had been developed or implemented to address the resident's documented elopement risk.There was no additional information provided by the exit of survey

Based on observations, interviews, and record reviews, the facility failed to clean and maintain food service equipment affecting 102 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.Findings include:On 12/15/2025 at 9:00 A.M., An initial tour of the food service was conducted with Nursing Home Administrator NHA and Dietary Manager D. The following items were noted: Domestic hot water supply temperatures were monitored for 2 of 2 hand washing sinks, utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following hot water supply temperatures were recorded: Hand Sink #1: 80.0 - 90.0 degrees Fahrenheit; Hand Sink #2: 85.0 - 95.0 degrees Fahrenheit. The wall mounted paper towel dispensers were also observed non-functional for 2 of 2 hand washing sinks. The Fridgidaire stainless steel refrigerator interior appliance light bulb was observed missing. NHA stated: I will have maintenance replace the bulb. The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. The Fridgidaire stainless steel refrigerator interior appliance light bulb socket was observed loose-to-mount. The light bulb socket assembly was also observed dangling from the interior refrigerator ceiling surface. NHA stated: I will have maintenance repair the socket. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The [NAME] Beach microwave oven interior door face plate was observed (etched, scored, corroded, particulate). NHA stated: I will discard and replace the microwave oven. The 2022 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. The meat slicer was observed soiled with accumulated and encrusted food residue. The blade guard assembly was also observed soiled with accumulated and encrusted food residue. Dietary Manager D indicated she would have staff thoroughly clean and sanitize the meat slicer assembly as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Janitor Closet: 1 of 2 overhead U-bulb lights were observed non-functional. The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. Janitor Closet: The overhead light plastic lens cover was observed cracked and broken. The 2022 FDA Model Food Code section 6-202.11 states: coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) Shielded, coated, or otherwise shatter-resistant bulbs need not be used in areas used only for storing FOOD in unopened packages, if: (1) The integrity of the packages cannot be affected by broken glass falling onto them; and (2) The packages are capable of being cleaned of debris from broken bulbs before the packages are opened. (C) An infrared or other heat lamp shall be protected against breakage by a shield surrounding and extending beyond the bulb so that only the face of the bulb is exposed. Janitor Closet: One dead insect carcass was observed within the overhead light lens cover. The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. The mechanical dish machine pounds-per-square inch (PSI) gauge was observed non-functional during the final rinse cycle. NHA stated: I will have the gauge replaced. The 2022 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). On 12/18/2025 at 08:30 A.M., Record review of the Policy/Procedure entitled: Sanitation Inspection dated (no date) revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Inspection dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects.

Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant affecting 103 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include:On 12/15/2025 at 09:50 A.M., Three 6-inch by 6-inch [NAME] tiles were observed (cracked, broken, missing), within the facility entrance foyer. Nursing Home Administrator NHA stated: We can just fill the holes in with concrete. On 12/15/2025 at 11:03 A.M., An environmental tour of the facility Laundry Service was conducted with Nursing Home Administrator NHA. The following items were noted: Three of three commercial dryer enclosed fire box exteriors, safety shields, and flooring surfaces were observed soiled with accumulated and encrusted dust and lint deposits. NHA indicated he would have staff thoroughly clean behind the commercial dryers as soon as possible. The flooring surface, located directly behind the two commercial washers, was observed soiled with accumulated and encrusted dust, dirt, and debris (paper products, cloth products, etc.). NHA indicated he would have staff thoroughly clean and sanitize the flooring surface as soon as possible. The clean laundry room concrete flooring surface was observed (etched, scored, particulate). NHA indicated he would have maintenance clean and repaint the flooring surface as soon as possible. On 12/15/2025 at 11:20 A.M., An interview was conducted with Nursing Home Administrator NHA regarding the facility Director of Housekeeping and Laundry Services position. NHA stated: I let the person go about a month ago. On 12/15/2025 at 12:18 P.M., The 2-North Dining Room was observed unoccupied and cold. The two panel sliding glass door was also observed with air drafts protruding between the door panels. The two panel sliding glass door tracks were further observed severely soiled with accumulated and encrusted dust/dirt deposits. On 12/15/2025 at 12:33 P.M., The 2-North Dining Room triple panel window was observed covered with clear visqueen sheeting to assist with reducing cold air drafts protruding from the window. On 12/15/2025 at 12:45 P.M., The 1-North Dining Room was observed with four of five windows covered with clear visqueen sheeting to assist with reducing cold air drafts protruding from the windows. On 12/15/2025 at 1:00 P.M., Ten cushioned metal chairs, within the Memory Care Dining Room, were observed (etched, scored, particulate), exposing the inner Styrofoam padding. NHA stated: I will remove and replace the chairs. On 12/15/2025 at 2:25 P.M., The restroom flooring tile was observed cracked/broken, within Resident room [ROOM NUMBER]. The restroom flooring tile was further observed stained and heavily soiled, adjacent to the commode base. On 12/15/2025 at 2:30 P.M., The restroom hand sink paper towel dispenser was observed empty, adjacent to resident room [ROOM NUMBER]. Blue colored water was also observed pooling, within the bathtub drain assembly. On 12/15/2025 at 3:21 P.M., The 1 South Clean Linen Room was observed with three (cracked, broken, missing) vinyl flooring tiles measuring 12-inches-wide by 12-inches-long each. On 12/15/2025 at 3:26 P.M., The 2 South Clean Linen Room was observed with a soiled return-air-ventilation grill. Nursing Home Administrator NHA stated: The technician is coming to clean the vent now. The flooring surface, adjacent to the metal entrance door frame, was further observed severely soiled with accumulated and encrusted (dust, dirt, grime). On 12/15/2025 at 3:30 P.M., The 2nd Floor Soiled Utility Room was observed with open exposed plumbing pipes. One plumbing pipe was also observed dripping water slowly onto the flooring surface. On 12/15/2025 at 3:32 P.M., The 1st Floor Soiled Utility Room was observed with three uncapped plumbing pipes. The return-air-ventilation grill was also observed soiled with accumulated and encrusted dust/dirt deposits. The Laboratory Specimen Refrigerator was further observed resting upon a warped one-quarter inch piece of plywood. The plywood surface was additionally observed raised and splintered from previous moisture exposure. On 12/16/2025 at 8:52 A.M., An interview was conducted with Maintenance Supervisor F regarding domestic hot water temperature monitoring and domestic water supply flushing to reduce the risk of Legionellosis. Maintenance Supervisor F stated: I don't have any records for flushing the water. Maintenance Supervisor F also stated: I believe (Name of Nursing Home Administrator) has records in TELS. On 12/16/2025 at 9:20 A.M., The 1st Floor Shower Room wand assembly was observed missing an atmospheric vacuum breaker. The hand sink waste plumbing escutcheon was observed severely corroded. One purple vinyl glove was also observed pressed between the plumbing polyvinyl chloride (PVC) discharge pipe and wall hole perimeter. The entrance door interior was additionally observed (etched, scored, particulate). One acoustical ceiling tile was further observed moist from an active water leak. The metal entrance door slab was additionally observed scraping the tile flooring surface. On 12/16/2025 at 9:35 A.M., The smoking area North Exit Door was observed with daylight protruding into the facility. The opening measured approximately 2-inches-wide by 4-inches-long. The weatherstripping was also observed missing on the non-hinge side of the entrance/exit door. The opening measured approximately 0.50 -inch-wide by 36-inches-long. One small plastic cup was further observed placed into the lock assembly hole. One 12-inch-wide by 12-inch-long [NAME] wooden flooring panel was observed loose-to-mount, resting against the wall surface. On 12/16/2025 at 10:05 A.M., The Memory Care Staff Restroom was observed with the following items: (1) The commode tank top was observed missing. (2) The commode seat was also observed loose-to-mount. (3) 1 of 2 overhead lights were observed non-functional. (The operable overhead light assembly was also flickering). (4) The flooring drain metal plate cover was further observed loose-to-mount. On 12/16/2025 at 10:20 A.M., The 2nd Floor Shower Room was observed with the following items: (1) Four 10-inch-wide by 12-inch-long ceramic wall tiles were observed missing, adjacent to the shower control assembly. (2) One of three overhead light assemblies were observed non-functional. (3) The white wall mounted ceramic towel rack was observed missing the crossbar. (4) The ceramic wall tile was also observed with duct tape adhered to a false cover plate. (5) Two ceramic flooring tiles were further observed missing. (6) Special Note: A very strong medicinal odor was also observed permeating throughout the shower room atmosphere. On 12/16/2025 at 11:50 A.M., The 2-North Bath/Shower Room entrance door was observed with a space between the metal threshold plate and ceramic tile flooring surface. The dimensions of the empty space measured approximately 2-inches-wide by 36-inches-long by 1-inch-deep. On 12/16/2025 at 12:39 P.M., An interview was conducted with Nursing Home Administrator NHA regarding the facility maintenance work order system. NHA stated: We have TELS for maintenance tracking. NHA also stated: We have not payed our bill to date. NHA further stated: We are currently in arrears for $8,000.00. NHA additionally stated: The TELS system is currently down due to non-payment. On 12/16/2025 at 12:41 P.M., An interview was conducted with Nursing Home Administrator NHA regarding the domestic hot water supply boiler mixing valve. NHA stated: Mechanical Heating and Cooling will be here today around 4:00 p.m. - 6:00 p.m. On 12/16/2025 at 3:42 P.M., The 2-North Dining Room table surfaces (1 of 9) were observed (etched, scored, stained, particulate). On 12/16/2025 at 3:49 P.M., The 1st Floor Dining Room table surfaces (7 of 10) were observed (etched, scored, stained, particulate). Special Note: Detailed environmental cleaning (housekeeping) and maintenance services are needed for the following: (1) Hallway flooring corners and wall/floor junctures were observed severely soiled and black in color. (2) Numerous resident room radiant heat covers were observed missing. (3) Air gaps were observed between window mounted resident room Air Conditioning Units and window/wall surfaces. (4) Door slabs, walls, ceilings, and door frames were observed (etched, scored, particulate), needing cleaning and repainting. On 12/18/2025 at 10:00 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated (no date) revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. On 12/18/2025 at 10:15 A.M., Record review of the Policy/Procedure entitled: Maintenance Inspection dated (no date) revealed under Policy: It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 12/18/2025 at 10:30 A.M., Record review of the Policy/Procedure entitled: Safe and Homelike Environment dated (no date) revealed under Policy: In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk.

Based on observations, interviews, and record reviews, the facility failed to: (1) provide sufficient domestic hot water supply, and (2) provide appropriate ambient room temperatures affecting 103 residents, resulting in the increased likelihood for resident discomfort.Findings include:On 12/15/2025 at 9:00 A.M., An initial tour of the food service was conducted with Nursing Home Administrator NHA and Dietary Manager D. The following items were noted: Domestic hot water supply temperatures were monitored for 2 of 2 hand washing sinks, utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following hot water supply temperatures were recorded: Hand Sink #1: 80.0 - 90.0 degrees Fahrenheit; Hand Sink #2: 85.0 - 95.0 degrees Fahrenheit. On 12/15/2025 at 12:18 P.M., The 2-North Dining Room was observed unoccupied with a cool/cold ambient air temperature. Note: Residents were also observed seated at bedside tables awaiting their lunch meal, within the adjacent hallway corridor outside of the 2-North Dining Room. The two panel sliding glass door was also observed with air drafts protruding between the door panels. On 12/15/2025 at 12:30 P.M., The 2-North Dining Room ambient air temperature was monitored utilizing an ETEKCITY Lasergrip model 1080 infrared thermometer. The following ambient air temperature range was recorded, within the 2-North Dining Room: 61.0 - 68.0 degrees Fahrenheit. On 12/15/2025 at 12:33 P.M., The 2-North Dining Room triple panel window was observed covered with clear visqueen sheeting to assist with reducing cold air drafts from the window. On 12/15/2025 at 12:45 P.M., The 1-North Dining Room ambient air temperature was monitored utilizing an ETEKCITY Lasergrip model 1080 infrared thermometer. The following ambient air temperature range was recorded, within the 1-North Dining Room: 65.0 - 70.8 degrees Fahrenheit. Four of five dining room windows were also observed with clear visqueen sheeting to assist with reducing cold air drafts from the windows. On 12/15/2025 at 12:47 P.M., An interview was conducted with Resident #49 regarding dining room ambient air temperatures. Resident #49 stated: I am freezing. On 12/15/2025 at 12:50 P.M., Ambient air temperatures were monitored within Resident room [ROOM NUMBER] utilizing an ETEKCITY Lasergrip model 1080 infrared thermometer. The following ambient air temperature range was recorded: 68-70 degrees Fahrenheit. On 12/15/2025 at 1:10 P.M., Ambient air temperatures were monitored within the Memory Care Dining Room utilizing an ETEKCITY Lasergrip model 1080 infrared thermometer. The following ambient air temperature range was recorded: 68.0 - 70.0 degrees Fahrenheit. The lower range temperature was captured within a 7-feet-wide by 18-feet-long section, adjacent to the television set. On 12/16/2025 at 12:41 P.M., An interview was conducted with Nursing Home Administrator NHA regarding the domestic hot water supply boiler mixing valve. NHA stated: Mechanical Heating and Cooling will be here today around 4:00 p.m. - 6:00 p.m. On 12/15/2025 at 2:21 P.M., Domestic hot water supply temperatures were monitored, within Resident room [ROOM NUMBER], utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following restroom hand sink hot water temperature was recorded: 89.9 degrees Fahrenheit. On 12/15/2025 at 2:30 P.M., The restroom hand sink hot water temperature was monitored, adjacent to resident room [ROOM NUMBER], utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperature was recorded: 85.0 degrees Fahrenheit. On 12/15/2025 at 2:40 P.M., The restroom hand sink hot water temperature was monitored, adjacent to resident room [ROOM NUMBER], utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following domestic hot water temperature was recorded: 73.7 degrees Fahrenheit. On 12/16/2025 at 9:16 AM The 2-North Dining Room ambient air temperatures were monitored utilizing an ETEKCITY lasergrip model 1080 infrared thermometer. The following temperature range was recorded: 67-71 degrees Fahrenheit. On 12/16/2025 at 9:55 A.M., The first floor Main Dining Room ambient room air temperatures were monitored utilizing an ETEKCITY model 1080 infrared thermometer. The following temperature range was recorded: 66-71 degrees Fahrenheit. On 12/16/2025 at 10:05 A.M., The Memory Care Staff Restroom hand sink domestic hot water supply was monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following hot water temperature was recorded: 80.7 degrees Fahrenheit. On 12/16/2025 at 10:20 A.M., The 2nd Floor Shower Room hand sink domestic hot water temperature was monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following temperature was recorded: 79.8 degrees Fahrenheit. Appendix PP states at F584: S483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- S483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. S483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 F. On 12/18/2025 at 9:00 A.M., Record review of the Policy/Procedure entitled: Safe Water Temperatures dated (no date) revealed under Policy: It is the policy of this facility to maintain appropriate water temperatures is resident care areas. Record review of the Policy/Procedure entitled: Safe Water Temperatures dated (no date) further revealed under Policy Explanation and Compliance Guidelines: (4) Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperature (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. (5) Water temperatures will be set to a temperature of no more than (blank) degrees Fahrenheit (blank) degrees Centigrade, or the state's allowable maximum water temperature. (7) Documentation of testing will be maintained for 3 years and kept in the maintenance office.

Based on observation, interview, and record review, the facility failed to develop and implement a discharge plan of care for one (R66) of six residents reviewed for discharge planning. Findings include: On 12/15/2025 at 9:18 AM, R66 was observed in her room and interviewed. R66 said she was supposed to be discharged from the facility, but no one had come to talk to her about the process. R66 stated, I was only supposed to be at the facility for short term rehabilitation. During the conversation R66 became tearful and anxious. Record review of R66's Electronic Health Record (EHR) revealed she was admitted on [DATE] with pertinent diagnoses of fracture of left fibula, hypertension, cognitive communication deficit, dementia, hypothyroidism, and anemia. The EHR revealed the residents' most recent admission date of 10/28/2025. The resident had a court-appointed guardian. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11 - indicative of mild cognitive impairment. The MDS also revealed the resident needed partial/moderate assistance with most Activities of Daily Living (ADL's). Record review revealed R66 did not have a discharge plan of care initiated or social work progress notes related to discharge goals or planning. On 12/17/2025 at approximately 11:00 AM, Social Services Director (SSD) A was interviewed regarding R66's discharge plan and said the resident was planning on returning to their group home after therapy. When asked if there was a discharge plan of care initiated for R66, SSD A was unable to provide evidence of a discharge plan of care. During an interview with the Nursing Home Administrator (NHA) on 12/18/2025 at approximately 9:00 AM, the NHA reported that discharge planning starts on day one of admission and that discharge goals and planning is initiated by the social services department. In addition, it was their expectation that a discharge plan of care be initiated and part of the medical record. A review of the facility policy titled, Comprehensive Care Plans dated 6/18/2025, revealed the following: 3- The comprehensive care plan will describe, at a minimum, the following: . d. The resident's goals for admission, desired outcomes, and preferences for future discharge; and e. Discharge plans, as appropriate.

This citation pertains to Intake MI00150156. Based on interview and record review, the facility failed to ensure appropriate information was communicated to the receiving hospital for one resident (R105) out of five residents reviewed for transfer. Findings include: It was reported to the State Agency that the facility failed to transfer a resident to the hospital with pertinent medical information. An anonymous complainant reported that the EMTs (Emergency Medical Technicians) that transported R105 to the hospital were only provided a piece of copy paper with the resident's name, date of birth, physician's name, and facility's medical record number for the resident written on it. A review of the clinical record for R105 documented an initial admitted [DATE] and readmission on 1/14/25. R105's diagnoses included dementia, unspecified psychosis, and delusional disorders. A Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment. A review of progress notes documented in part the following: - 2/9/25 at 9:09 PM. Transfer to hospital summary: Patient was transported to hospital per doctor order for abscess on left upper back. Patient was transported by ambulance on stretcher with two ems staff. Patient family member were notified. - 2/9/25 at 11:02 PM. Patient returned from hospital after upper back abscess drainage and packed with gauze. Patient was assessed .Patient is prescribed Bactrim DS (double strength) 800mg-160mg bid (twice daily) for 7 days. Patient Doctor and family member were notified. call light within patient reach and bed in low position. Staff monitor patient. On 2/20/25 at 12:16 PM, Unit Manager, Licensed Practical Nurse (LPN) D said when a resident is transferred to the hospital a transfer (eINTERACT) form should be completed. This form is given to the receiving institution because it includes proper information to ensure there is no lapse in service. On 2/20/25 at 12:55 PM, Unit Manager, LPN E said prior to transferring a resident to the hospital, if it's not an emergency, the nurse should gather information. The nurse is to use the eINTERACT form to document the resident's information. This form is printed and sent with the resident along with the face sheet and medication list. On 2/20/25 at 2:02 PM, the Acting Director of Nursing (ADON) said the procedure for transferring a resident to the hospital, in a non-emergency situation, included the completion of the eINTERACT form and sending it to the hospital with the resident along with the resident's face sheet and copy of the resident's medication list. The ADON reviewed R105's clinical record and confirmed there was no transfer form (eINTERACT) completed regarding R105's transfer to the hospital on 2/9/25. The ADON could not provide documentation to support the receiving hospital had received any information about the resident's transfer. On 2/20/25 at 3:25 PM, the Nursing Home Administrator (NHA) said the facility should send resident information to the hospital. A review of the policy titled, Transfer and Discharge, dated 2025, documented in part the following: For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: - Contact information of the practitioner who was responsible for the care of the resident; - Resident representative information, including contact information; - Advance directive information; - All other information necessary to meet the resident's needs, which includes, but may not be limited to: -- Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; Diagnoses and allergies; Medications (including when last received); and Most recent relevant labs, other diagnostic tests, and recent immunizations. - All special instructions and/or precautions for ongoing care, as appropriate such as: Transmission-based precautions such as contact, droplet, or airborne; - All other information necessary to meet the resident's needs, which includes, but may not be limited to: Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; Diagnoses and allergies; Medications (including when last received). - For a transfer to another provider, ensure necessary information (as listed above) is provided along with, or as part of, the facility's transfer form. On 2/20/25 at approximately 4:20 PM during the exit conference, the NHA had nothing else to add or provide pertaining to this deficient practice.

Based on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed. Findings include: On 10/08/24 at 3:36 PM the facility's back-up box designated for controlled drugs was observed to have a red plastic lock on it. There was no medication log or any documentation to record what medications were in the back-up box. There was no reconciliation log to determine receipt of, administration of, or disposition of any medication in the medication room. The interim Director of Nursing, Registered Nurse C was present during the observation of the back-up box. RN C said, We don't have a reconciliation log. It was accidentally locked inside this medication cart and nobody knows where the keys are. RN C pointed to a locked medication cart that was inside the medication storage room next to the back-up box. RN C left the room to get the current Director of Nursing (DON). At approximately 3:45 PM the current DON entered the medication room and confirmed there was no reconciliation log for any of the controlled drugs in the back-up box. The DON said, I just got here and there was no lock on the back-up box. I just put the red plastic lock on it before you came in here. I can't determine what medications have been taken out or administered at this time. I have no idea if there are discrepancies. Both RN C and the DON acknowledged that there was no way to determine what medications have been removed from the back-up box. Neither RN C or the DON could determine how long the medication cart had been locked without a key. RN C found some pharmacy slips that were illegible. There was no way to determine resident's name, the drug removed from the back-up box or which nurse removed the drug. On 10/9/24 at 9:03 AM the facility's back-up box for controlled drugs was observed to have a green plastic lock on it. There was no reconciliation log. The medication cart inside the medication room remained locked without ability to open it. There were no pharmacy slips or receipt that pharmacy had delivered medications to the facility. The DON was present and during interview could not determine if pharmacy had delivered any medications to the facility. The number to the facility's pharmacy was requested. On 10/8/24 at 9:30 AM and 3:30 PM the pharmacy number was called and a message was left requesting a return call. There was no return call from the facility's pharmacy prior to the end of the survey. According to the facility's Medication Storage policy (undated) read in part: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 2. Narcotics and Controlled Substances: a. Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. b. Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. c. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators. a. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies.

Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was completed and sent to the local state agency for an evaluation for a Level II determination for one (R1) of six residents reviewed for PASSARs, resulting in R1 not being screened for mental disorder or intellectual disability care needs and the potential for R1's care needs being unmet. Findings include: According to R1's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included bipolar disorder and schizophrenia. R1 admitted with the following psychoactive medications prescribed: - Duloxetine 60 mg (milligrams) QD (every day) for depression. - Sertraline 50 mg QD for obsessive compulsive disorder and depression. On 9/4/24 the Social Work (SW) progress notes documented the resident admitted with bipolar disorder, schizophrenia, and was prescribed psychotropic medications. There was no PAS/ARR DCH-3877 form in the resident's EHR. There was no documented evidence that R1 was screened for MI/ID or related conditions health care needs. There was no documented evidence that R1 was evaluated for a Level ll determination of MI/ID health care needs. On 10/09/24 at 11:26 AM Social Worker (SW) B reviewed R1's EHR and confirmed there was no DCH-3877 form. SW B said, It was missed. No we don't have one. The hospital did one and the resident may be exempt. SW B reported that R1 was going to be discharged back to her group home, but there were no progress notes to indicate R1 had discharge planning in progress. On 10/9/24 at 12:45 PM SW B presented a paper copy DCH-3877 form for R1 that indicated the resident had hospital exemption criteria. The form was incomplete and did not include a physician name, address, phone number, or physician signature. SW B presented a second paper copy DCH-3877 form for R1 that indicated a level l screening had occurred a the facility on 8/30/24. The form was incomplete and did not include the clinician's signature, address, or phone number. According to the facility's policy for Behavioral Health Service last revised on 7/8/24 in part reads; It is the policy of this facility that all residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. 2. The facility utilizes a comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes: . b. PASSAR screening.

Based on observation, interview, and record review, the facility failed to apply hand splinting as ordered for two (R18 amd R81) of five residents reviewed for Range of Motion (ROM), resulting in a potential loss of ROM to dependent residents with known contractures and the potential for decline in overall health status. Findings include: R18 On 10/08/24 at 9:54 AM, R18 was observed in the hallway propelling their wheelchair with their left hand. R18's right hand fingers were curled into the palm. R18 was asked if they could open their right hand and they said, No. I had a stroke and my fingers are stuck this way. R18 was asked if they had a splint and the resident said, They (staff) don't always put it (splint) on. On 10/09/2024 AM at 08:46 AM, R18 was observed in their room sitting in a wheelchair. R18's right hand was wrapped with a white kerlix dressing while holding an Adaptive utensil. R18 was asked why their hand was wrapped. R18 said it wrapped so that they could hold their fork. A review of R18's electronic medical records noted readmission of 1/19/2024 with the diagnosis of Hemiplegia and Hemiparesis (hemiplegia is a severe or complete loss of strength, while hemiparesis is a relatively mild loss of strength) following a Cerebral Infarct (cerebral infarction occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Congestive Heart Failure (occurs when the heart can't pump enough blood to meet the body's needs), Anxiety, Glaucoma (eye Condition), Muscle Wasting (the decrease in size and wasting of muscle tissue), Stiffness of right elbow, Right Hand Contracture (the decrease in size and wasting of muscle tissue), and Type II Diabetes. R18's Brief Interview for Mental Status (BIMS) noted a score of 10 out of 15 that indicated a moderate cognitive impairment dated 7/30/2024. R18's Minimum Data Set (MDS) noted the resident required substantial/Maximum assistance with Activity of Daily Living. A review on R18's care plan noted the following, I have a right-hand contracture .Goal-To prevent further contracture in (their) right hand while maintaining ROM and flexibility .Interventions-Apply right hand splint palm protector every day .Notify Physician of refusals. R18's electronic medical records did not indicate the R18's refusal of wearing a splint. A review of R18's Occupational Therapy documentation noted a goal of the following: Patient will safely wear right hand resting hand splint during daily tasks .Dated 5/14/2024. A review of R18's electronic medical record indicated Order Details of: Restorative Nursing: To manage and wear splint every day for joint mobility .Dated 10/03/2024. R81 On 10/08/24 at 09:51 AM, R81 was observed in bed with their eyes closed. R81 did not answer to their name being called. R81 was wearing a gown. There was a wheelchair next to R81's bed. R81 was not wearing a splint. On 10/08/24 at 11:05 AM, in bed with eyes closed. R81 was asked how they were doing. R81 said, I'm alright. R18's right hand fingers were curled into their palm R81 was not wearing a splint. On 10/09/2024 at 09:10 AM, R81 was observed watching TV. R81 asked if they could open their hand and responded no. R81 asked if they wore a splint on their right hand and arm which they responded no. The Resident's right arm was slightly bent upward toward their chest at the elbow joint, and R18's right hand fingers remained curled into their palm. On 10/09/24 at 11:00 AM, R81 was observed in bed, receiving a bed bath. After their bath, Certified Nurse Assistant did not apply R81's splint. Certified Nurse Assistant (CNA) D was asked they were going to apply R81's splint. CNA D looked in the drawers and closet and said it was not in (R81) room and they would check with therapy. A review of R81's electronic medical records noted readmission of 5/14/2024 with the diagnosis of Renal Calculous, Chronic Fatigue, Heart Disease, Myocardial Infarct (heart attack), Kidney Failure, Depression, Hemiplegia and Hemiparesis (hemiplegia is a severe or complete loss of strength, while hemiparesis is a relatively mild loss of strength) following a Cerebral Infarct (cerebral infarction occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it.), Cerebrovascular Disease (stroke), and Muscle weakness. R18's Brief Interview for Mental Status (BIMS) noted a score of 10 out of 15 that indicated a moderate cognitive impairment dated 8/21/2024. R81's The Minimum Data Set (MDS) noted the resident required substantial/Maximum assistance with Activity of Daily Living. A review of the electronic medical record noted Order Details of: Restorative Nursing: To manage Contractures, Resident to donn (sic) right hand resting hand splint and right elbow extension splint everyday .Dated 06/10/2024 A review of R81's Occupational Therapy documentation noted a goal of the following: Patient will tolerate R [right] elbow extension splint .Patient will tolerate right resting hand splint .dated 08/15/2024 On 10/10/2024 at 11:14 AM, the Therapy Manager E was interviewed and asked about R18 and R81's ordered splints, and he said, They are both supposed to wear splints. On 10/10/2024 at 2:12 PM, the facility Nursing Home Administrator (NHA) was interviewed regarding expectations for staff applying ordered splints to residents with known contractors. The Administrator stated, We expect staff to apply the residents' ordered splints. A review of the facility's policy entitled, Restorative Nursing Programs dated October 2023 noted, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .3. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to .e. Assisting residents in adjustment to their disabilities and use of any assistive devices.

This citation pertains to Intake MI00143461. Based on interview and record review, the facility failed to ensure resident's medical record accurately documented the administration of prescribed medications for one resident (R101) out of three residents reviewed for medical record documentation, resulting in the potential for staff and providers lacking accurate information to care for the resident. Findings include: A review of the Admission Record for Resident #101 (R101) documented an initial admission into the facility on [DATE]. R101's clinical record documented multiple readmissions and discharges, including a readmission on 1/9/24 with a discharge on 1/27/24, a readmission on 2/20/24 with a discharge on 3/20/24, and finally a readmission on 3/23/24 with a discharge on 3/28/24. R101's diagnoses included foreign body of alimentary tract, unspecified intestinal obstruction, specified eating disorder, non-suicidal self-harm, schizoaffective disorder, anxiety disorder, and bipolar disorder. A Minimum Data Set (MDS) dated [DATE] documented intact cognition. On 3/28/24 at 4:45 PM, an interview and record review were conducted with the Assistant Director of Nursing (ADON) and MDS Coordinator, Licensed Practical Nurse (LPN) I. A review of R101's Medication Administration Record (MAR) for March 2024 revealed the following: 1. An order for one 50 mg tablet of Briviact (used for seizure disorder) given twice daily at 9:00 AM and 9:00 PM was entered on the March 2024 MAR twice. Nursing documented that 50 mg of Briviact was administered twice at 9:00 AM from 3/1/24 through 3/10/24 and twice at 9:00 PM on 3/2/24, 3/3/24, 3/5/24, and 3/8/24. 2. An order for one 500 mg tablet of metformin (used for blood sugar management) given twice daily at 9:00 AM and 9 PM was entered on the March 2024 MAR twice. Nursing documented that 500 mg of metformin was given twice at 9:00 AM from 3/1/24 through 3/11/24 and twice at 9:00 PM on 3/2/24, 3/3/24, 3/5/24, 3/6/24, and 3/8/24. 3. An order for 50 mg topiramate (use for seizure disorder) given twice daily at 9:00 AM and 9:00 PM was entered on R101's March 2024 MAR twice. Nursing documented that 50 mg of topiramate was administered twice at 9:00 AM on 3/1/24 through 3/11/24 and twice at 9:00 PM on 3/2/24, 3/3/24, 3/5/24, 3/6/24, and 3/8/24. 4. An order for 40 mg pantoprazole sodium (used for gastroesophageal reflux) given at 9:00 AM was entered on R101's March MAR twice. Nursing documented that 40 mg pantoprazole sodium was administered twice at 9:00 AM on 3/1/24 through 3/19/24. The ADON and LPN I said when R101 was readmitted to the facility on [DATE], and the previous medication orders had not been discontinued, nursing should have discontinued the old orders, verified the new orders, and put the new orders in. If there were any questions about the medications, the doctor should have been called for clarification. This is a standard of practice for nursing. During an interview on 3/29/24 at approximately 8:45 AM, MDS Coordinator, Registered Nurse (RN) J said when a resident goes to the hospital and does not return within 24 hours, the resident's medications should be discontinued by nursing. A review of the facility policy titled, Documentation in Medical Record, dated 1/29/24, revealed in part the following: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. A review of the facility policy titled, Medication Administration, dated 1/29/24, revealed in part the following: Correct any discrepancies and report to nurse manager. On 3/29/24 at 11:15 AM during the exit conference, the Nursing Home Administrator was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observation, interview, and record review, the facility failed to repair an unattached closet door for one resident (R905) of three residents reviewed for environment, resulting in resident dissatisfaction with the living environment and concern over protection of personal belongings. Findings Include: On 3/7/24 at 10:10 AM, R905 was observed pointing at the closet door reserved for R905's belongings. The door was off the hinges and in front of the open closet. The closet items were visible. R905 expressed unhappiness with the condition of the closet door and the exposure of personal belongings. The resident said having the door unattached was upsetting because anyone could come inside the room and see and take personal belongings. The resident stated My Coca Cola was taken. R905 also said the door had been in this condition since his admission, date of, 1/15/24 (over two months). Review of the clinical record of R905 admitted [DATE] according to the MDS (Minimum Data Set) dated 1/22/24 documents that resident has intact cognition. Resident is able to make all needs known independently. On 3/7/24 at 10:50 AM, LPN (Licensed Practical Nurse) B was asked about the condition of the door. LPN B explained she had not noticed R905's closet door was missing. LPN B acknowledged that R905 should have a functional door for the closet. On 3/7/24 at 3:40 p.m. the Nursing Home Administrator (NHA) was interviewed and said daily rounds are made by the Maintenance Supervisor. The facility is working to get (Tels) back. Maintenance does not have a check list to use for repairs needed. We are currently working on replacing furniture however I was unaware of the closet prior to today. On 3/7/24 at 4:30 PM the Maintenance/Services Log Sheet was reviewed for dates 2/24/24 - 3/8/24. There was no entry for the broken closet door in R905's room. Review of the facility policy titled, Accommodation of Needs dated January 2024 states in part, The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.

This citation pertains to intakes MI142286 and MI141954. Based on observation, interview, and record review, the facility failed to maintain a clean bathroom and comfortable water temperatures for one resident (R902) and failed to maintain a clean bathtub (in a tub room commonly used by residents for toileting) to include R905, resulting in dissatisfaction with facility cleanliness and resident comfort. Findings Include: On 3/7/24 at 10:10 AM R905, was interviewed and expressed dissatisfaction with the cleanliness of the facility, specifically mentioning the tub room, I won't go in there now. Review of the clinical record of R905 admitted [DATE] according to the MDS (MDS (Minimum Data Set) dated 1/22/24 documented that resident has intact cognition. Resident is able to make all needs known independently. On 3/27/24 at 10:25 AM, an observation of the tub room revealed a dry dark green, thick substance covering the area just above the drain for an area approximately the size of a dollar bill and extending side to side across the entire surface of that section of the tub. Splattered dark green areas and streaks of of dark green and brown splatter were observed throughout the tub extending top to bottom. On 3/7/24 at 10:59 AM, Housekeeper E was queried about the condition of the tub. During the observation of the tub Housekeeper E said the tub had been in the stained and uncleaned condition at least two weeks. Housekeeper E said attempts had been made to scrape the substance off. On 3/7/24 at 11:17 AM the Maintenance Supervisor (MS) A said the condition of the tub had been unknown to the department of maintenance. On 3/7/24 at 3:40 p.m. the Nursing Home Administrator (NHA) was interviewed and said daily rounds are made by the Maintenance Supervisor and Housekeeping Supervisor. The NHA added that Housekeeping has a check list they are to utilize for cleaning. 38230 R902 On 3/7/24 at 9:37 a.m., a complaint that was submitted to the state agency's complaint hotline on 1/8/24 at 16:55 (4:55 pm) was reviewed. The complainant who was also the resident (R902) alleged the facility did not have hot water and was not clean. Review of the clinical record documented R902 was admitted into the facility on [DATE] and discharged from the facility on 12/28/23. According to admission MDS assessment dated [DATE], R902 was cognitively intact and required supervision with ADLs. On 3/7/24 at 11:59 p.m., the bathroom sink in room [ROOM NUMBER] was observed with a single handle sink fixture. When the fixture was turned on, it was loose at the base. The hot water was turned on and ran with a low stream. The longer the water ran, the slower the stream became to nearly a slow drip. The water did not get warm. The cold water was turned on and ran with a steady stream. Further observation of the bathroom revealed dried, dark-colored solid material on the seat of the toilet. There was also a painted shelf-like board over the top of the toilet that was unevenly cut and exposed ragged edges. The wall near the base board had missing patches of paint. On 3/7/24 at 12:09 p.m. the binder for maintenance work orders was located at the nurse's station. There were no entries in the binder for room [ROOM NUMBER]. Review of the document titled Maintenance/Environmental Services Log Sheet for the month of December 2023 did not document a work order or repairs in room [ROOM NUMBER]. On 3/7/24 at 3:05 p.m. Maintenance Supervisor A was interviewed about the bathroom's disrepair and said maintenance rounds are completely every morning. The facility no longer utilizes the electronic maintenance data base (Tels) that would notify when repairs are required for residents. Maintenance Supervisor A acknowledged the bathroom water in room [ROOM NUMBER] should not have a slow drip, should be running, and supplying hot water along with the other general repairs. On 3/7/24 at 3:40 p.m. the Nursing Home Administrator (NHA) was interviewed and said daily rounds are made by the Maintenance Supervisor. The facility is working to get (Tels) back. Maintenance does not have a check list to use for repairs needed. The facility's policy titled Environmental Services Safety Procedures dated January 2024 was reviewed but did not document daily maintenance procedures.

This citation pertains to intake MI00140622. Based on interview and record review the facility failed to inform the resident representative for R901 of a change in condition out of three residents reviewed for hospitalization , resulting in R901's representative being unaware of a change in condition and transfer to the hospital. Findings Include: During an interview on 11/15/23 at 12:45 PM with Concerned Family Member A, it was reported that R901 was sent to the hospital on 10/22/23 and the facility did not make the family aware. Record review of Nursing Progress Notes dated 10/22/23 noted the following: Writer spoke with Dr (name redacted), regarding resident having diarrhea, and decreased appetite, patient is malaise (with discomfort). Resident stated he feels very ill. Resident requested to go to hospital. Dr (name redacted) gave order to send resident out, ADON (Assistant Director of Nursing) notified. Further record review revealed no documentation that a resident representative was made aware of the resident's change in condition and transfer to the hospital. Review of R901's face sheet revealed resident was admitted into the facility on [DATE] with a diagnosis of transient paralysis (part of the body's muscle control comes and goes periodically). According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and required extensive assistance with Activities of Daily Living (ADLS). During an interview on 11/15/23 at 1:15 PM, R901 verbalized that it was expected that the facility would have called a family member when he was sent to the hospital. In an interview on 11/15/23 at 2:45 PM, the Director of Nursing reported that nursing staff did not contact family when R901 went out to the hospital on 10/22/23. In an interview with the Nursing Home Administrator on 11/15/2023 2:50 PM, it was reported when a resident has a change in condition and is transferred to the hospital a resident representative should be informed. Record review of policy Notification of Change (no date) noted the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

This citation pertains to Intake MI00133617. Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively maintain the food production kitchen physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 08/28/23 at 06:57 A.M., An initial tour of the food service was conducted with Registered Dietetic Technician (DTR) C and Dietary Cook F. The following items were noted: The #1 hand wash sink hot and cold-water supplies were observed switched. The hot water supply was observed on the right-hand side and the cold-water supply was observed on the left-hand side. The cold-water supply should be on the right-hand side and the hot water supply should be on the left-hand side of the faucet assembly respectively. The #2 hand wash sink was observed with two actuation knobs, one for cold water and one for hot water. The Registered Dietetic Technician (DTR) C stated: The cold water combines with the hot water. Registered Dietetic Technician (DTR) C further stated: The cold-water valve is shut off. Cooks Sink: The faucet assembly was observed leaking water from the spout. The 2017 FDA Model Food Code section 5-201.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The #1 hand wash sink was also observed loose-to-mount. The distance between the hand sink basin and the wall surface was observed to be approximately 0.5-1.0 inches. The #1 hand wash sink caulking bead, located between the wall surface and sink was also observed heavily soiled, stained, and separated from the hand wash sink backsplash. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The Unit #5 Freezer was observed with accumulated ice-[NAME]. Registered Dietetic Technician (DTR) C stated: We need to defrost the unit. The South Bend convection oven interior and exterior surfaces were observed heavily soiled with food residue. The South Bend Select oven exteriors were observed heavily soiled with food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Refrigerator/Freezer Room: The return-air ventilation grill, located directly above Unit #8 Freezer, was observed heavily soiled with accumulated dust and dirt deposits. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. Forty 6 by 6 [NAME] tiles were observed cracked and/or missing, adjacent to the Dietary Manager's Office. Twenty 6 by 6 [NAME] tiles were observed cracked and/or missing, adjacent to the mechanical dish machine. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair 6 eight-foot-long fluorescent T12 light bulbs were observed missing from 3 overhead light fixtures, within the food production kitchen. Dry Storage Room: 5 of 8 four-foot-long fluorescent T8 light bulbs were observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. 16 eight-foot-long fluorescent T12 light bulbs were observed missing protective plastic sleeves and end caps, within the food production kitchen. One eight-foot-long fluorescent T12 light bulb was observed missing 2 end caps, within the food production kitchen. Dry Storage Room: 6 end caps were observed missing on the overhead light assemblies. The 2017 FDA Model Food Code section 6-202.11 states: (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) Shielded, coated, or otherwise shatter-resistant bulbs need not be used in areas used only for storing FOOD in unopened packages, if: (1) The integrity of the packages cannot be affected by broken glass falling onto them; and (2) The packages are capable of being cleaned of debris from broken bulbs before the packages are opened. (C) An infrared or other heat lamp shall be protected against breakage by a shield surrounding and extending beyond the bulb so that only the face of the bulb is exposed. The ice machine was observed impaired producing minimal amounts of ice. Registered Dietetic Technician (DTR) C stated: The parts are on backorder. Register Dietetic Technician (DTR) C further stated: We are currently purchasing ice from our supplier. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. The Dietary Manager's Office metal entrance door frame was observed heavily corroded and particulate. The metal door frame was also observed completely disintegrated approximately 10-12 inches from the flooring surface on both sides of the frame. The fresh air supply grill, located adjacent to the food production tray line, was observed heavily corroded and missing the center deflector plate. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. Janitor Closet: The mop sink basin was observed soiled with dirt and grime deposits. Registered Dietetic Technician (DTR) C stated: We will clean the mop sink and organize the room. The 2017 FDA Model Food Code section 4-602.13 states: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 08/30/23 at 12:45 P.M., Record review of the Policy/Procedure entitled: Sanitation Policy dated 01/2023 revealed under Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Record review of the Policy/Procedure entitled: Sanitation Policy dated 01/2023 further revealed under Policy Explanation and Compliance Guidelines: (1) All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects. On 08/30/23 at 01:00 P.M., Record review of the Policy/Procedure entitled: Sanitation dated 01/2023 revealed under Policy: Sanitation is monitored on a regular basis. Record review of the Policy/Procedure entitled: Sanitation dated 01/2023 further revealed under Purpose: To provide an overview of sanitation and identify areas needing attention.

This citation pertains to Intake MI00133617 and MI00134554. Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 8/28/23 at 6:08 AM during the initial tour of the Memory Care unit the following was observed. Two unidentified residents were observed awake and sitting in the Memory Care dining room. Gnats were observed in the dining room. The left side panel of the window air conditioning (AC) unit was not fully closed, creating about a six-inch opened area. A screenless upper window panel in the dining room was opened about six inches. The opened AC side panel and screenless upper window made it possible for flying insects to enter the dining room. On 08/29/23 at 09:00 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services B. The following items were noted: Clean Laundry Room: The stationary wall fan was observed soiled with accumulated dust and dirt deposits. The flooring surface was observed (etched, scored, particulate), exposing the concrete sub-surface. Director of Housekeeping and Laundry Services B indicated he would have maintenance repaint the flooring surface as soon as possible. The walls and floors were observed heavily soiled with dust, dirt, and debris behind the three commercial driers. The walls and floors were observed heavily soiled with dust, dirt, and debris (paper products, plastic products, etc.) behind the commercial washers. 2 of 3 clean linen transportation cart covers were observed (worn, torn, particulate). 1 of 3 clean linen transportation carts were also observed broken (1 of 3 shelving units broken). Soiled Laundry Room: The stationary wall fan was observed soiled with accumulated dust and dirt deposits. The return-air ventilation grill was observed soiled with accumulated dust and dirt deposits. The two-compartment sink faucet assembly was observed leaking water from the spout. On 08/29/23 at 10:45 A.M., A common area environmental tour was conducted with Regional Maintenance Director A and Director of Housekeeping and Laundry Services B. The following items were noted: Basement Central Supply: The flooring surface was observed with numerous (cracked, chipped, missing) vinyl 9-inch-wide by 9-inch-long flooring tiles. Numerous 24-inch-wide by 24-inch-long acoustical ceiling tiles (18) were also observed severely stained from previous moisture leaks. The room was further observed in complete disarray. Cardboard boxes resting directly on the flooring surface. Regional Maintenance Director A indicated he would have staff make necessary repairs as soon as possible. Housekeeping Storage Room: The room was observed in severe disarray and soiled with accumulated dust, dirt, and debris (cardboard boxes, plastic bags, etc.). Staff Breakroom: Numerous 24-inch-wide by 24-inch-long acoustical ceiling tiles (14) were observed severely stained from previous moisture leaks. The microwave oven interior was also observed soiled with accumulated food residue. The refrigerator interior and exterior were further observed soiled with accumulated and encrusted food residue. The refrigerator was additionally observed missing the interior appliance bulb. The chest freezer interior was finally observed with accumulated ice [NAME]. Occupational Therapy/ Physical Therapy: The microwave oven interior was observed severely (etched, scored, corroded, particulate). The restroom toilet tissue was also observed resting on top of the plastic dispenser instead of within the dispenser. The paper towel was additionally observed resting on top of the commode tank cover, instead of within the plastic wall mounted dispenser. The commode tank cover was further observed ill-fitting to the existing stool tank. Human Resources/Admissions Office: The Human Resources flooring surface was observed severely (worn, etched, scored, sticky, particulate). Numerous vinyl flooring tiles were also observed missing, exposing the concrete subsurface. Medical Records: Numerous 24-inch-wide by 24-inch-long acoustical ceiling tiles (8) were observed severely stained from a previous moisture leak and/or missing. The room was also observed in severe disarray (cardboard boxes, medical records, etc.). First Floor (South) IT Room: Numerous empty cardboard boxes were observed resting directly on the flooring surface. The flooring surface was also observed soiled with accumulated dust and dirt deposits. The room was further observed in disarray. The metal entrance door was finally observed soiled with accumulated dust and dirt deposits between the door slab and frame. Nursing Supply Closet: The shelving unit was observed soiled with accumulated dust, dirt, and debris. One 24-inch-wide by 24-inch-long acoustical ceiling tile was also observed severely stained from a previous moisture leak. The supply closet was further observed in disarray. Clean Linen Room: The drywall surface was observed (etched, scored, particulate). The flooring surface was also observed severely worn and pitted, exposing the subsurface. Nurse Station: The stationary wall fan was observed soiled with accumulated dust and dirt deposits. Exposed telephone wiring was also observed dangling from the lower drywall surface. The drywall surfaces were further observed severely soiled and stained. Restroom: The flooring surface was observed missing ceramic tile squares in several locations. The commode base caulking was also observed (etched, stained, cracked). The commode base tank cover was further observed ill fitting. 1 of 2 overhead light fixtures were finally observed stained and corroded from a previous moisture leak. Business Office: The air conditioning filter and housing unit was observed heavily soiled with accumulated dust and dirt deposits. Main Dining Room: The air conditioning unit filter and housing cabinet were observed heavily soiled with accumulated dust, dirt, and food residue deposits. The Popcorn Machine interior ceiling and light bulb assembly were also observed heavily soiled with accumulated food and popcorn oil residue. First Floor (North) Bathroom: Six 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from previous moisture leaks. The commode base caulking was also observed (etched, scored, particulate). The toilet tissue was further observed resting on top of the plastic wall mounted dispenser. The shower wand assembly was finally observed missing an atmospheric vacuum breaker to prevent a potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. Nurse Station: The hand sink basin was observed severely stained and corroded. The overflow plate was also observed enlarged from the excessive corrosion. The stationary wall mounted fan was further observed soiled with dust and dirt deposits. Soiled Utility Room: The sharps container was observed without a cover plate. The metal entrance door between the door slab and frame was also observed heavily soiled with accumulated dust and dirt deposits. The return-air ventilation grill was further observed heavily soiled with dust and dirt deposits. Second Floor (South) (Memory Care Unit) The entrance door magnetic security closure assembly was observed continuously buzzing when activated. Restroom: The return-air ventilation grill was observed soiled with dust and dirt deposits. Three 24-inch-wide by 24-inch-long acoustical ceiling tiles were also observed stained from a previous moisture leak. Oxygen Storage Room: The return-air ventilation grill was observed soiled with dust and dirt deposits. Nursing Supply Room: The flooring surface was observed soiled with dust, dirt, and debris (plastic spoon, plastic knife, plastic bag). The supply room was also observed in disarray. Nursing Station: The wall mounted stationary fan was observed soiled with dust and dirt deposits. The perimeter drywall surface was also observed scuffed and etched. Main Dining Room: The wall and flooring surfaces were observed soiled with dust, dirt, and food residue (sticky). The restroom was also observed soiled and in disarray. The air conditioner unit housing was further observed soiled with dust, dirt, and food residue. The air conditioner unit filter was further observed missing. Janitor Closet: The mop sink was observed partially filled with wastewater. The flooring surface was also observed heavily soiled, corroded, and extremely wet. The wall surfaces were additionally observed (etched, scored, particulate). The interior mop sink basin was further observed heavily soiled with dust, dirt, and grime. Regional Maintenance Director A indicated he would have staff make necessary repairs as soon as possible. Solid Waste Storage Room: The wall surfaces were observed (etched, scored, particulate). The flooring surface was also observed soiled with dust, dirt, and grime. Soiled Utility Room: One 24-inch-wide by 24-inch-long acoustical ceiling tile was observed missing. Two 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak. Second Floor (North) Shower Room: 2 of 3 overhead light assemblies were observed non-functional. The shower wand assembly was also observed missing an atmospheric vacuum breaker, to prevent a potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. The restroom commode was further observed non-functional. Nursing Station: Exposed electrical wiring was observed on the wall surface, adjacent to the chair. The stationary wall fan was also observed heavily soiled with accumulated dust and dirt deposits. The hand sink basin overflow port was additionally observed heavily stained, corroded, and enlarged from excessive corrosion. One seven-foot section of vinyl base coving was further observed missing. The floor surface was finally observed severely worn, exposing the concrete subsurface. Workstation Alcove: The drywall surfaces were observed (etched, scored, particulate). Soiled Utility Room: The flooring surface was observed soiled with dust, dirt, and debris (paper products, vinyl gloves, etc.) The return-air ventilation grill was also observed heavily soiled with accumulated dust and dirt deposits. One 24-inch-wide by 24-inch-long acoustical ceiling tile, located adjacent to resident rooms [ROOM NUMBERS], was observed stained from a previous moisture leak. On 08/30/23 at 08:45 A.M., An environmental tour of sampled resident rooms was conducted with Regional Maintenance Director A and Director of Housekeeping and Laundry Services B. The following items were noted: 105: The restroom commode base caulking was observed (etched, scored, particulate). 1 of 2 overhead light bulbs were also observed non-functional. The hand sink faucet aerator was additionally observed faulty. The return-air ventilation grill was further observed heavily soiled with accumulated dust and dirt deposits. 1 of 3 bedside table slabs were finally observed (etched, scored, particulate). 110: The window air conditioner unit filter was observed heavily soiled with accumulated dust and dirt deposits. The restroom return-air ventilation grill was also observed soiled with dust and dirt deposits. The commode base caulking was additionally observed (etched, cracked, stained). 1 of 2 restroom overhead light bulbs were also observed non-functional. 2 of 3 overhead light fixtures were also observed non-functional. The bed 3 floor fan was additionally observed heavily soiled with dust and dirt deposits. The resident room flooring surface was further observed heavily soiled with accumulated dust, dirt, and food residue. The restroom metal door frames were also observed (etched, scored, chipped). 111: The restroom entrance door metal threshold plate was observed extremely soiled with accumulated dirt and grime deposits. The restroom hand sink basin was also observed heavily soiled with accumulated dirt and grime deposits. 1 of 2 restroom overhead light bulbs were additionally observed non-functional. The restroom flooring surface was also observed soiled with dirt and grime deposits. The commode base caulking was further observed (etched, chipped, cracked, stained). The flooring surface was also observed soiled with dust and dirt deposits. The air conditioner filter was finally observed soiled with accumulated dust and dirt deposits. 114: 1 of 4 overhead light fixtures were observed non-functional. The perimeter vinyl wall/floor base coving was also observed missing. The restroom commode base caulking was additionally observed (etched, scored, particulate). 117: The perimeter vinyl wall/floor base coving was observed missing. The air conditioner unit filter was also observed heavily soiled with dust and dirt deposits. 120: 1 of 4 overhead light fixtures were observed non-functional. The flooring surface was also observed soiled with accumulated dirt and grime deposits. 1 of 2 restroom overhead light bulbs were additionally observed non-functional. The restroom flooring surface was further observed (cracked, chipped, missing), adjacent to the commode base. 121: The air conditioner unit filter was observed extremely soiled with accumulated and encrusted dust and dirt deposits. 1 of 2 overhead light assembly plastic protective lens covers were also observed missing. 1 of 2 restroom overhead light bulbs were additionally observed non-functional. The restroom hand sink basin was further observed with standing water within the basin. The restroom return-air ventilation grill was also observed heavily soiled with dust and dirt deposits. 125: The air conditioner unit filter was observed heavily soiled with dust and dirt deposits. The flooring surface was also observed soiled with accumulated dust, dirt, and food residue. 201: The air conditioner unit filter was observed heavily soiled with dust and dirt deposits. Numerous dead insect carcasses were observed within the overhead light fixtures. The air conditioner unit sliding side panels were further observed loose-to-mount and open. 204: The call system pull extension cord was observed dangling from the overbed light assembly. The call system metal protective face plate cover was also observed dangling from the pull extension cord within the overbed light assembly. 1 of 2 overhead light fixtures were also observed non-functional. The television set was further observed resting at a 45-degree angle on top of the bedside table. 208: The air conditioning unit filter was observed soiled with accumulated dust and dirt deposits. 3 of 3 desk fans were also observed soiled with dust and dirt deposits. The restroom commode base was additionally observed loose-to-mount. The commode base could be moved from side to side approximately 3-6 inches. 211: The window shade panel was observed broken. A hole was also observed behind the restroom commode base. The hole measured approximately 6-inches-wide by 6-inches-long. 212: A hole was observed behind the restroom commode base. The hole measured approximately 6-inches-wide by 6-inches-long. Eight 12-inch-wide by 12-inch-long vinyl flooring tiles were also observed cracked, chipped, missing. 214: 1 of 5 overhead light fixtures were observed non-functional. The air conditioner unit filter was also observed heavily soiled with accumulated dust and dirt deposits. The restroom return-air ventilation grill was additionally observed soiled with dust and dirt deposits. 215: 2 of 4 overhead light assembly fixtures were observed non-functional. The air conditioner unit filter was also observed missing. The air conditioner unit internal coil fins were additionally severely soiled with accumulated dust and dirt deposits. 220: 3 of 4 overhead light assemblies were observed non-functional. The air conditioner unit filter was also observed heavily soiled with accumulated dust and dirt deposits. The restroom flooring surface was additionally observed soiled and malodorous (urine odor). The flooring surface was further observed missing, adjacent to the commode base. The restroom call system panel protective metal cover plate was finally observed dangling from the pull cord extension. 222: Five 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from previous moisture leaks. The restroom flooring surface was also observed soiled and malodorous (urine odor). The flooring surface was additionally observed missing, adjacent to the commode base. The restroom call system panel protective metal cover plate was further observed dangling from the pull cord extension. Note: Finer detailed cleaning, within resident rooms and common areas, is essential to reduce bacterial harborage and cross-contamination inoculations. On 08/30/23 at 01:30 P.M., Record review of the Policy/Procedure entitled: Cycle Cleaning dated 01/2023 revealed under Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks. Record review of the Policy/Procedure entitled: Cycle Cleaning dated 01/2023 further revealed under Policy Explanation and Compliance Guidelines: (1) Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free. (5) Specific areas include: (a) Hallways/Dayrooms/Dining Rooms, (b) Offices/Support Rooms/Exterior, (c) Showers/Utility/Bathrooms, (d) Resident Rooms. On 08/30/23 at 01:45 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns. 34901

This ciations pertains to Intake numbers MI00137230 and MI00137425. Based on observation, interview, and record review the facility failed to maintain a clean and homelike environment by providing storage space to put personal belongings in and remove trash and food off the floor for two residents (#33, #67) reviewed for safe, clean, comfortable homelike environment resulting unsanitary living conditions and the opportunity for missing personal items. Findings include: Resident #33 On 8/28/23 at 9:02 a.m. during the initial pool process, upon entering R33's room there were flies in the room landing on the resident's bed and privacy curtain. Upon further entrance, a pile dried food (noodles and vegetables), a dried red liquid, and plastic cup lids were observed on the floor from the night before. R33 was observed in the bed and asked what happened to the floor. The resident stated, It was an accident. I knocked my tray on the floor. They won't clean it up because I knocked it on the floor by mistake. It happened last night. Further observation of the room revealed broken blinds and a missing armoire (closet). There were two in the room, however there were three residents in the room. Neither belonged to R33. R33 was asked where his closet was. R33 stated, They didn't give me one. Prior to entering the room, a nurse and a nurse aide were observed going into the room. After leaving out of the room the nurse was observed going into the room then said to the nurse aide in the hall to get housekeeping to the clean the floor. On 8/29/23 at 1:16 p.m. review of the clinical record documented R33 was admitted into the facility on [DATE] with diagnoses that included schizoaffective disorder, delusional disorders, and atrial fibrillation. According to the quarterly Minimum Data Set assessment dated [DATE], R33 was cognitively intact and required total two-person assistance with activities of daily living (ADLs). Review of the ADL care plan dated 1/12/23 documented, Resident has impaired ability to complete ADL care and needs assistance related to impaired mobility . Intervention: Anticipate and meet the resident's needs. Assist resident with meals for adequate intake. On 8/31/23 at 3:15 p.m. Unit Manager J was interviewed about the missing armoire and the cleaning of the room. The Unit Manager said the aides are to clean up spills and pick up trash in the rooms. Housekeeping is responsible for deep cleaning and sanitizing the rooms. The Unit Manager reported not being aware the resident did not have a armoire in the room. 39465 R67 On 8/28/2023 at 8:43 a.m., R67 's room was observed with multiple pair of pants and sweaters folded on a wheelchair next to the bed, multiple pair of shoes on bedside table, pants and sweater stacked on pillows, towels and wash clothes hanging at the foot of the bed, and a bag of clothes on the bed against the wall. R67 's privacy curtain was observed with clothes, hats, towels, and wash cloths hanging on hangers from one end of the privacy curtain to the end. During an interview, R67 said the closet was too small to hold all the clothes and no one had offered any other accommodations to store clothes. R67 also said the staff sees the clothes all over the room every time they walk in but never offered to help put the clothes away. On 8/312023 at 231 p.m., during an interview, Nursing Home Administrator (NHA) said the resident supposed to have an armoire for their clothes, and the facility is talking about where the patients can keep their clothes and things. The NHA stated, We might have to buy some extra dressers long as it doesn't interfere with other resident's space. Their clothes should not be on the curtains. According to the EHR, R67 was admitted to the facility on [DATE] with diagnoses of heart failure, and chronic obstruction pulmonary disease. R67's annual Minimum Data Set (MDS) with a reference date of 8/11/2023 indicated R67 was cognitively intact with a BIMS (brief interview for mental status) score of 15. Review of the ADLS care plan-initiated date of 9/26/2022 revealed, R67 has the potential for a decrease ADLS assistance related to the diagnosis of heart failure, and generalized weakness .Anticipate resident's needs every shift and accommodate accordingly .

This citation pertains to Intakes #MI00137110 and MI00137114. Based on interview, and record review, the facility failed to timely investigate and submit to State Agency reports of abuse for 4 residents (R385, R536, R537, R2) out of 23 sampled residents for abuse resulting in the potential for further allegations of abuse to not be investigated timely. Findings include: R385 Review of the medical record revealed R385 was a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses including postlaminectomy syndrome, abnormalities of gait, and low back pain. Review of the facilities incident report dated 4/20/23 revealed Resident reported to the administrator that he was jumped on by staff on midnight shift. When asked if he could explain what they did to him he expressed that they did like they did to him for 32.5 years that he was locked up. On the night he spoke off the staff at the facility had called the police because of (name of R385's) aggressive behavior; cursing at staff and threatening that he was going to beat them up. Police came to the building and interviewed (name of R385). Investigation on this matter has started. Review of the facilities investigation report dated 5/15/23 revealed On the day he reported that he was abused by staff; upon further interview the resident stated that a rhino and snake have been fighting him all night, when asked if he could describe who was beating him up he could not stay on topic. He wanted to talk about boxing or his military father. Interview with staff revealed that the previous night the resident was verbally abusive and had cornered staff at the nurses station until the police came to the building. Upon seeing the police the resident was calm and did not continue with his aggressive behavior. The detective made the decision to leave (name of R385) in the facility. A psychological evaluation on the resident indicated that the resident was delusional and was not able to stay on topic with the evaluator. He also kept interrupting the session by yelling for staff on the hallway. (Name of R385's brother) who is the support person for his brother planned to take him home after therapy and physician clearance, which occurred on 4/23/2023. Through interview with staff and the resident facility concludes that the allegation of abuse could not be substantiated. In an interview with the Nursing Home Administrator (NHA) on 8/31/23 at 1:45 PM revealed allegations of abuse should be reported within 2 hours to the State Agency and investigations should be reported by 5 days. The NHA agreed the investigation report for R385 was reported almost a month late. 39958 R537 Review of an admission record revealed, R537 admitted to the facility 8/27/22 with pertinent diagnosis which included Urinary Tract Infection (UTI) and Bacteremia (bacteria in the blood). Review of a MDS assessment, with a reference date of 9/13/22 revealed R537 was independent with cognition and required limited assistance with one staff for transfers and locomotion on the unit. Review of the Incident form provided to State Agency (SA) revealed the following details about the incident: Occurred on 10/3/22 Discovered on 10/7/22 Reported to SA on 10/17/22 Review of an Investigation Summary/Actions Taken with a date of 10/17/23 revealed, . On 10/07/2022 the facility was notified by hospital staff that resident had alleged that (R537) was roughed up and beaten at the facility and that (R537) did not fall . In an interview on 8/29/23 at 2:06 p.m., the NHA acknowledged R537's allegation of abuse was not reported to the SA within a two hour timeframe. Review of a Abuse, Neglect and Exploitation policy with a revised date of 7/25/23 revealed, It is the policy of this facility to provide protections for the health, wealth, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property . 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services . a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, the facility failed to develop a dialysis and activity daily living (ADLS) baseline care plan for one (R9) of one residents reviewed for baseline care plans, resulting in the potential for unmet needs of ADLS and dialysis care. Findings include: On 8/28/2023 at 10:28 a.m., R9 dialysis shunt dressing was observed with no date. Facility Staff confirmed later R9 gets dialysis at the facility and the shunt dressing get changed on dialysis days. According to the electronic medical record (EMR), R9 was admitted into the facility on [DATE] with diagnoses of end stage renal disease, fluid overload, proteinuria (Protein in the urine), anemia, secondary hyperparathyroidism of renal origin, hypertension, hyperkalemia (high potassium level), diabetes mellitus type two, chronic diastolic heart failure, peripheral vascular disease, and major depressive disorder. R9's admission Minimum Data Set (MDS) assessment with a reference date of 6/18/2023 indicated R9 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15, required extensive assistance of one person with bed mobility, required limited assistance of one person with transfers, toileting, and ADLS with impairment on both sides of the lower limbs. The Physician's orders revealed R9 received dialysis on Mondays, Wednesday's and Fridays located in the basement of the facility. Further review of the EMR revealed no ADLS and Dialysis care plans. On 8/31/2023 at 12:57 p.m., reviewed the EMR with the Administrator and the Director of Nursing (DON) confirmed there was no ADLS or Dialysis care plans for R9 observed. A request was made to the DON for hard copies of the ADL and the Dialysis care plan for R9. A hard copy of R9's ADLS and Dialysis care plan were brought to the conference room with the initiated date of 8/31/2023. In an interview, on 8/31/2023 at 2:31 p.m., the DON stated, The admitting nurse should put care plans in the resident's medical record at first and the MDS nurse does the comprehensive care plans. Every resident should have a baseline care plan starting. According to the facility's undated Baseline Care Plan policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: -1. a. The baseline care plan will be developed within forty-eight hours of a resident 's admission. b. Include the minimum healthcare information necessary to properly care for a resident .

This citation pertains to intake MI00137425. Based on observation, interview, and record review, the facility failed to ensure medication was administered timely and accurately per physician's orders for three residents (#30, #40, #284) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not administered properly. Findings include: Resident #30 In an observation on 8/28/23 at 7:28 a.m. Licensed Practical Nurse (LPN) G prepared medication for Resident #30 (R30). LPN G placed a Ibuprofen (pain reliever) in the medication cup. LPN G then entered R30's room and administered the medication. In an observation and interview on 8/28/23 at 7:28 a.m. LPN G documented the medication administration in the MAR (Medication Administration Record). LPN G reported the MAR screen was red because R30's medications were late. Review of an admission record revealed, R30 admitted to the facility 12/10/14 with pertinent diagnosis which included Pain and Benign Prostatic Hyperplasia (BPH) Review of Physician orders revealed R30 had orders for 6:00 a.m. administration which included, IBU (Ibuprofen)Tablet 600 MG (milligram) Give 1 tablet by mouth every 8 hours for ble (bilateral lower extremities) pain. Resident #40 In an observation on 8/28/23 at 7:33 a.m. LPN G prepared medication for R40. LPN G placed a three pills (Pantoprazole, Phenytoin and HYDROCO/APAP-narcotic pain reliever) in a mediation cup. LPN G then entered R40's room and administered the medication. LPN G exited the room and documented the medication administration. Review of an admission record revealed, R40 readmitted to the facility 7/6/21 with pertinent diagnosis which included Pain in Right Foot and Gastro-Esophageal Reflux Disease (GERD). Review of Physician orders revealed R40 had orders for 6:00 a.m. administration which included, Pantoprazole (treats stomach ulcers) give 40 mg by mouth one time a day, Phenytoin (treat and prevent seizures) give 200 mg by mouth one time a day, HYDROCO/APAP 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain. Resident #284 In an observation on 8/28/23 at 8:54 a.m. LPN H prepared medication for R284. LPN H placed four pills in a medication cup which included Colace 250 mg. LPN H entered R284's room and administered the medication. LPN H exited the room and documented the administration. Review of an admission record revealed, R284 readmitted to the facility 8/18/23 with pertinent diagnosis which included Vascular Dementia and Type 2 Diabetes. Review of Physician orders revealed R284 had an order for Colace (Docusate Sodium) give 100 mg by mouth two times a day. Review of the MAR for 8/28/23 revealed LPN H documented the administration of Colace 100 mg. In an interview on 8/28/23 at 11:55 a.m. LPN H reported Colace 250 mgs (more than 2 x's what the physician ordered) was given instead of 100 mg because R284 is always constipated. In an interview on 8/29/23 at 1:59 p.m., the Director of Nursing (DON) reported the nurse must follow Physicians orders and give the ordered dose or call the physician for an order change. The DON reported medications should be administered one hour before or after scheduled time. Review of Medication Administration policy with a revised date of July 2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 10. Review MAR to identify medication to be administered . 11. Compare medication source with MAR to verify . b. Administer within 60 minutes prior to or after scheduled time unless ordered by physician .

This citation pertains to Intakes#: MI 747, MI 866, MI 147. Based on interview, and record review the facility failed to administer scheduled and as needed (PRN) pain medications per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R#6 Resident #6 was observed on 8/24/21 at 2:00 p.m. in bed, alert and able to be interviewed. R#6 stated, I believe it was August 1st on the midnight shift, I didn't get my 8:00 p.m. and 3:00 in the morning medications. I know my scheduled times for my pain medications, and I didn't get them. The one scheduled at 4:00 in the morning they usually give it to me an hour early at 3:00 a.m. I called 911 because I didn't get my pain medications, I heard it was only one nurse, and I was scared something might happen to me. Review of the face sheet on 8/24/21 at 2:45 p.m., revealed R#6 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#6 is receiving Hospice care. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#6 was cognitively intact with a BIMS score of (15). Review of the physician's orders revealed, Resident #6 scheduled pain medications times and as needed (PRN) pain medications frequency were as following: [MEDICATION(S)] ER (Extended Release) tablet 60 mg (Milligrams) give one tablet by mouth three times a day related to other chronic pain ordered date 1/31/2021, [MEDICATION(S)] tab 600 mg give one tablet by mouth every six hours as needed for pain order date 5/30/2019, [MEDICATION(S)] (Concentrate) Solution 100 mg/5ml give 0.25 ml by mouth every three hours as needed for pain break through order date 1/25/2021. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R#6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses Progress notes revealed no documentation of R#6 getting pain medications, no pain assessment/evaluation documented. Review of R#6 Pain Level values dated 8/22/2021 documented, Pain level of (6). Review of the Pharmacy Controlled Substance Proof-Of-Use Record revealed no documented nurses' signatures of R#6 scheduled pain medication ([MEDICATION(S)] 60 mg) doses given on 8/1/2021 at 8:00 p.m. and on 8/2/2021 at 4:00 a.m. No documented nurse's signatures of R#6 PRN [MEDICATION(S)] tab 600 mg give one tablet by mouth every six hours for pain, and [MEDICATION(S)] (Concentrate) Solution 100 mg/5ml give 0.25 ml by mouth every three hours for pain break through given. Review of the Hospice care plan initial date of 1/27/2021 documented, I am currently under .Hospice care related to resident has terminal diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Comfort measures will be maintained, and episodes of pain/discomfort will be relieved within one hour of intervention . Interviewed the facility's Director of Nursing (DON) B regarding R#6 missed doses of scheduled pain medications and PRN pain medications administration. DON B confirmed she was aware of R#6's scheduled pain medications was not given on 8/1/2021 at 8:00 p.m. and 8/2/21 at 4:00 a.m., and aware of R#6 calling the police because of the missed medications. DON B verified the police officer came into the facility around 6:00 a.m. that morning and talked to her regarding some residents did not get their medications. DON B stated, The police wanted to see the residents' records for med. (Medication) Pass, and I decline because it was a HIPPA (Health Information Privacy Protection Act) violation. DON B statated,I followed up on the alleged missed medications. R#6 did not get his medications, they were late. DON B verified the physician was not called regarding the missed medications and to administer PRN pain medications. DON B verified R#6 was upset, and he did not get any medication after it was brought to her attention. DON B verified after talking to the resident taking his complaints at 6:00 a.m., there was no follow up to ensure the resident receive all his medication and pain level evaluation. DON B confirmed no PRN pain medication were administered. Reinterviewed R#6 on 8/25/21 at 4:20 p.m. regarding his missed doses of pain medications. R#6 stated, OH yes, I was in pain. My pain was about a (10) on a scale of (10). I didn't get any pain medications until about 10:00 that morning. She (DON) did come and talked to me about 6:00 a.m. that morning, but I didn't get pain meds until 10:00. R#8 Review of the face sheet on 8/25/2021 at 4:35 p.m. R#8 was initially admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#8 was cognitively intact with a BIMS score of (15). Review of the physician's orders revealed R#8 scheduled pain medications are as following: [MEDICATION(S)] Tablet 5-325 mg ([MEDICATION(S)] Acetaminophen) give one tablet by mouth every 12 hours for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#8 Pain level value dated 8/26/2021 documented, Pain level of (9). Review of facility's Medication Pass Guidelines policy dated 8/2021 documented, Purpose: To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing the administration of drugs in an accurate, accordance with State and Federal Guidelines .5. Administer medications within sixty minutes before or after the scheduled time. Unless otherwise specified by the physician .

This citations pertains to intakes MI 896, MI 947, MI 996. Based on observation, interview, and record review, the facility failed to ensure resident remained free from physical restraints for the sole purpose of staff convenience in 1 of 4 residents (R501) reviewed for restraints, resulting in an immediate jeopardy when on 6/19/21 at approximately 4:39 PM, R501 who had severe cognition impairment and a history of wandering, was seen on video scooting out of the 2 South Dining Room while restrained to a chair by a bedsheet tied around her waist and two staff members visibly present. R501 was observed struggling to remove herself from the chair for eight minutes (4:39 PM - 4:47 PM) until R501 put her feet on the railing, pushed herself over, and fell on the floor still tied to the chair. The restraint then loosened and R501 was able to remove the restraint. This deficient practice is likely to cause serious injury, serious harm, and/or death to any resident in the facility who is subjected to a physical restraint that is not ordered by a physician and monitored accordingly. Findings include: According to a Facility Reported Incident (FRI) dated 6/19/21 at 10:15 PM and the subsequent Facility Investigation Report dated 6/28/21, the facility substantiated that R501 was physically restrained to a dining room chair with a bed sheet tied around her waist. The facility's investigation revealed that three employees, Licensed Practical Nurse (LPN) C, Certified Nurse Aide (CNA) D, and CNA E were present and/or aware of R01's physical restraint to the chair. These employees were immediately suspended on 6/19/21, and subsequently terminated on 6/24/21 after the results of the investigation were revealed. On 7/6/21 at 8:30 AM during an interview with Administrator A she confirmed that R501 was physically restrained to a dining room chair with a bed sheet tied around her waist from approximately 4:39 PM until 4:47 PM after review of the video from the 2 South hallway. On 7/6/21 at 10:30 AM the 2 South video was reviewed with Maintenance Director (MD) H and Administrator A. The video showed that on 6/19/21 at 4:33 PM, CNA E walked out of the 2 South dining room and left the 2 South unit. At 4:36 PM CNA D walks into the dining room doorway for a brief moment and then both LPN C and CNA D walked out of the 2 South dining room. LPN C walked into the nurse's station area which has one chair that directly faced toward the dining room, approximately 8 feet away but is out of video range and CNA D walked into the storage area located behind the nurses station. At 4:39 PM R501 was seen scooting out of the dining room doorway pushing an empty dining room chair in front of her while being restrained to another dining room chair with a bed sheet tied around her waist like a belt. Both LPN C and CNA D were at the nurses station, LPN C was out of range, but CNA D was visible approximately 8 feet away with her back towards R501. At approximately 4:41 PM R501 was clearly visible in the 2 south hallway still restrained to the dining room chair, struggling to free herself. CNA D walked away from the nurses station and was seen looking directly at R501 who was struggling to free herself of the restraint. CNA D returned to the nurses station within one minute, standing with her back to R501. At 4:47 PM R501 put her feet up on the 2 South doorway and hand rail pushed backward and fell to the floor sideways, on her left side into the 2 South dining room. R501's legs were seen in the doorway and her upper body was out of camera range inside the 2 South dining room. LPN C and CNA D were seen in the 2 South hallway going toward R501. Within a few seconds R501 walked out of the dining room on her own accord. LPN C and CNA D appeared to be having a discussion between themselves and CNA E returned to the unit. On 7/6/21 at 8:42 AM, during an interview with CNA D she said that on 6/19/21 at approximately 4:30 PM she was standing at the 2 South nurses station when she heard a thud. CNA D said she turned around to see R501 laying sideways on the floor, tied to a dining room chair with a sheet around her waist in the doorway of the 2 South dining room. CNA D said R501 removed the sheet and immediately got up and walked away without any signs of injury. CNA D said she was unaware that R501 was restrained to a chair with a sheet until the time she fell . On 7/6/21 at 12:00 PM during an interview with LPN C she said that on 6/19/21 at approximately 4:30 PM she went into the 2 South dining room to complete a skin treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN C said that CNA E was present at this time and she told her (CNA E) to remove the restraint. CNA E said that the sheet was not tied and just laying across R501's lap and not a restraint. LPN C said she directed CNA E to remove it anyway and then began to do the skin treatment on R503. LPN C said that she did not remove the restraint on R501 because she thought CNA E was going to remove it. On 7/6/21 at 1:24 PM during an interview with CNA E she said that on 6/19/21 at approximately 4:30 PM she was in the dining room with several residents including R501 and R503. When LPN C came into the 2 South dining room she (CNA E) decided to go on her break. CNA E said, I never tied anyone up with a bed sheet. I just laid the sheet across her (R501's) lap because I didn't want anyone to fall on it. CNA E said when she returned from her break she heard that R501 was restrained to a chair and fell . CNA E offered no explaination as to why a bedsheet would have been in the dining room. On 7/6/21 at approximately 9:00 AM R501 was observed in her room seated on her bed receiving morning care by CNA P. R501 was free from any visible signs of injury and was unable to be interviewed due to severe cognition impairment. R501 refused to wear her shoes at this time, stood up and took several steps away. CNA P attempted to redirect her by gently placing his hand on her right forearm and R501 fell on to the bed in a seated position. R501 did not sustain any injury, immediately stood up and freely ambulated out of her room and into the 2 South hallways with one-to-one supervision by CNA P. CNA P said he attempted to put R501's shoes on, but she refused. R501 was observed wandering at a fast pace down 2 South hallway with an abnormal but fairly steady gait, unassisted by CNA P. According to R501's face sheet, she initially admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] identified R501 to have severe cognition impairment with daily behaviors of wandering with intruding on others privacy. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for 'supervision/falls' was revised on 6/20/21 to include one-to-one supervision for R501 at all times. During an interview with the facility's Medical Director (MD) S on 7/7/21 at 11:50 AM he said that he was unaware that R501 was physically restrained and sustained a fall until today (7/7/21). MD S said that he would never write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD S said he would not support any type of restraint for the residents at the facility. The IJ was identified on 7/6/21. The Administrator A was notified on 7/6/21 at 12:44 PM of the IJ that began on 6/19/21 at approximately 4:36 PM when the facility failed to ensure R501 was free from the use of a physical restraint. The Immediate Jeopardy was removed on 7/7/21 at 12:30 PM based on surveyor verification that the facility had implemented the following to remove the Immediate Jeopardy: · Resident R501 was evaluated on 6/19/21 and there were no new injuries as the result of the incident of her being tied to a chair. ·The employees involved in the incident were suspended on 6/19/21 pending investigations and terminated on 6/23/21 and 6/24/21. ·On 7/6/21, the facility has started the process for reporting the cenas certification to the state agency and the nurse's license to the Michigan Licensing Board. This was completed on 7/7/21. ·The Administrator and DON reviewed the Abuse and Restraint Policy on 6/21/21 and deemed it appropriate as written. · The facility started inservicing the staff on the Abuse and Restraint Policy on 6/28/21 and it's ongoing. There have been 81 out of 82 staff members inserviced as of 7/7/21 at 12:30 PM. · Effective 6/19/21, resident R501 had a sitter daily and in the event the sitter has to leave the Unit, the Unit Managers/Nurses will continue monitoring Resident R501 whereabouts until the sitter returns. One on one monitoring continues for Resident R501. ·The Social Worker conducted 54 resident interviews on 6/24/21 regarding mistreatment and restraints. No resident verbalized witnessing or experienced any mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . ·Starting the week of 6/27/21, the Social Worker and/or designee will conduct random weekly interviews with the residents to ask if they've witnessed and/or experienced mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Although the Immediate Jeopardy was removed on 7/7/21, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy pending the completion of inservice training of all staff and confirmation of the facility's ability to maintain sustained compliance, as verified by the State Agency (SA).

This citation pertains to intakes MI 127, MI 478, MI 985, MI 858, MI 550, and MI 492. This citation has 2 Deficiency Practice Statements. Based on observation, interview, and record review, the facility failed to ensure sufficient staffing was available to render care, pass meal trays, and meet resident needs for all 67 residents in the facility. An Immediate Jeopardy was determined on 6/15/2021 when on the following dates and times, there was only one licensed or registered nurse in the building: 5/4/2021 (census of 69) between 7:00 AM and 7:00 PM; 5/9/2021 (census of 65) between 7:00 AM and 2:30 PM; 6/4/2021 (census of 67) between 9:00 PM and 12:15 PM on 6/5/2021; and 6/5/2021 (census of 66) between 12:16 PM and 7:00 PM. The facility staff did not administer prescribed insulin, IV antibiotics, anti-psychotics, anti-coagulants, anti-hypertensives, and/or anti-convulsants for Residents #1, #16, #19, #20, #22, #27, #32, #36, #38, #39, #42, #44, #51, #52, #56, #172, and #173. This deficient practice resulted in the likelihood for actual harm for Residents #1, #16, #19, #20, #22, #27, #32, #36, #38, #39, #42, #44, #51, #52, #56, #172, and #173, and placed all residents residing in the facility at risk for serious harm, injury, and/or death. Based on observation, interview, and record review, the facility also failed to ensure meals were delivered and served in a timely manner for three residents (#8, #36, and #38) due to insufficient staffing resulting in resident dissatisfaction. Findings include: On 6/6/2021 at 8:10 AM, Licensed Practical Nurse (LPN) U was observed on the first floor. LPN U stated her shift began at 7:00 PM on 6/5/2021 and she was waiting for her relief to arrive. LPN U stated LPN V's, who was working on the second floor, shift began at 7:00 PM and there were two Certified Nurse Aides (CNA) working the midnight shift as well. LPN U said, Having only two CNAs on the midnight shift has been a habit lately. On 6/6/2021 at 8:25 AM, CNA T, who worked on the locked dementia unit, said, I actually have help today. CNA T said, Sometimes I work by myself. On 6/6/2021 at 10:00 AM, during the initial tour of the facility, no nursing staff was observed on the 2 North unit. There were eleven residents residing on the unit. At 10:12 AM, Resident #27 (R27) was observed awake and lying in his bed. On R27's overbed table was a plastic bag containing a disposable carryout container. Gnats were observed swarming around the bag. During an interview at this time, R27 stated the contents of the bag contained uneaten Chinese carryout from the evening before and no one had been in his room to dispose of the bag. On 6/6/2021 at 10:25 AM, Certified Nurse Aide (CNA) EE was observed on 2 North. When interviewed, CNA EE said, I was supposed to arrive at 7 AM but I arrived at 9:30 AM today. CNA EE stated he did not know the nurse that was working on 2 North, I haven't seen her. On 6/6/2021 at 10:37 AM, an unidentified resident stated he was in pain. When interviewed, he said, I went from evening to morning without pain meds. I have to wait forever for pain meds. Usually there is no one here. On 6/6/2021 at 10:55 AM, Resident #172 (R172) was observed awake and in his room. When interviewed, R172 stated he had a bone infection in his foot after a toe amputation and was to receive intravenous (IV) antibiotics. R172 stated that yesterday he had to go downstairs to the first floor to get some nursing help regarding his scheduled IV antibiotic treatment. R172 stated he finally received a treatment at 1:15 AM but had not received any treatments since. On 6/6/2021 at 11:03 AM, Resident #173 (R173) was heard calling for a nurse. When interviewed, R173 stated his urinary catheter bag needed to be changed, he needed some water, and he had pain in his foot. R173 pulled his call light. The call light system at the nurse's station was observed lit signifying that R173 needed assistance but there was no staff observed around the nurse's station. On 6/6/2021 at 11:10 AM, the telephone located at the 2 North nurse's station was ringing. An unidentified resident answered the phone and said, No one is here. You'll have to call back. When queried about the phone call the unidentified resident said, They wanted a nurse. On 6/6/2021 at 11:18 AM, Resident #52 (R52) was observed awake and lying in her bed. When interviewed R52 said, There might not be a nurse to work this side of the floor (2 North) on afternoon and midnights. I take a lot of meds and have gone without. On 6/6/2021 at 11:23 AM, when interviewed CNA EE stated he still had not seen a nurse on 2 North. On 6/6/2021 at 11:37 AM, when interviewed LPN HH stated she arrived at 11:00 AM today to work on 2 South and that the facility called her in to relieve the midnight nurse. On 6/6/2021 at 11:51 AM, Registered Nurse (RN) C was observed on 2 North. When interviewed she stated she arrived around 10 AM and had been watching over the 1 South med cart. Director of Nursing (DON) BB had just instructed her to come to the 2 North unit. A review of the Medication Administration Records (MAR) for R27, R52, R172, and R173 was conducted with RN C and the following medications were not administered on 6/6/2021 at the designated times: R27: 9:00 AM antibiotic, anticonvulsant, anti-hypertensive, insulin per sliding scale. R52: 6:00 AM anticoagulant, 8:00 AM anticonvulsant, antibiotic, topical wound solution, anticonvulsant, and 9:00 AM antibiotic. R172: 6:00 AM IV antibiotic, 9:00 AM anticonvulsant and long-acting insulin. R173: 9:00 AM anti-coagulant, anti-hypertensive, mood-stabilizer, anti-convulsant, fast-acting insulin, and long-acting insulin. On 6/6/2021 at 12:43 PM during an interview, R173 said, Ain't no nurses usually on shift. When you push the (call) light don't no one come. Today, I ain't had no meds yet. On 6/7/2021 at 10:30 AM, a confidential resident council meeting was held with four facility residents in attendance all of whom were alert and oriented and able to express themselves without difficulty. The following statements were made regarding facility staffing: -There is not enough staff. -The facility is cheap, and they won't hire people. -I was getting ready to go to bed and no one was there to give me a night gown or brief. I slept in my underwear without a gown. -I'm smelling urine and feces on residents. The residents in the building aren't being cleaned. On 6/9/2021 at 3:19 PM, the clinical record for Resident #53 (R53) was reviewed with DON BB in terms of a fall with major injury that occurred on 5/4/2021. DON BB authored the following progress note: Writer called to resident's room by the Housekeeping supervisor. Upon arrival writer noticed three cenas surrounding resident who was face down on the floor in the room in front of the bed. Writer noted pooled blood on the floor coming from the face of the resident. Writer and other staff were calling the resident by name and he was responsive. Writer rolled the resident into a supine position and cleansed the blood with a clean towel. It was then noted a large gash to the middle of the forehead. The resident remained responsive. 911 was called and in route. Dr. (name) was also notified and wanted the resident transferred to the hospital . DON BB stated she responded to the fall because the only nurse on duty on 5/4/2021 was at lunch. A review of staffing schedules and individual staff punch sheets revealed that the facility had only one nurse working on the following dates and times: 5/4/2021 (census of 69) between 7:00 AM and 7:00 PM 5/9/2021 (census of 65) between 7:00 AM and 2:30 PM 6/4/2021 (census of 67) between 9:00 PM and 12:15 PM on 6/5/2021 6/5/2021 (census of 66) between 12:16 PM and 7:00 PM When interviewed Confidential Staff Informant #1 said, A lot of the residents don't get meds right because there is no one to give it to them. Sometimes I won't see a nurse (on the unit) my entire shift. When interviewed Confidential Staff Informant #2 said, Residents will ask for meds. I have to go to another unit to ask the nurse for the residents' meds and the residents have to wait a long time. When interviewed Confidential Staff Informant #3 said, Wound dressings haven't been done. I will come on shift and will be the only nurse and because of that wound care is further delayed because of med pass. Resident #1 Review of an Admission Record revealed, Resident #1 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 3/12/21 revealed Resident #1 had severe cognitive impairment, with a Brief interview for Mental Status (BIMS) score of 2, out of a total possible score of 15. Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Medications that were not passed on 6/5/2021 included an anticonvulsant, antibiotic, antianxiety, and antipsychotic. Resident 8 (R8) On 6/6/21 at 11:44 A.M, R8 complained frequently his food was served cold and on last night (Saturday 6/5/2021) meals were served very late because the food cart had been left on the elevator. R8 reported the food cart was left on the elevator for over an hour and there was no nursing staff to pass the trays on the 1 North Hall. R8 continued stating, his grits at breakfast were sometimes so cold they jelled because there may be only one nurse aide or nurse to pass their trays. R8 stated: There is not enough staff and on 6/5/21 for dinner the nurse was not available for residents on this hall. Review of the Admission Record for R8 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented R8 had a BIMS of 15/15 (intact thought process). The resident was identified as being independent for eating and required set up only. Resident #16 (R#16) During interview on 6/6/21 at 9:30 AM, R#16 stated, There is never enough staff here and we don't get medications on time and sometimes not at all. Record review of R#16's Admission Record on 6/7/21 revealed resident was admitted into facility on 2/9/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS dated [DATE], R#16 had intact cognition and was extensive to total dependence with Activities of Daily Living (ADLS). Record review of R#16's MAR for 5/9/21 at 9:00 AM revealed medications that were not signed out as administered included an antipsychotic, diuretic for hypertension, and two antipsychotics. Resident #19 Review of an Admission Record revealed, Resident #19 originally admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment, with a reference date of 2/13/21, revealed Resident #19 had severe cognitive impairment. Review of a MAR for Resident #19 revealed medication not passed on 6/5/2021 included an anticonvulsant and antipsychotic. Resident 20 (R20) Review of the Admission Record revealed R20 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R20's May 2021 MAR, medications not passed on 5/4/2021 included an anti-hypertensive, anti-coagulant, anti-convulsant, fast-acting insulin per sliding scale, long-acting insulin, and pancreatic enzymes. Medications not passed on 5/9/2021 included an anti-coagulant, anti-convulsant, fast-acting insulin per sliding scale, anti-hypertensive, and pancreatic enzymes. According to R20's June 2021 MAR, medications not passed on 6/5/2021 included an anti-hypertensive, anticoagulant, anticonvulsant, fast-acting insulin per sliding scale, long-acting insulin, and pancreatic enzymes. Resident #22 Review of an Admission Record revealed, Resident #22 originally admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MAR for Resident #22 revealed medications not passed on 6/5/2021 included an antihypertensive, anticoagulant, and antipsychotic. R27 Review of the Admission Record revealed R27 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R27's May 2021 MAR, medications not passed on 5/4/2021 included an anticoagulant, anticonvulsant, anti-hypertensive, and fast-acting insulin per sliding scale. Medications not passed on 5/9/2021 included an anticoagulant, anticonvulsant, anti-hypertensive, and fast-acting insulin per sliding scale. According to R27's June 2021 MAR, medication not passed on 6/5/2021 included an antibiotic, fast-acting insulin per sliding scale. Resident #32 R(#32) During interview with R#32 on 6/6/21 at 8:42 AM, R#32 stated, They (facility) needs more help. Record review of R#32's Admission Record, revealed an original admission into facility on 4/6/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS dated [DATE], R#32 had intact cognition and needed supervision with most ADLs. Record review of R#32's MAR for 5/9/21 revealed the following 9:00 AM medications were not signed out as administered an antiplatelet and antihypertensive. Resident #36 (R36) On 6/6/21 at 11:44 A.M. during the initial tour and on 6/7/21 at 2:00 P.M., R36 complained on Saturday, 6/5/2021, the dinner trays were left on the elevator for over an hour because there was no nursing staff to pass trays. R36 stated: It's not enough staff to take care of the residents. Food is served cold, and we end up waiting for our medications because the nurse is on the other side passing those residents their medications. R36 commented: Sometimes (R8 in the room across the hall) responded to his call light because nursing staff was on another floor. Review of the Admission Record for R36 indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] documented R36 had a BIMS of 15/15 (intact thought process), was independent for eating and required set up only. Review of the May 2021 MAR For R36 revealed medication not passed on 5/4/2021 included an inhaler. Medications not passed on 5/9/2021 included a pain medication, inhaler, antihistamine, antihypertensive agent, antipsychotic and antianxiety. Resident 38 (R38) Review of the Admission Record for R38 indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/21 at 10:30 A.M., review of the MDS dated [DATE], documented R#38 had a BIMS of 15/15 (intact thought process) required limited assistance with eating. Review of R38's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/6/21 at 11:44 A.M., R38 approached the surveyor and stated: There is not enough staff. The resident continued to follow the surveyor and commented: On 6/5/21 at the dinner meal he was the last resident to receive his tray because there was not enough nursing staff, and the nurse could not be located to inquire about his food. R38 asked to be interviewed later (6/7/21) after smoking time. R38 stated he had requested for the carton containers on his tray to be opened because of his arthritis but on 6/5/21 he could not open the carton. Pointing to the unopened milk cartons on the bedside table, the resident stated: No one could help me there was no staff downstairs. On 6/7/21 at 1:17 P.M. during an interview with Dietary Cook O concerning the delivery of the resident's meals tray on 6/5/21. Cook O stated: Around 6:30 P.M. She went to the first floor to return the food cart to the kitchen. The Cook discovered the one North Food Cart still on the elevator with approximately 10-12 resident's trays that had not been served. Cook O was instructed by her supervisor and the Administrator (who were contacted by phone) to pass the trays to the residents. Cook O stated: there was no nurse or Aide on the floor. I passed the trays as I was instructed by the Union Steward. In a subsequent Interview Dietary Manager H confirmed Cook O had been directed to pass the resident's their trays on the one North hall on 6/5/21. On 6/17/21 at 2:20 P.M. during an interview, DON BB stated on 6/5/2021 there was a staff shortage but provided no other reasons why the nurse aides assigned to the floor did not pass trays to the residents on the 1 North hall. Resident 39 (R39) Review of the Admission Record for R39 indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R39's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications not passed on 6/5/2021 included a mood stabilizer, antihypertensive agent, anti- [CONDITION(S)], and neuropathic (nerve) pain agent. Resident #42 (R#42) During interview on 6/6/21 at 8:50 AM, R#42 stated, Sometimes we don't get medications like we are supposed to, and they sure don't have enough staff. Record review of R#42's Admission Record revealed admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS dated [DATE], R#42 had intact cognition and was extensive assist with personal hygiene. Record review of R42's May 2021 MAR for 5/9/21 at 9:00 AM revealed the following medications were not signed out as administered two antihypertensives, anti hyperglycemic, antiplatelet, and antipsychotic. Resident #44 (R#44) Review of an Admission Record revealed, Resident #44 originally admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment, with a reference date of 4/29/21 revealed Resident #44 had severe cognitive impairment with a BIMS score of three, out of a total possible score of 15. Record review of R#44's May 2021 and June 2021 MARs revealed the following medication were not passed. May 4, 2021 included a fast acting insulin and June 4 2021 included an anticonvulsant, antianxiety, fast acting insulin, long acting insulin, antidepressant, and anti-tremor. Resident #51 (R#51) During interview on 6/6/21 at 8:50 AM, R#51 stated, I have to ask for medications they(facility) take forever to get them delivered. Record review of R#51's Admission Record revealed admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS dated [DATE], R#51 had intact cognition and was independent with most ADLs. Record review of R51's MAR for 5/9/21 at 9:00 AM revealed R51's anti-hypertensive medication was not signed out as administered Resident 52 (R52) Review of the Admission Record revealed R52 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R51's MAR for 6/5/2021 revealed medications not passed included an antibiotic, anticonvulsant, and anticoagulant. Resident #56 Review of an Admission Record revealed, Resident #56 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment, with a reference date of 5/21/21 revealed Resident #56 had severe cognitive impairment. Record review of MARs for Resident #56 revealed: Medication not passed on 5/4/2021 included an anticoagulant. Medication not passed on 6/4/2021 included an anticoagulant and antipsychotic. R172 Review of the Admission Record revealed R172 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R172's MAR for 6/5/2021 revealed medications not passed included an IV antibiotic, muscle relaxant, and insulin per sliding scale. R173 Review of the Admission Record revealed R173 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of R173's MAR for 6/5/2021 revealed medications not passed included an anticoagulant, anticonvulsant, antihypertensive, long-acting insulin, and fast-acting insulin per sliding scale. During an interview 6/15/21 at 10:23 AM, DON BB confirmed being the only nurse on duty on 5/9/21 from 7:00 AM to 2:30 PM. On 6/15/2021 at 4:05 PM, during an interview, Nursing Home Administrator (NHA) AA stated they did not have an emergency staffing plan. She said, We're still working on trying to get it where it meets the needs of the facility. When asked if she had a plan to show me, NHA AA said, No. A telephone interview was conducted with the facility's Consultant Pharmacist (CP) JJ on 6/15/2021 at 3:17 PM. CP JJ provided the following information regarding the clinical implications of missed or untimely medication administration for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -anticonvulsants: if being used for seizures it should be given on a timely basis. If it is used as a mood stabilizer, it is less critical but should not be delayed more than two hours. -anticoagulant: if being used as a prophylactic, it is a good practice to stay within plus or minus one hour of the designated administration time. -antipsychotics should be given as prescribed because it is being used for [CONDITION(S)]. -pancreatic enzymes: for the sake of the patient, they should be given regularly, or the patient may experience diarrhea. -insulin: timing is very important. Long-acting insulin should be administered within plus or minus one hour of the designated administration time. Fast-acting insulin should be administered 15 minutes before mealtime or with a meal. On 6/17/2021 at 10:33 AM, when the Director of Nursing was interviewed regarding staffing concerns identified during the survey, she said, I anticipated it, because we have a staffing crisis. I've been in the building as the only nurse, and I know how difficult it is. This is a direct result of not having enough staff. A review of the facility policy titled, Nursing Services and Sufficient Staff, undated, documented the following: It is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident . Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. On 6/15/2021 at 4:35 PM, NHA AA was verbally notified and received written notification of the immediate jeopardy that began on 5/4/2021 and was identified on 6/15/2021 due to the facility's failure to provide sufficient staffing to meet resident needs. The following written plan for removal for the immediate jeopardy was received and verified on 6/16/2021. 1. The facility staffing levels were adequate on 6/15/21 and the resident clinical needs were met as evidenced by the MAR's/TAR's (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The Social Worker interviewed 39 residents with BIMS (Brief Interview for Mental Status) score of 9 or higher for potential neglect on 6/15/21. There were no negative outcomes. 3. Nursing initiated a physical assessments for 28 residents with BIMS score of 8 or below for potential neglect on 6/15/21. There (were) no negative outcomes. 4. Facility staffing policies and procedures were reviewed/revised on 6/15/21. 5. The Emergency Staffing policy was reviewed and revised to include the procedure to address resident clinical needs in the event there are call offs which only leaves (1) nurse in the facility. 6. The policy, (item 4 (e) which now states, The Director of Nursing, Unit Managers, Staffing Coordinator and Administrator will be expected to report to work in the event there are call-offs or no shows of licensed nurses resulting in only one nurse in the building. The Director of Nurses and Unit Managers will facilitate and assist with resident needs based on diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. The Emergency Contingency Plan was reviewed and revised on 6/16/21. 8. A staff Town Hall meeting was initiated by the Administrator on 6/15/21 to provide education and facility staffing policies and procedures. Town hall meetings will be held monthly to provide updates to staff, as well to receive staff feedback and input. 9. A corporate consultant began providing oversight on 6/15/21 of staffing and provides weekly facility visits. Visits will continue weekly for at least 3 months. 10. The Administrator reviewed and revised the Facility Assessment on 6/15/21 and the staffing patterns were adjusted accordingly. Nursing Managers rotate weekends for nursing staffing/scheduling. 11. The facility is actively .recruiting nurses and nurse aides. There were (2) LPN's in orientation on 6/15/21 and (1) LPN interviewed on 6/15/21. 12. The facility is initiating additional staffing resources/agencies, as needed to keep staffing numbers in acceptable parameters. Although the Immediate Jeopardy was removed on 6/15/21, the facility remained out of compliance at a scope widespread and severity of no actual harm with the potential for more than minimal harm that is not an immediate jeopardy due to sustained compliance could not be verified by the state agency.

This citation pertains to MI 492. This citation has three deficient practices. Deficient practice #1. Based on observation, interview, and record review, the facility failed to provide physician ordered wound care treatments, assess and monitor resident's skin condition, and follow the wound care team's recommendations for oral and topical antibiotics for one resident (#27) reviewed for quality of care, resulting in an immediate jeopardy when the resident was sent to the hospital on 5/21/21 and was found to be septic (life threatening blood infection), developed a left foot abscess, and experienced excisional debridement of his left foot down to the level of muscle. Findings include: On 6/6/2021 at 10:12 AM, during the initial tour of the facility, Resident #27 (R27) was awake and lying in his bed. R27 stated he just got back from the hospital on Friday (6/4/2021). R27 said I had poison in my blood. They cut my feet open and cleaned them. I had an infection in both feet. My pain level was 10 out of 10 when I went to the hospital. On 6/8/2021 at 9:50 AM, R27 stated he was sick the whole day prior to going to the hospital. R27 said, I slept the whole day. The next day I got up to go to [CONDITION(S)] and because I was in so much pain, I told the ambulance driver to take me straight to the hospital. The (nursing home) staff were not changing my dressing. Review of the Admission Record revealed R27 was originally admitted on [DATE]. R27 went to the hospital on 5/20/2021 and was readmitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set, dated dated dated [DATE] documented R27 had intact cognition. A review of R27's progress notes revealed the following: -5/21/2021 at 1:26 PM: Resident sent to hospital from [CONDITION(S)]. Doctor and responsible party notified. (This note was created on 5/22/2021 at 1:27 PM.) -6/4/2021 at 5:07 PM: Resident received from (local hospital) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Open area to sacrum coccyx treatment intact .Right lateral foot has an open area treatment intact .Left plantar foot with multiple sutures treatment intact. Left (foot) has an open area to plantar foot. (Nurse Practitioner) aware of admission and current medication. Resident voices no pain at this time. On 6/8/2021 beginning at 11:10 AM, R27's clinical record was reviewed with Director of Nursing (DON BB) and the following was revealed: R27's May 2021 Treatment Administration Record (TAR) review documented: Bilateral feet apply dry bulky protective dressing every two days and prn (as needed) every night shift every other day for protection. Ordered 2/27/2021. During May 2021, the dressing was not done on 5/2, 5/4, 5/6, 5/8, 5/10, 5/12, 5/14, and 5/20. According to DON BB, the implications of not receiving the proper wound care could result in non-healing of the wound, potentially it could have gotten worse, and potentially it could become infected. DON BB said, [CONDITION(S)] is an infection. We know he had a foot infection. R27's Wound care team's note of 5/12/2021 documented in part the following: Wound #8 left MP (metatarsophalangeal) joint is a diabetic ulcer and has received a status of not healed. Subsequent wound encounter measurements are 2.4 cm (centimeter) length x 2.2 cm width x 0.4 cm depth, with an area of 5.28 square cm and a volume of 2.112 cubic cm. There is a moderate amount of sero-sanguineous drainage noted which has a mild odor. Wound bed has pink base epithelialization. Treatment recommendation: [MEDICATION(S)] (topical antibacterial) daily and prn to left foot wounds. [MEDICATION(S)] (oral antibiotic) 500 mg 1 po (by mouth) twice a day x 10 days. Per review of R27's May 2021 TAR, the wound care team changed recommendations from [MEDICATION(S)] (topical wound dressing) to [MEDICATION(S)] daily to left foot wounds. DON BB said, It is not documented on the TAR so we can assume he didn't get it. This could cause the wound to become worse or get worse. A review of R27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A request for skin assessments and shower sheets for March 2021, April 2021, May 2021, and June 2021 yielded one document dated June 8, 2021. On 6/8/2021 at 12:53 PM, DON BB, in the presence of the State Surveyor, called the medical transportation company that takes R27 to and from the hemodialysis center and spoke with Dispatcher UU. Dispatcher UU said, (R27) was taken from (the nursing home) to (local hospital) by us because he was in a lot of pain. On 6/9/2021 at 10:31 AM, Wound Care Team Nurse Practitioner (NP II) stated she recommended the [MEDICATION(S)] for left plantar foot because it had an odor and that's an indication that there may be an infection. I ordered a topical antibiotic. I want them to go ahead and follow my order. If they can't get the treatment, I want them to call me. They did not call about the [MEDICATION(S)] or they could have called (R27's) primary (care physician). A review of R27's consultation from Doctor of Podiatry Medicine (DPM) 3/5/2021 (created on 3/31/2021 at 9:02 PM) documented in part the following: .This patient is seen for a nursing home visit. Patient is seen for preventative foot care. Patient is unable to perform daily checkups to feet .Assessment .Pain in toes .Left foot more breakdown .Plan .Please continue off loading techniques to prevent any ulcerations or breakage of skin .Order wound care . A review of R27's consultation from Nurse Practitioner (NP ZZ) on 4/1/2021 documented in part the following: NP acute visit .follow up on acute and chronic medical problems .Assessment: Diabetic foot ulcer- local care as directed by Wound Care Team . A review of R27's consultation from NP ZZ on 5/6/2021 documented in part the following: NP acute visit .follow up on acute and chronic medical problems .Assessment: Diabetic foot ulcer - local care as directed by Wound Care Team . A review of R27's hospital records for the admission between 5/20/2021 and 6/4/2021 documented the following: Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Surgical Procedure: I&D (incision and drainage) debridement left foot; excisional wound debridement right foot; repeated debridement of primary closure. -5/20/2021 at 4:02 PM: lab results: Staphylococcus aureus - [CONDITION(S)] resistance detected. Interpretation: positive for [CONDITION(S)] resistant staphylococcus aureus (MRSA). -Blood Culture Collected 5/20/2021 at 4:02 PM. Critical value called to and read back by RN (Registered Nurse) 5/21/21 at 3:06 PM. Culture: staphylococcus aureus anaerobic bottle culture. Results: this result has been designated as a possible significant finding. -Radiology / Diagnostics of 5/20/2021 at 4:21 PM: Left foot. Impression: Skin ulcer and/or gas forming infection or abscess involving the plantar aspect of the fourth metatarsophalangeal joint. -Infectious Disease consult. Blood culture 5/20/2021 MRSA. Radiology: x-ray foot: possible abscess in the plantar aspect foot on admission. Assessment: [CONDITION(S)] with MRSA. Most likely source: foot infection. admitted with right foot diabetic foot ulcer and a left foot diabetic foot ulcer associated with abscess. Status/post (s/p) left foot wound debridement with incision and drainage of abscess. S/P incision and debridement on 5/25/2021. Plan/Recommendation: [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (antibiotic). -Radiology report of 5/21/2021 at 11:02 PM: Complete left foot. Impression: skin ulcer and/or gas forming infection or abscess involving the plantar aspect of the fourth metatarsophalangeal joint. -Progress note 6/4/2021 at 10:30 AM: Impression: left foot abscess status post [MEDICAL RECORD OR PHYSICIAN ORDER] . -DPM: Left foot: lateral forefoot ulceration measure 2x1.5x1.5 cm opening to muscle layer, surgical closure site with sutures intact. On 6/08/2021 at 3:10 PM, observations of R27's feet were made in the presence of Certified Nursing Assistant (CNA) PP. Bottom of Right foot had small opening with red base. Left foot had open area where baby toe was removed. Multiple sutures were observed across the bottom of the left foot diagonally (baby toe to heel). Small opening noted midway of sutures. A facility policy titled, Wound Treatment Management, undated, was reviewed and revealed the following: -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. -Treatments will be documented on the Treatment Administration Record Nursing Home Administrator (NHA) AA was notified of an Immediate Jeopardy on 6/9/2021 at 9:20 AM that began on 5/21/21, due to the facility's failure to provide the physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A written plan for removal for the immediate jeopardy was received and verified on 6/14/2021. 1. Resident #27 will receive wound care treatment per the physician orders on 6/9/21, which reflects the order of using [MEDICATION(S)] daily and prn to his left foot wounds. Effective 6/9/21, it will be documented on the TAR in (electronic health record) as being done. 2. Effective 6/10/21, the days in which the resident has to go to [CONDITION(S)], the contracted wound care team will evaluate and provide care upon his return back to the facility. In the event the contracted wound care specialist has left before he returns, a licensed nurse will provide his wound care treatment, which includes measurements. 3. The licensed nurses will conduct skin assessments on 6/9/21 for the residents within the facility to ensure there are no new skin issues. On 6/9/21, 66 of 67 skin assessments were completed. One resident was out to [CONDITION(S)] and their skin assessment will be completed upon their return. One of the skin assessments revealed that a resident had excoriation on both feet. The physician and resident's responsible party was notified, and a treatment was put in place. This resident will be evaluated by the contracted wound team on 6/16/21 and current treatment plan will remain in place. 4. On 6/9/21, the wound care policy was reviewed by the Administrator, Medical Director and Director on Nursing to ensure it's appropriate as written. it was deemed appropriate as evidenced by, meets the current standard of care. 5. On 6/9/21, the licensed nurses will be re-in-serviced on the wound care policy and their responsibility to ensure weekly skin assessments are being completed. Approximately 5 out of 15 licensed nurses have been in-serviced as of today. Only those who have been educated on the wound care policies and standards of care, will be allowed to provide those services. The education of the remaining nurses should be completed by 6/10/21. 6. On 6/2/21, a new wound care nurse was hired, and her official start date will be 6/14/21. Her sole responsibility will be wound care, skin care and preventative care, rounding with the contracted wound care team and carrying out any new recommendations from the contracted wound care team. The Unit Manager responsible for that floor, will complete wound care in the absence of the Wound Care Nurse and the Unit Manager is trained. 7. On 6/9/21, the contracted wound care notes will be scanned into the medical record when received from the wound care team. The licensed nurses will have access to the notes and/or recommendations given by the wound care company. The wound nurse or designee will be responsible for reviewing the information within 24 hours of receiving it from the wound care team and transcribing any new recommendations on to the TAR after verification from the primary care physician. The skin integrity care plan will be updated accordingly. If there are any new areas, the responsible party and physician will be notified. 8. On 6/14/21, 7 residents who are seen by the contracted wound team for either pressure ulcers, diabetic ulcers and/or surgical ulcers, were reviewed. Residents care plans were reviewed and/or revised. 9. On 6/14/21, a new wound care nurse started her full-time position. Her sole responsibility will be wound care, skin care and preventative care, rounding with the contracted wound care team and carrying out any new recommendations from the contracted wound care team. The Unit Manager responsible for that floor, will complete wound care in the absence of the Wound Care Nurse and the Unit Manager is trained. Although the Immediate Jeopardy was removed on 6/14/21, the facility remained out of compliance at a scope isolated and severity of actual harm due to not all facility staff had received education and the State Agency could not verify sustained compliance. Deficient practice #2. Based on interview and record review, the facility failed to monitor and assess a potentially toxic medication ([MEDICATION(S)]) for one resident (#53), reviewed for management of drug levels, resulting in a missed opportunity for timely management of known physiological condition and potential for relapse in mood symptoms. Findings include: A review of the Admission Record revealed Resident #53 (R53) was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] documented severe cognitive impairment. A review of R53's clinical record documented the following: -[MEDICATION(S)] solution 250 mg/5ml, give 750 mg by mouth two times a day related to mood disorder due to known physiological condition. Order date 5/27/2020. -[MEDICATION(S)] ([MEDICATION(S)]) levels one time a day every 90 days for labs. Order date 3/3/2020. -[MEDICATION(S)] level requested 2/21/2021. On 6/15/2021 at 12:29 PM, according to Director of Nursing (DON BB) [MEDICATION(S)] levels are to be obtained so you know if the resident is therapeutic or not. Review of R53's clinical record did not reveal the [MEDICATION(S)] level results requested on 2/21/2021. On 6/16/2021 at 10:42 AM, DON BB stated, Yesterday we requested the lab results (from 2/21/2021) and ordered another lab (to be drawn). DON BB acknowledged the [MEDICATION(S)] results were not obtained and reviewed and the subsequent lab obtained in a timely manner. A review of R53's lab test performed on 2/22/2021, obtained by the facility on 6/15/2021, documented [MEDICATION(S)] of 25L (low) ug/ml (micrograms per milliliter). Reference range: 50.0-100.0 ug/ml. On 6/17/2021 at 3:14 PM, a telephone interview was conducted with Psychiatric Nurse Practitioner (NP GG) who stated R53 had a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP GG stated she did not receive the lab results obtained February 2021. NP GG said, That's what I need, and I never get it. I don't have access to the results. In reference to R53's level of 25 ug/ml, NP GG stated, That's too low. I think that it could cause mood levels that would not be as stable as they could be. If the lab results come in, as a courtesy it would be nice to get a call if the levels are subtherapeutic. A review of the facility document used to train nursing staff titled, Laboratory, X-ray and EKG Orders, undated, revealed the following: -To ensure that diagnostic procedures are done based on medical necessity on a timely manner and abnormal results are referred to the physician. -Abnormal lab and X-ray results must be referred by the licensed nurse to the attending physician as needed and flagged for review. The attending physician will address any abnormal labs and will document interventions as needed and the reason why no intervention was required. A review of the facility policy titled, Laboratory Standing Order, undated, revealed the following: -It is the policy of this facility to obtain, maintain and monitor labs and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab draw will be ordered on admission and subsequently thereafter, based on diagnosis, symptoms, and/or medication ordered as follows: -[MEDICATION(S)] level every 3 months. Deficiency Practice Statement #3 Based on interview and record review the facility failed to ensure follow-up appointments were scheduled for 1 of 22 residents (Resident #19) resulting in the potential for undetected decline in health. Findings include: Review of an Admission Record revealed, Resident #19 originally admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/13/21 revealed Resident #19 had severe cognitive impairment. Resident #19 required extensive assistance of one staff with dressing, hygiene, and bathing. Review of a Progress Note with a date of 3/11/21 at 8:38 a.m. revealed, .Resident was transferred to (hospital name) instantly. Review of a Progress Note with a date of 3/13/21 at 10:50 p.m. revealed, pt alert and verbally responsive . arrived via ambulance-medications reviewed and transcribed as ordered . Review of Patient Discharge Instructions with a date of 3/3/21 revealed, Resident #19 had follow-up appointments which included: physician appointment in 1 to 2 weeks and Eye Institute 1 to 2 weeks. Review of a Transition of Care Form with a date of 3/12/21 revealed, follow-up appointment with physician in 2 weeks, please follow up with neurosurgery and request HEAD CT WITHOUT CONTRAST for subsequent primary care follow up. In an interview on 6/15/21 at 12:06 p.m., Unit Manager HH reported the Unit Manager does the follow up appointments when a resident is admitted . In an interview on 6/15/21 at 12:31 p.m., Director of Nursing (DON) BB reported Resident #19 did not go on follow-up appointments. DON BB then reported follow-up appointments are done by Staffing Coordinator PP or the nurse that does the admit.

Based on observation, interview, and record review the facility failed to implement the wound care program for 1 of 22 residents (Resident #52) reviewed for pressure ulcers, who was admitted on [DATE] with a stage 4 (deep wound reaching into muscle and bone with extensive damage) pressure ulcer on Sacro coccyx (upper buttock-back area) and stage 4 right ischium (upper thigh) pressure ulcer and facility staff did not transcribe and implement the hospital wound care orders until 5/13/2021. Wound care was missed on 5/15/2021, 5/16/2021, and 5/21/2021. This deficent practice resulted an immediate jeopardy for R#52, when wound care orders from hospital were not implemented on 5/10/21 and R#52 was readmitted on [DATE] to the hospital emergency room with a septic (harmful infection) pressure ulcer. This deficient practice effects an additional 66 residents at risk for serious injury, harm, and/or death. Findings include: Review of R#52's face sheet revealed original admission into facility on 5/10/21 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#52's Minimum Data Set (MDS) dated [DATE] documented R#52 had intact cognition and was total dependence with most Activities of Daily Living (ADLS). Review of R#52's Treatment Administration Record (TAR) for May 2021 documented the following: Cleanse/irrigate with wound cleanser loosely pack sacrum and right ischium with kerlix(gauze) the is moistened with med honey (wound medication). Cover with ABD (large absorbent pad) pads and secure with fabric tape daily and prn (as needed) when soiled. Order date:5/12/21 (two days after admission). Review of TAR revealed missing treatment opportunities on 5/15/2021, 5/16/2021, and 5/21/2021. Review of R#52's hospital records dated 5/22/21 at 14:00 (2:00 PM) documented Reason for admission: [CONDITION(S)] (harmful infection) decubitus ulcer (pressure ulcer). During an interview with R#52 on 6/09/21 at 10:10 AM, R#52 confirmed she was unable to reposition herself and felt that her wounds were getting better. R#52 confirmed that she had not seen the wound care team yet but hoped to see them that day. During an interview with R#52 on 6/16/21 at 10:30AM, R#52 confirmed that in May the staff did not perform her wound care as ordered from hospital. R#52 confirmed wound care was not done for a couple days after arrival. R#52 confirmed that bandages would be saturated and left on all day. R#52 stated, My wounds were changed twice a day when I was in the hospital, I think the reason I got an infection was because they (facility) didn't do my wound care correctly. During an interview with Wound Consultant (DNP II) on 6/16/21 at 11:34 AM it was confirmed that wound consultants were not informed they needed to see resident until 6/9/21. During an observation of wound care on 6/16/21 at 11:45 AM it was confirmed R#52 had a stage 4 pressure ulcer to Sacro coccyx area and a Stage 4 to right ischium and both remained unhealed. During an interview on 6/17/21 at 2:10 PM, with Director of Nursing (DON) BB it was confirmed the admitting nurse documented on a progress note on 5/10/21 and acknowledged R#52 had pressure ulcers. DON BB confirmed all wound care should be done as ordered for new admissions as well as resident identified to have new pressure ulcers. DON BB confirmed that resident was admitted on [DATE] and wound care was not started until 5/13/21. DON BB confirmed that wound care for R#52 was not consistently administered. On 6/17/21 at 3:05 pm, Administrator AA was notified of the Immediate Jeopardy (IJ) that began on 5/1021 due to the facilities failure to implement wound care program for R#52. A written plan of removal for the immediate jeopardy was received and verified on 6/17/21. 1. Resident #52 received wound care treatment per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #52 was seen by the wound team on 6/16/21 and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was placed on a low air loss mattress, will be frequently repositioned, will evaluate bilateral lower extremities and we will float heels. Resident will continue to be seen by wound care team weekly and the facility wound nurse/designee will complete the treatments, as recommended. Treatment progress will be documented every other day and as needed. Physician will be notified immediately of any changes in the status of the wounds. 3. The licensed nurses will conduct skin assessments on 6-9-21 for the residents within the facility to ensure there are no new skin issues. On 6/9/21, 66 of 67 skin assessments were completed. One resident was out to [CONDITION(S)] and their skin assessment will be completed upon their return. One of the skin assessments revealed that a resident had excoriation on both feet. 4. On 6/14/21, 7 residents who are seen by the contracted wound team for either pressure ulcers, diabetic ulcers and/or surgical ulcers, were reviewed. Residents care plans were reviewed and/or revised. 5. On 6/9/21, the wound care policy was reviewed by the Administrator, Medical Director and Director of Nursing to ensure it is appropriate as written. It was deemed appropriate as evidenced by, meets the current standard of care. 6. On 6/9/21, the licensed nurses were re-in serviced on the wound care policy and their responsibility to ensure weekly skin assessments are being completed. Approximately 9 out of 15 licensed nurses have been in serviced as of 6/14/21. Only those who have been educated on the wound care policies and standards of care, will be allowed to provide those services. The education of the remaining nurses should be completed by 6/14/21. 7. On 6/14/21, a new wound care nurse started her full-time position. Her sole responsibility will be wound care, skin care and preventative care, rounding with the contracted wound care team and carrying out any new recommendations from the contracted wound care team. The Unit Manager responsible for that floor, will complete wound care in the absence of the Wound Care Nurse and the Unit Manager is trained. 8. On 6/9/21, The contracted wound care notes will be scanned into the medical record when received from the wound care team. The licensed nurses will have access to the notes and/or recommendations given by the wound care company. The wound nurse or designee will be responsible for reviewing the information within 24 hours of receiving it from the wound care team and transcribing any new recommendations on to the TAR after verification from the primary care physician. The skin integrity care plan will be updated accordingly. If there are any new areas, the responsible party and physician will be notified. Although the immediate jeopardy was removed on 6/14/21, the facility remained out of compliance at a scope of isolated and severity of actual harm due to sustained compliance had not yet been verified by the State Agency.

Based on interview and record review, the facility failed to provide proper supervision and implement appropriate safety interventions for 1 of 22 residents (Resident #53) reviewed for accidents, resulting in a fall, three-inch wound to forehead, and an emergency hospital encounter with admission. Findings include: A review of the Admission Record revealed Resident #53 (R53) was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included injury of head, muscle wasting and atrophy, [CONDITION(S)] with delusions, adjustment disorder with disturbance of conduct, mood disorder, and [CONDITION(S)]. Review of the Minimum Data Set (MDS) dated [DATE] documented severe cognitive impairment, one person limited physical assistance for bed mobility and transfers, supervision for locomotion about the unit, unsteady and only able to stabilize himself with staff assistance while walking, moving from seated to standing position and surface-to-surface transfers, and one-person extensive physical assistance for walking in his room. The MDS indicated R53 was to use a wheelchair for a mobility device. A review of R53's clinical record documented in part the following: -5/4/2021 nurse note: Writer called to resident's room by the Housekeeping supervisor. Upon arrival writer noticed three cenas (Certified Nurse Aides) surrounding resident who was face down on the floor in the room in front of the bed. Writer noted pooled blood on the floor coming from the face of the resident. Writer and other staff were calling the resident by name and he was responsive. Writer rolled the resident into a supine position and cleansed the blood with a clean towel. It was then noted a large gash to the middle of the forehead. The resident remained responsive. 911 was called and in route. (Physician) was also notified and wanted the resident transferred to the hospital . -5/12/2021 nurse note: Resident returned to facility at approx (approximately) 1130 am via stretcher accompanied by 2 EMTs (emergency medical technician) from (local hospital). Resident is a readmit from (unit) who suffered a fall about 1 week ago. (R53) is incontinent to (bowel and bladder) .and is a fall risk. Three inch wound noted to center of resident's forehead in late stages of healing with no signs of infection noted. (Physician) aware of resident's return and medications entered into (electronic health record). Review of R53's care plans documented the following: Actual Fall related to Confusion was reviewed/updated on 1/18/2019, 7/23/2019, and 5/14/2021. Interventions included: Remind resident to use call light and ask for assistance when needed. Alteration in Communication related to diagnosis of dementia with confusion . was reviewed and updated on 2/17/2015/8/7/2019. Interventions included .Anticipate needs and accommodate accordingly each shift and prn (as needed) . Staff will anticipate needs which resident cannot communicate clearly, will provide care as needed Potential for Fall and Injury related to [CONDITION(S)] medication use, dementia diagnosis with poor decision making skills, generalized weakness, poor safety technique, as evidenced by: impulsive attempts to transfer self and to stand without staff assistance. (R53) can be uncooperative with care. This care plan was reviewed/updated on 2/17/2015, 9/20/2016, 12/3/2018, and 8/7/2019. Interventions included: Check wheelchair for functionality and safety prior to resident using it, daily and prn (as needed) .Encourage and remind resident to use call light, to ask for assistance with transfers and ambulation, prior to attempts to transfer or ambulate alone. Answer call light in an appropriate amount of time, respond to resident's needs promptly .Ensure a safe environment; make sure call light is within reach for the resident. Maintain clutter free environment .Frequent visual checks throughout each shift .Monitor frequently if resident wanders, provide activities and refocus/reorient to a supervised area as often as possible .One person assist with all transfers. On 6/09/2021 at 3:19 PM, Director of Nursing (DON) BB stated she authored R53's nurse note of 5/4/2021. DON BB reported that there were no written witness statements because the witnesses did not have much to say. On 6/14/2021 at 11:58 AM, Certified Nurse Aide (CNA) Y stated, I was standing outside of (R53's) room talking with another CNA. I had my back to his doorway, so I don't know how he got back into his room. (R53) can walk but his gait is not great. He's unstable (while walking) and it's getting worse. On 6/14/2021 at 12:10 PM, CNA EE stated, (R53) was in the dining room (prior to his fall). I saw (R53) walking back to his room. He usually walks from the dining room to his room. He's not supposed to be walking independently. CNA EE denied assisting R53 or seeking assistance for R53 when the Resident was observed walking back to his room. On 6/16/2021 at 10:26 AM, when DON BB was interviewed regarding R53's fall and stated, (Prior to R53's fall) there was a CNA standing outside of his room. R53 is able to move about freely. He's not on a one-to-one. We believe he was trying to get back in bed. DON BB reported that if a resident is observed walking and appears to be unstable, staff should stabilize them and assist them. When DON BB was informed that staff reportedly saw R53 walking by himself but did not provide assistance, she stated, That's not what they told me. The facility document titled, Fall Prevention Program, undated, was reviewed and revealed the following, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

This citation pertains to intake MI 114. Based on interview and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #601) out of four residents reviewed for anticoagulant use, resulting in bleeding from the mouth and nose and an emergent transfer to the hospital. The initial Immediate Jeopardy (IJ) was identified on 3/3/2021 at 8:30a.m. which began on 2/8/2021. The facility Administrator was notified of the IJ and a request for a written plan for removal occurred on 3/3/2021 at 8:30 AM. Findings include: Resident #601 Review of an Admission Record revealed, Resident #601 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] · [MEDICATION(S)] Solution inject 1 ml subcutaneously every 8 hours for blood clotting prevention with a start date of 2/2/21. · [MEDICATION(S)] Sodium Tablet Give 21 mg via G-Tube (tube inserted in abdomen) one time a day every Monday and Friday . ** ENSURE THAT PT/INR ARE DONE AS ORDERED with a start date of 2/7/21. · [MEDICATION(S)] Sodium Tablet Give 15 mg via G-Tube at bedtime every Tue, Wed, Thu, Sat . ** ENSURE THAT PT/INR ARE DONE AS ORDERED also with a start date of 2/7/21. · PT/INR call lab for results q (every) Mon/Wed/Friday and md for [MEDICATION(S)] dosing with a start date of 12/29/20 and discontinued 2/9/21 but then, reordered (see below) · PT/INR call lab for results Friday and md for [MEDICATION(S)] dosing one time a day every Fri for dosing with a start date of 2/12/21. Resident #601's medical record revealed 8 doses of [MEDICATION(S)] and 26 doses of [MEDICATION(S)] continued to be administered after 2/7/21 without adequate monitoring. Review of the facility's policy titled, High Risk Medications - Anticoagulants with no date revealed, Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety . Policy Explanation and Compliance Guidelines . 3. Routine labs, including subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner . This policy does not prohibit the administration of high-risk medications when subsequent labs are not obtained as ordered. In an interview on 3/2/21 at 1:44 p.m., the Director of Nursing (DON) reported the nurse documents the PT/INR value on a sheet in the narcotic book and in the progress notes. Resident #601's medical record does not reflect that a PT/INR was obtained as ordered on Monday, 2/8/21 or on Friday, 2/12/21 and 2/19/21 for therapeutic dosing of the prescribed anticoagulant. Interview on 3/2/21 at 3:24 p.m., the DON reported the nurse should not give [MEDICATION(S)] ([MEDICATION(S)]) if the PT/INR is not obtained as scheduled. Further review of Resident #601's medical record revealed progress notes dated 2/22/21 at 4:16 p.m. Note Text: resident was bleeding from nose and mouth clots of blood vitals were t (temperature) 98.4, spo2(oxygen level) 100%, p (pulse) 107, bp (blood pressure) 148/94, r (respirations) 18 called MD new orders are transfer resident to (Hospital Name). Resident #602's Progress Note Discharge Summary read, . admitted following hospital stay for CVA (stroke) s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Earlier today he was noted to have oral bleeding with large clots per nursing staff. He was noted to have hypertension and tachycardia. Patient was discharged to nearest hospital for evaluation . Review of a Facility Investigation summary for Resident #601 revealed, Writer was notified on 2/22/21 at approximately 4:30 pm the (Resident #601) was noted to have blood that seemed to be coming from the nose and mouth . Upon assessment it was noted that a small amount of dried blood was at the base of nares and a small amount of bleeding at the right corner of the mouth. Writer also noted blood on left hand and under fingernails . In an interview on 3/2/21 at 3:20 p.m., the DON reported Physician A told her that Resident #601 received Vitamin K, had an elevated INR, and was admitted to the ICU (Intensive Care Unit). The DON then reported R#601's INR value was last monitored on 2/5/21. Review of Emergency Department (ED) records provided by the hospital revealed, on 2/22/21 9:55 p.m. Resident #601 presented to the ED with a complaint of epistaxis (bleeding from the nose). The patient received a craniotomy last week and has had nosebleed for the last 5 hours . Laboratory work . INR 4.29 (normal value of INR is 0.80 - 3.50) . There is evidence that this patient is on [MEDICATION(S)] and subcutaneous [MEDICATION(S)]. His anticoagulation will be reversed with [MEDICATION(S)] (medication used to reverse the effects of [MEDICATION(S)]) and vitamin K IV (medication through vein) . The facility's plan to remove the Immediate Jeopardy was accepted on 3/3/21 by the state agency and on 3/3/21, the state agency verified the immediacy was removed. The removal plan included: · Beginning 3/3/21, an audit of all residents on anticoagulants ensured physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] · Beginning 3/3/21, a revision of the anticoagulant therapy policy titled High Risk Medications - Anticoagulants to include that no anticoagulant therapy ([MEDICATION(S)]) will not be dispensed to any resident with the absence of lab results. · Beginning 3/3/21, all licensed nurses to be in-serviced on the revised anticoagulant policy and to follow professional standards of practice as it relates to anticoagulant therapy. · Beginning 3/3/21, weekly auditing or residents on anticoagulants ([MEDICATION(S)]) to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Although the immediate jeopardy was removed on 3/3/2021, the facility remained out of compliance with a scope of isolated and severity of actual harm due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance had not been verified by the state agency.

Based on observation, interview, and record review, the facility failed to 1.) isolate 3 newly admitted /readmitted residents (Residents #509, #510, and #511) for Transmission Based Precautions per National Standard (Centers for Disease Control) guidelines and Local Health Department recommendations from a total of 3 sampled residents reviewed for infection control , 2.) ensure staff wore the appropriate recommended PPE (Personal Protective Equipment) while providing care for and working with newly admitted /readmitted residents, and 3.) ensure newly admitted /readmitted residents were properly monitored for signs and symptoms for COVID-19 , resulting in an immediate jeopardy starting on 8/14/20, when the facility staff did not follow National Standard guidelines for Transmission Based Precautions. This deficient practice placed all 84 residents and staff members at risk for serious harm, injury and/or death. On 8/20/20 at 5:40 p.m., The initial Immediate Jeopardy (IJ) concern was identified on 8/20/2020 at 1:14 a.m. and began on 8/14/2020. The facility Administrator was notified of the IJ and a request for a written plan of correction for removal occurred on 8/20/2020 at 5:40 a.m. Findings included: On 8/20/20 at 11:07 a.m., during the Entrance Conference with the Director of Nursing was asked to confirm the number of COVID-19 positive residents if applicable, where in the building was the resident located. The DON stated there was one COVID positive resident in the facility located on 2 North and on isolation precautions. The DON was then asked does the facility have an observation unit for new admissions or readmissions, and if so where are they located. The DON stated, No not necessarily, they are put on 2 North for observation if there is a room available. And if not, they are put on a regular long-term unit. But we try to. Review of the facility's list of new admissions or readmission residents from 7/20/20 to 8/20/20 identified three new admission/readmission residents R#509, R#510, and R#511 with unknown COVID-19 status. Resident #509 On 8/20/20 at 11:43 a.m. review of the clinical record documented R509 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the Resident was cognitively intact and required limited one-person assistance with ADLs. R509 was also identified to be roomed on the first floor in room [ROOM NUMBER], a long-term care unit within the facility. On 8/20/20 at 12:02 p.m., R509 was observed in room [ROOM NUMBER] with two other residents. Upon further observation, there was no PPE cart or precaution sign outside of the room. At that time, lunch was also being passed by staff. On 8/20/20 at 12:05 p.m., CENA F was observed going into room [ROOM NUMBER] to deliver meal trays. CENA F did not have on PPEs except for a surgical mask. CENA F was observed going in and out of the room three times. CENA F was also observed passing out meal trays to other residents on the hall without washing or sanitizing her hands between meal pass. CENA F was asked was room [ROOM NUMBER] an isolated room. CENA F stated, No one in there has COVID, so I don't think so. CENA F was also asked how often should hand sanitizing or hand washing occur between tray pass. CENA F stated, Every 4th tray or something like that. On 8/20/20 at 2:59 p.m., further review of clinical records documented in the electronic record, R509's temperature was not taken consistently since admission. Upon admission (8/14/20), the Resident's temperature was taken and recorded once, on 8/15/20 was taken and recorded once, 8/16/20, was taken and recorded once, 8/17/20 was taken and recorded once, 8/18/20 was taken and recorded once, 8/19/20 was taken and recorded twice. Respiration was taken once a day from the dates of 8/14/20-8/20/20. O2 (oxygen) status was taken once a day except for the dates of 8/14/20, 8/15/20, and 8/18/20. Review of the physician's orders [REDACTED]. Order Date 08/19/2020. There were no readmission orders [REDACTED] Review of the Physician's Progress Note dated 8/14/20, 8/17/20 and 8/18/20 did not document the need the isolation precautions. Resident #510 On 8/20/20 at 3:20 p.m. review of the clinical records documented R#510 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. No MDS were available. According to the facility's admission assessment dated [DATE] documented, R#510 is alert and oriented to name only, and is chair and bed bound. R#510 was identified to be roomed on the second floor in room [ROOM NUMBER]. On 8/20/20 at 3:40 p.m., during the tour of the facility R#510's room door was observed with no isolation precaution signage and PPE cart outside the room. R#510 was observed in his room (220-2) lying in bed without a facial mask with two other residents present also not wearing masks. On 8/20/20 at 3:55 review of R#510's clinical records revealed, no consistency of 14-day monitoring for COVID-19 in the electronic record since admission. Resident #511 On 8/20/20 at 3:30 p.m., R#511's room door was observed with no isolation precaution signage, and PPE cart outside the door. R#511 was observed sitting in the hallway on unit 2 near the nurse's station with no mask. On 8/20/20 at 4:10 p.m., review of the clinical records documented R#511 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. No available MDS available. According to the admission Nurses Progress notes documented, R#511 was alert and oriented x's three, required limited assistance with bed mobility, transfers, and Activity Daily Living (ADLs). On 8/20/20 at 4:25 p.m., review of the Nurses Progress' notes revealed no documentation of monitoring the resident's for signs and symptoms of COVID-19 Review of the resident's clinical record revealed no infection control (COVID-19) care plan. During the interview on 8/20/20 at 12:59 p.m., the Director of Nursing (DON) confirmed that R#509, R#510, and R#511 were not on 14-day isolation precaution. The DON was asked, why was not the newly admitted /readmitted residents in isolation precaution. The DON stated, They are not in isolation because we require the admission residents to have two negative COVID-19 testing before admission and the last negative COVID-19 test within seven days, before they are admitted into the facility. The DON was asked if that was the facility's policy? The DON responded, Yes, I pulled the policy straight from the Center for Disease Control (CDC) guidelines, I get all my policies from the CDC. The DON submitted test results for R#509 while at the hospital for the dates of 7/21/20 and 7/31/20, in which were negative however the R#509 was not admitted into the facility until 8/14/20. The DON did not have preadmission COVID-19 test results for residents R#510 and R#511. The DON was informed that the CDC recommendation stated, .negative results using RT-PCR for detection from at least two consecutive respiratory specimens collected ?24 hours apart (total of two negative specimens) . The DON was then asked, how are the newly admitted /readmitted residents being monitored for sign and symptoms of COVID-19 and where is the nurse's documentation. The DON responded, The nurses monitor the residents and document in the Nurses Progress Notes. Review of the facility's policy titled, Standard Precaution Infection Control, date implemented 04/7/20 and revised 5/18/20 the facility did not include the National Standard (CDC guidelines) for new admissions or readmission residents admitted into the facility. According to the Centers for Disease Control, updated 6/25/20 Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected . Actively monitor all residents upon admission and at least daily for fever (T?100.0oF) and symptoms consistent with COVID-19. Evaluate and Manage Residents with Symptoms of COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry The facility presented an acceptable removal plan for the immediate jeopardy on 8/21/20 at 9:50 a.m. Actions that were performed to address the recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed: Resident #510 no longer resides in the facility, Resident #509, and #511 were moved with their permission to an observation room immediately for 14-day observation and placed on transmission-based precautions on 8/20/20. Resident #511 was assessed by the Nurse Practioner and the assigned nurse and exhibits no signs and symptoms of distress or decline noted. Resident #511vitals were noted to be within normal limits and displays no signs and symptoms of infection on 8/20/20. Resident #509 was assessed by the nurse and displays no signs and symptoms of distress or decline. Resident #509 vitals were noted to be within normal limits and displays no signs and symptoms of infection on 8/20/20. Resident #509 and #511 orders and care plans were reviewed and revised as needed on 8/20/20. CNA #1 was educated on wearing appropriate PPE while providing care and working with newly admitted residents in the building on 8/20/20. The facility's actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when those actions were completed. A facility wide sweep was conducted on 8/20/20 of all residents to assess for sign and symptoms of infection, all remained without signs and symptoms of infection as assessed by the nurse. New admits and re admits will be placed in 14-day observation to include shift to shift monitoring of vital signs. All staff have been educated prior to their next shift of work in the revision of the Coronavirus Surveillance policy which includes being placed in 14-day designated observation of all new admissions and readmissions to include being placed on Transmission Based Precautions for 14 days. All staff have been educated prior to their next working shift on wearing appropriate PPE while providing care and working with newly admitted /readmitted residents in the building. All licensed nursing staff have been educated prior to their next working shift to ensure that all admissions/readmissions are properly monitored for signs and symptoms for COVID-19. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/20/20.

This citation pertains to intakes: MI 0, MI 4, MI 4, MI 3, MI 4. Based on interview and record review the facility failed to provide mental health services for one (R#602) who had a documented severe history of: [MEDICAL CONDITION], autism, auditory hallucinations, and aggressive behavior, resulting in an immediate jeopardy caused by the physical attack and abuse against another resident (R#603) (whom also had documented severe mental health needs and did not receive mental health services), continued unmet mental health needs, and the likelihood of future violent and aggressive behaviors towards others. The immediate jeopardy was identified on 5/22/20 at 11:19 a.m. The immediate jeopardy began on 5/15/20 at 8:15 p.m. when R#603 was observed being physically assaulted by R#602 via social media. The Administrator was notified of the Immediate Jeopardy on 5/22/20 at 3:45 p.m. and a plan for removal was requested. The immediacy was removed on 5/21/20 when R#602 was arrested by local law enforcement and removed from the facility. Surveyors verified the removal of the immediacy on site by record review and interview on 5/27/20. Although immediacy was removed, the facility's deficit practice was not corrected and remained isolated with harm that is not immediate jeopardy. Findings include: On 5/22/20 at 9:34 a.m., the facility submitted a facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 5/15/20. It was initially reported that R#603 had a fall out of the bed that was witnessed by R#602 (unwitnessed by staff), however the facility reported to the state agency as an injury of unknown origin due to the multiple injuries sustained to R#603's head and face. On 5/15/20 at approximately 11:10 p.m., R#603 was transferred to the hospital. On 5/21/20, a video appeared via social media, showing R#602 striking (with closed fists) R#603 multiple times on the head and face areas while whispering profanities, then placing R#603 on the floor. On 5/21/20 at 11:35 a.m., R#602 was arrested by local law enforcement. R#603 remains at the hospital. R#602 Review of R602's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the Resident was cognitively intact (BIMS score of 13) and required one-person assistance with activities of daily living (ADLs). According to the Hospital Referral dated 5/9/20, R#602 (who had a history of [REDACTED]. R#602 stated the voices were telling him to hurt himself. The group home staff reported to the hospital social worker the Resident had been intermittently (not steady or continuously)) aggressive towards group home staff. According to the Risk Assessment, R#602 had risk factors that included: current [MEDICAL CONDITION], highly impulsive/reckless behavior, history of [MEDICAL CONDITION], and history of criminal behavior/violence. On 5/13/20 at 11:08 a.m. the attending psychiatrist reported and documented, .he reports seeing visions of someone murdering another person yesterday . On 5/13/20 at 3:57 p.m., a correspondence between the hospital and facility documented in Referral Comments stated, .Not stable from a psych prospective, no concerns of violence . can you take at your facility . On 5/13/20 at 3:59 p.m., the facility responded with, Yes. Willing to accept patient. Resident #602 arrived at the facility on 5/13/20 at 19:51 (7:51pm). Upon further record review for R#602, baseline care plans (nursing, dietary, behavior, mood, infection control, etc.) were not developed. Record review of R#602 also revealed the Resident was admitted without obtaining a Preadmission Screening/ Annual Resident Review (PASAAR Level I Screening- used to identify prospective and current nursing facility residents who meet the criteria for possible mental illness or intellectual/developmental disability, or a related condition and who may be in need of mental health services.) prior to nursing facility admissions. The PASAAR Level I Screening is typically completed by the transferring entity (i.e. the hospital, the community, or another nursing facility). On 5/28/20 at 11:20 a.m., during a telephone interview with Physician D stated, he was notified by the facility of R602's arrival to the facility on [DATE] at 7:39 a.m. Physician D stated he was surprised of the Resident's age was and prescribed an antipsychotic that is not usually given in a nursing facility. The nurse was uncertain why R#602 was prescribed the medication. Physician D ordered a psych consult due to the antipsychotic. Physician D assessed R#602 on 5/16/20 which was that Saturday. The Resident did not display behaviors or distress; however, Physician D was concerned with the appropriateness of R#602's admission into the facility. Physician D did think the Admissions Coordinator should have reviewed the Resident's other [DIAGNOSES REDACTED]. On 5/27/20 at 11:04 a.m., the Social Service Director A (SSD) was interviewed. The SSD stated, Psych services (psychiatrist, psychologist, and nurse practitioner) were coming into the facility on ce a week on Tuesday before the COVID-19 pandemic. They are now providing services virtually. The SSD was asked was R#602 referred to psych services upon admission. The SSD stated a referral was faxed over to psych services on 5/20/20 (on a Wednesday, presumptive next service date on 5/26/20). The SSD was asked about the delay in referring the Resident to psych services upon admission. The SSD stated, I had just returned to work on 5/7/20 and it had not been sent due to me being off. The SSD was asked was there someone else that could have sent the referral to psych services. The SSD stated, Nursing could have sent referrals while I was off, but I usually send them. The SSD was then asked when should psych referrals be sent. The SSD then stated, I send them as soon as possible but no more than three days after admission. Lastly the SSD was asked if she was aware of the Resident's psych history. The SSD stated, I was not aware; however, I am now. The referral would have been sent immediately. R#603 Review of R603's clinician record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the Resident was cognitively intact (BIMS score 13) and required supervision and one-person assistance with ADLs. According to the Hospital Referral from the psychiatric hospital dated 4/27/20, R#603 initially presented to the emergency room with suicide ideation and attempt (attempted to slice wrists) and increased depression over the past year. The Resident was transferred to the hospital's psychiatric unit on 4/28/20. Per the social worker's evaluation, R#603 was at high risk for suicide as evidenced by current suicide attempt, previous attempts/ideation, poor behavioral control/impulse control, and high emotional distress, and currently requires continuous redirection. The Resident also presented with poor judgement and cognitive impairment. Per the Behavioral Health Admission, R#603 also made statements of, not wanting to be on this earth anymore and getting someone mad at me and stabbing or shooting me. On 5/7/20 at 11:03 a.m., the facility accepted the Resident for admission. R#603 arrived at the facility on 5/7/20 at 16:57 (4:57 pm). Upon further record review for R#603, a baseline care plan for behavior/mood concerns regarding suicide ideation/attempt was not developed. Further record revealed R#603 did have a completed PASAAR Level I Screening completed by the transferring hospital dated for 5/5/20 and indicated the Resident has a current mental illness diagnosis, received treatment for [REDACTED]. This Resident had not been referred to mental health services from the time of admission (5/7/20) to the time of discharge (5/15/20). On 5/14/20, the attending Physician for R#603, recommended a psych consult for the use of an antidepressant medication. On 5/28/20 at 3:42 p.m., the SSD was interviewed and asked if she was aware of R#603's psych history and was the Resident referred to psych services. The SSD stated, No. The Resident had not been seen or referred to psych services and I was not aware of the history. On 5/28/20 on 3:11 p.m., the DON was interviewed and stated, I was unaware of R602's or R#603's prior psychiatric or behavioral history. There was a small window when psych services and other ancillaries were not coming into the facility due to the COVID-19 pandemic. Psych services provided a tablet for virtual services about a week ago and the nurse practitioner provided services for the first time virtually on 5/26/20. On 5/22/20 review of the facility's policy titled Behavioral Health Services 2020 documented: It is the policy of this facility that all residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning . The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes: PASARR screening; obtaining history from medical records . ongoing monitoring of mood and behavior; care plan development and implementation, and evaluation . Behavioral health care and services shall be provided in an environment that promotes emotional and psychosocial well-being . The Social Services Director shall serve as the facility's contact person behavioral services provided by the facility and outside sources such as physicians, psychiatrists, or neurologist. On 5/27/20, the Administrator presented the facility's plan to remove immediacy. The plan included: 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. R602 was assessed by assigned nurse and denies hallucinations, thoughts of harming self or others and queried regarding allegation, R602 denied all allegations on 5/21/20 11:30am. R602 chart was reviewed and R602 has not exhibited any aggressive behavior as noted by the nurse since admission. On 5/21/20. R602 was transported by Detroit Police Department to an [MEDICATION NAME] Crisis Center 5/21/20 at 11:35 am. Physician and family informed regarding allegation of resident R602 and was made aware that R602 was transported to an [MEDICATION NAME] Crisis Center. Residents identified with like behaviors and a facility wide assessment for residents with identified behaviors. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when those actions were completed. Admissions Director/DON were educated on adhering to the Admission Checklist to include notification to administrator prior to admission for any patients with severe psych history 5/22/20. All new admissions with a psych history will be reviewed by Social Worker to ensure that a patient with a 3877/3878 has been referred for Psych services and will have behaviors monitored according to the Behavior Management Policy. A new admits with identified psych history will have care to indicate non pharmalogical intervention to manage behaviors. Behavior logs will be reviewed in the clinical meeting to ensure interventions are initiated for patients exhibiting behaviors. 3. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: May 22, 2020.

This citation pertains to intakes: MI 0, MI 4, MI 4, MI 3, MI 4. Based on observation, interview, and record review, the facility failed to provide supervision to prevent a [AGE] year old vulnerable male resident (R603) from physical abuse and injury inflicted by a [AGE] year old male resident (R602) who had a previously documented severe psychiatric history ([MEDICAL CONDITION], auditory hallucinations, autism, and aggressive behavior), resulting in head trauma, fracture to left middle finger, soft tissue swelling to left wrist, left sided soft tissue swelling to the head, and soft tissue swelling to bilateral lower face and subsequent hospitalization in addition to the likelihood of compromised safety for all residents that resided in the facility. The immediate jeopardy was identified on 5/22/20 at 11:19 a.m. The immediate jeopardy began on 5/15/20 at 8:15 p.m. when R603 was observed being physically assaulted by R602 via social media. The Administrator was notified of the Immediate Jeopardy on 5/22/20 at 3:45 p.m. and a plan for removal was requested. The immediacy was removed on 5/21/20 when R602 was arrested by local law enforcement and removed from the facility. Surveyors verified the removal of the immediacy on site by record review and interview on 5/27/20. Although immediacy was removed, the facility's deficit practice was not corrected and remained isolated with harm that is not immediate jeopardy. Findings include: On 5/22/20 at 9:34 a.m., the facility submitted a facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 5/15/20. It was initially reported that R#603 had a fall out of the bed that was witnessed by R#602 (unwitnessed by staff), however the facility reported to the state agency as an injury of unknown origin due to the multiple injuries sustained to R#603's head and face. On 5/15/20 at approximately 11:10 p.m., R#603 was transferred to the hospital. On 5/21/20, a video appeared via social media, showing R#602 striking (with closed fists) R#603 multiple times on the head and face areas while whispering profanities, then placing R#603 on the floor. On 5/21/20 at 11:35 a.m., R#602 was arrested by local law enforcement. R#603 remains at the hospital. R#602 Review of R602's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the Resident was cognitively intact (BIMS score of 13) and required one-person assistance with activities of daily living (ADLs). According to the Hospital Referral dated 5/9/20, R#602 (who has a history of [MEDICAL CONDITION] and ASD (Autism Spectrum Disorder) presented from the group home he resided with concerns of worsening auditory hallucinations and paranoid delusions. R#602 stated the voices were telling him to hurt himself. The group home staff reported to the hospital social worker the Resident had been intermittently (not steady or continuously)) aggressive towards group home staff. According to the Risk Assessment, R#602 had risk factors that included: current [MEDICAL CONDITION], highly impulsive/reckless behavior, history of [MEDICAL CONDITION], and history of criminal behavior/violence. On 5/13/20 at 11:08 a.m. the attending psychiatrist reported and documented, .he reports seeing visions of someone murdering another person yesterday . On 5/13/20 at 3:57 p.m., a correspondence between the hospital and facility documented in the Referral Comments which stated, .Not stable from a psych prospective, no concerns of violence . can you take at your facility . On 5/13/20 at 3:59 p.m., the facility responded with, Yes. Willing to accept patient. Resident #602 arrived at the facility on 5/13/20 at 19:51 (7:51pm). Upon further record review for R#602, baseline care plans (nursing, dietary, behavior, mood, infection control, etc.) were not developed. R#603 Review of R603's clinician record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the Resident was cognitively intact (BIMS score 13) and required supervision and one-person assistance with ADLs. According to the Hospital Referral from the psychiatric hospital dated 4/27/20, R#603 initially presented to the emergency room with suicide ideation and attempt (attempted to slice wrists) and increased depression over the past year. The Resident was transferred to the hospital's psychiatric unit on 4/28/20. Per the social worker's evaluation, R#603 was at high risk for suicide as evidenced by current suicide attempt, previous attempts/ideation, poor behavioral control/impulse control, and high emotional distress, and currently requires continuous redirection. The Resident also presented with poor judgement and cognitive impairment. Per the Behavioral Health Admission, R#603 also made statements of, not wanting to be on this earth anymore and getting someone mad at me and stabbing or shooting me. On 5/7/20 at 11:03 a.m., the facility accepted the Resident for admission. R#603 arrived at the facility on 5/7/20 at 16:57 (4:57 pm). Upon further record review for R#603, a baseline care plan for behavior/mood concerns regarding suicide ideation/attempt was not developed. On 5/27/20 at 10:49 a.m., the Admissions Coordinator (J) was interviewed with the Regional Director of Marketing (E) present was interviewed. The Admissions Coordinator confirmed being in the position for three weeks and could not give details of R#602's admission, however the Regional Director of Marketing (E) confirmed he approved the admission of R#602 into the facility. The Regional Director of Marketing was asked was he, the Director of Nursing (DON), and/or Administrator aware of R#602's behaviors prior to admission. The Regional Director of Marketing stated, I was aware of intermittent aggression towards staff in February. There was nothing noted in the hospital referral that indicated the Resident exhibited current aggression, so I felt confident to admit the Resident based on the information given by the hospital. The DON nor the Administrator were made aware of the Resident's psychiatric history. Had they been aware, R#602 would have been put in a private room. On 5/28/20 on 3:11 p.m., the DON was interviewed and stated, I was unaware of R602's or R#603's prior psychiatric or behavioral history. They were both admitted for COVID-19 monitoring. If I were made aware prior to admission, the Residents would have been placed in a private room with one to one supervision for at least 72 hours. Once I learned of the incident that was recorded on 5/15/20 and viewed on 5/21/20, R#602 was place on one to one supervision until the police arrived. When the incident initially presented as R#603 having a fall, the Resident was moved closer to the nurse's station for increased monitoring and supervision. On 5/22/20 review of the facility's policy titled Accidents and Supervision 2019 documented: The residents environment remains as free of accident hazards as is possible; and each resident receives adequate supervision. This includes: identifying hazards and risk; evaluating hazards and risks; implementing interventions to reduce hazards and risk; and monitoring and modifying interventions when necessary . Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards and the risk of a resident having an avoidable accident . All staff (e.g., professional, administrative, etc.) are to be involved in observing and identifying potential hazards while taking into consideration the unique characteristics and abilities of each resident . The facility should make a reasonable effort to identify the hazards and risk factors for each resident . Various sources provide information about hazards and risk factors: .medical history, facility assessment, and individual observation . This information is to be documented and communicated across all disciplines . Supervision- The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: Based on the individual residents' assessed needs and identified hazards. On 5/27/20, the Administrator presented the facility's plan to remove immediacy. The plan included: 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. R602 chart was reviewed and R602 as assessed by the nurse denies observation of R602 exhibiting any aggressive behavior since admission. Following allegation as reported by Washtenaw Detective R602 was queried about allegation, R602 denied all allegations on 5/21/20 11:30am. Local police were notified immediately of allegation as reported by Detective and R602 was transported by Detroit Police Department to an [MEDICATION NAME] Crisis Center on 5/21/20 at 11:35am. R603 was assessed on 5/15/20 by assigned nurse to have been observed on the floor and was sent out to the hospital for further intervention. R603 remains in the hospital for clinical intervention and services at this time. R603 will be assessed for care and interventions upon return to the facility. An Investigation was initiated on 5/15/20 to include nuerochecks, SBAR along with a chart review by the DON and reported to LARA for further review. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when those actions were completed. A facility wide audit was completed for residents who currently reside in the building to ensure appropriate room placement with respect to preference and appropriateness. Admissions/DON/SW was educated to on the appropriate room placement of new admits to the building. New admits will be reviewed in clinical meeting to ensure appropriate room placement per preference. A facility wide audit was completed on 5/22/20 to identify resident with behaviors. Residents identified to have a history of behaviors requiring supervision care plans were reviewed and revised to include a task to monitor behaviors in EMAR. Residents assessed to be exhibiting behaviors that require supervision will be managed according to behavior management policy. A facility wide audit was completed to ensure that current residents feel safe in the facility, Guardian angel program will be initiated to ensure resident needs and concerns are addressed according policy. A skin sweep was conducted to assess residents with cognitive impairment for skin alterations. Residents identified to have skin alterations will be managed according to Skin Care Management policy. 3.Date Facility Asserts Likelihood for Serious Harm No Longer Exists: May 22, 2020.

This citation pertains to intake MI 1766, MI 1925, MI 1893 Based on interview and record review the facility failed to 1. Provide consistent assessment and treatment of [REDACTED]. Follow Physician's wound care orders, effecting three residents (R#96, R#98, R#99) out of three residents reviewed for wound care, resulting in opportunities to treat and evaluate wounds to encourage healing and worsening of R#96's wound requiring hospitalization and possible amputation of limb. Findings Include: R#96 On 4/30/20 at 8:30 a.m., during phone conversation with complainant/ Emergency Medical Technician (EMT), when asked the condition of the wound , EMT stated, When I came to transport the resident to the hospital the wound was exposed with no bandages applied and had a bad odor. I had to wait almost an hour before staff would wrap the resident's foot so that I could transport to hospital. On 4/30/20, record review revealed R#96 had been admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Daily Set ((MDS) dated [DATE], R#96 had impaired cognition and was total dependent of most Activities of Daily Living (ADLS) and transfers. On 4/30/20, Review of Nurse Progress Notes revealed on admission resident had . R (right) and L (left) necrotic heels noted, wound consult needed. Physician notes dated 3/31/20, . She was noted to [MEDICAL CONDITION] secondary to MD (multi-drug) resistant UTI (urinary tract infection) and necrotic bilateral decubitus heel ulcer . Review of Podiatrist order noted on 4/6/20 After speaking with staff nurse and DON (Director of Nursing), recommend patient be sent to hospital (Provider Name) due to worsening right ankle ulcer, patient has active purulence to right ankle with necrosis. Patient would benefit from radiographs (X-rays), CBC with diff (lab test), IV (intravenous) antibiotics and podiatry and vascular consults. Review of Physicians orders, laboratory results and radiology related to above order was not implemented by facility. Physician order [REDACTED]. Noted malodor. I did speak with day nurse in person and DON via phone, we will order stat (as soon as possible) radiographs. Patient needs ER (emergency room ) visit CBC with diff, ESR, CRP (tests), podiatry consult. Review of Nurse Progress notes revealed resident was not sent to ER until 4/15/20. Review of Treatment Administration Record revealed first order Cleanse bilateral feet with ns (normal saline), pat dry, apply kerlix every 2 days. Second order noted Med honey CA alginate (wound dressing). Apply to Right heel topically every day shift every 2 days for diabetic ulcer . Documentation revealed treatments were not performed on 4/1,4/5,4/7,4/9 and 4/11. Review of progress notes revealed no assessment or measurement of wounds performed by nursing staff at facility from 4/1/20- 4/13/20. Review of Discharge Summary by primary physician documented She was sent to ER via EMS (Emergency Medical Services), case discussed with vascular surgery, patient may need amputation. R#99 On 4/30/20, during record review revealed R#99 was originally admitted into facility on 3/26/14 with [DIAGNOSES REDACTED]. According to MDS dated [DATE], R#99 had intact cognition and was extensive assist with ADLs. On 4/30/20, record review revealed R#99 had multiple wounds. Review of Treatment Administration Record noted first order [MEDICATION NAME] Extra AG+Pad (wound dressing) - Apply to left lateral ankle topically one time a day . ; second order noted [MEDICATION NAME] Extra AG+Pad (wound dressing) - Apply to sacral topically one time a day . Review found no documentation that treatment was performed for first order on 4/4, 4/5, 4/8, 4/9, 4/14 and 4/28. Review of second order revealed no documentation that order was performed on 4/4, 4/5, 4/8,4/9,4/14. Review of Assessments revealed no weekly documentation of wound observations or measurements. On 5/1/20 at 1:15pm, during a phone interview with DON, when asked if Physicians orders should always be followed, DON stated, Yes. When asked if nursing staff are not sure how to follow Physician orders [REDACTED]. After reviewing TAR and Assessments, DON was asked if staff should document after administering treatment and provide weekly documentation of observation and measurements of resident's wounds, DON stated, Yes. Resident #98 On 4/30/20 at 9:57 a.m., the complainant reported to the State Agency that the facility did not provide adequate and appropriate care to treat pressure sores and ensure R98 was properly assessed in a timely manner. On 5/1/20 at 9:34 a.m., review of R98's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident left the facility against medical advice on 4/26/20. According to the admission MDS assessment dated [DATE], the Resident was cognitively intact and required one-person extensive assistance with ADLs. Further record review revealed in the nurses notes the following: 4/16/2020 19:08 .Pain was indicated from coccyx, wound on coccyx. 4/25/2020 04:29 .Dressing in dry and intact with moderate amount of drainage. 4/25/2020 19:11 Cleanse sacrum with wound cleanser, pat dry, apply dry dressing and foam pad. Two times a day for Wound care. discharged . According the physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) documented the following wound care treatments were applied: 4/23/20 Cleanse sacrum with wound cleanser, pat dry, apply dry dressing and foam pad. Two times a day for wound care -order Date 04/23/2020, hours 0900 and 1700, 4/23/20 at 0900 not administered; 1700 administered; 4/24 and 4/25 administered at both times indicated by nurse initials. Review of the Skin Care Plan dated 4/19/20 documented: Resident is at risk for skin breakdown related to impaired mobility and medical condition. Interventions: Assess skin during care, report any red, bruised medical condition. Interventions: Assess skin during care, report any red, bruised areas to be completed on shower days. Skin assessment upon admission. Prompt incontinence care with barrier cream prn (as needed). On 5/1/20, review of policy Provision of Physician Ordered Services revised on 4/6/20 documented the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Definition: Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a clinical discipline or in a specific clinical situation or setting. Policy Explanation and Compliance Guidelines: 1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders [REDACTED]. 2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity. 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [REDACTED]. 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record. 5. In instances where diagnostic testing or consultations are not available to be performed on-site OR the Physician has requested that the services be performed at an off-site facility, this facility will work with the resident and their family to secure appropriate transportation arrangements for such appointments.

This citation pertains to intake #MI 503. Based on observation, interview and record review, the facility failed to provide proper supervision and implement appropriate safety interventions for two (#702 and #704) of three sampled residents reviewed for accidents, resulting in falls, lacerations, bruising, hematoma, fracture and three emergency hospital encounters. Findings include: Resident #704- On 11/26/18, resident #704 was observed asleep in bed. The resident had a severely contracted right arm (permanently flexed at the elbow) with a splint in place. The clinical record and Incident/Accident (I/A) reports were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets (MDS) completed 8/15/18 and 11/7/18 noted the resident had severe cognitive impairment, was non-ambulatory, had limited range of motion to extremities, incontinent of bowel/bladder, required total assistance for care, including bed mobility and had no falls. An Alteration in Safety care plan initiated 7/1/10 noted the resident had impaired mobility related to stroke with [MEDICAL CONDITION] and had contracture of the right upper extremity. Fall Risk Assessments dated 8/12/18 and 11/4/18 noted that the resident was at moderate risk for falls even after a fall occurred on 11/4/18 at 6 AM. Per an I/A report and nursing note dated 11/4/18: At 6 AM, while the resident was being changed by a nurse aide, he rolled out of bed on to the floor. Lacerations occurred above the left eye, the side of the right eye and two scratches occurred to the back. The I/A Report Affidavit noted a laceration also to the middle forehead. The steps to prevent recurrence of the incident: Educate the staff and respect the resident's right to refuse care. The nurse aide wrote in a witness statement dated 11/8/18: The resident was turned on to his side toward the wall, away from the aide while being changed. The resident became agitated, began shaking and moving away from the aide and started slipping out of bed. The resident was transported to the hospital for sutures to right lateral head per the nursing note. On 11/8/18, a nurse noted that the resident had returned from the hospital with a small bruise above the left eye and 9 staples to a right hip incision. Both of the resident's arms were noted to be contracted. On 11/13/18, the physician noted that contractures to right upper extremity, right hand and left hand were present and that a right intertrochanteric femur (hip) fracture was sustained from the fall. The incident investigation included a one to one training record dated 11/8/18 for the nurse aide involved in the incident. The subjects covered: positioning safety, the resident's right to refuse care and When repositioning in bed, always turn the resident toward you. A Techniques in Moving Bed Patients guide was attached that noted: When working alone, always turn the patient toward you. Stand on the side of the bed toward which the patient is to be turned. An Employee Disciplinary Record dated 11/8/18, noted that the aide was issued a warning for Failure to satisfactorily perform jobs, duties and responsibilities due to carelessness and Violation of facility and resident care standards. At 1 PM, the Administrator said a decision was then made to terminate the nurse aide due to turning the resident away from him instead of toward him and if the resident was resisting care, he should have left him alone but instead, he kept going. He had the right to refuse. Resident #702- On 11/26/18 at 2 PM, resident #702 was observed sitting in a chair in the day room with a hat on. The nurse said that the resident had just returned from the hospital about 1 PM following a fall. The resident was alert but confused and did not remember having a fall and just coming back from the hospital, when asked. The resident had a dark scab with sutures around the left eye. The clinical record and I/A reports were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS' completed 8/28/18 and 11/19/18 noted that the resident had moderate cognitive impairment, was ambulatory and required supervision to limited assistance for all care, including ambulation. The resident was prescribed [MEDICATION NAME] twice a day for anxiety and [MEDICATION NAME] once a day for depression. Fall Risk Assessments dated 7/24/18, 10/24/18 and 11/19/18, noted that the resident was at low risk. Elopement Risk Assessments dated 7/24/18 and 10/24/18 noted that the resident was at risk and had exhibited signs of sundow[DIAGNOSES REDACTED] (increased confusion and/or agitation in late afternoon) with increased pacing and a history of wandering. The resident was initially admitted to a secured (locked) unit for residents requiring heightened supervision until 9/12/18, then transferred to a general unit on another floor after exposing himself around a female resident. The following occurred per notes and I/A reports: 11/19/18 nursing note- The resident was wandering through the hall and went into (another resident's room), fell and received a laceration to the side of his left eye. Prior to this, writer tried to redirect resident to lay down several times. Cleansed laceration, put bandage on it laceration continued to bleed. Sent out to (hospital) for further care. 11/19/18 I/A report- The incident occurred at 4 AM; Resident walking all night, tired and fell , hit head and received laceration The solution to prevent the incident from occurring again: Transfer resident to lock down unit. The resident returned the same day from the hospital to the same unit, with 5 sutures. 11/25/18 at 12:38 PM nursing note- Observed ambulating with an unsteady gait/balance. Also increased confusion/periods of delusions noted. At 11:39 PM- Resident observed ambulating into room observed resident lose balance and fall to floor There was no noted injury. The solution to prevent recurrence: Encourage resident to take frequent rest periods. 11/26/18 nursing note- Resident observed on the floor. Large hematoma noted on right side of head Resident sent to hospital for observation 11/26/18 I/A report- The incident occurred at 4:24 AM; Resident had multiple falls during shift Observed on the floor, large knot noted on right side of head, increased confusion noted. There were no documented solutions to help prevent recurrence. The resident's Alteration in Safety care plan initiated 7/25/18 noted an intervention: Monitor frequently if resident wanders, provide activities and refocus/reorient to a supervised area as often as possible. Per a Risk for Elopement care plan initiated 7/25/18: Risk for injury due to wandering throughout facility. Observed in others' rooms. Goals included: Will have no injury, fall, or altercation with other residents through next 90 day period Interventions included: Monitor frequently while up wandering throughout facility for safety and safe mobility .; Provide a safe and secure environment. There were no documented revisions/updates to this care plan. At 3:30 PM, the Administrator, the Director of Nursing and the Social Worker were queried about mental health and safety interventions for the resident and records were reviewed. The resident was evaluated on 9/18/18 by mental health services following the exposure incident on 9/12/18. The evaluation noted that the resident had wandering behavior. The plan: Continue [MEDICATION NAME] continue with [MEDICATION NAME] may decrease libido and sexually inappropriate behavior Patient will continue to be seen for monitoring of the current [MEDICAL CONDITION] drug regimen, including its efficacy There was no mention in the notes of a medication adjustment, having sundow[DIAGNOSES REDACTED] or timeframe for follow-up evaluations. There were no documented social service notes regarding the falls with injuries, sundow[DIAGNOSES REDACTED], the continued wandering or plans for follow-up mental health referrals. The staff did not respond why. Interventions related to increased supervision of the resident were not documented. A documented monitoring schedule was not provided. When asked why the resident was not returned to the secured unit as recommended after the fall on 11/19/18, the Administrator said because of the past behavior displayed around a female resident. There were no documented attempts to place him back on the unit since the incident that occurred two months ago. There were no further documented incidents involving other females since that time. Per review of the facility's policies on Fall Prevention Program dated 11/1/18, Elopements and Wandering Residents dated 11/1/18, Wandering, Unsafe Resident dated 12/2008 and Behavior Health Services dated 9/27/18: - The facility will: .Provide interventions that address unique risk factors psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: .Increased frequency of rounds, sitter (one to one staff monitoring of the resident), if indicated - This facility ensures that residents who exhibit wandering behavior receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering Adequate supervision will be provided to help prevent accidents The effectiveness of interventions will be evaluated, and changes will be made as needed A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults - The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment Staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering Interventions to try to maintain safety will be included in the resident's care plan Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of unsafe behavior - It is the policy of this facility that all residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychological functioning Behavioral health care plans shall be reviewed and revised as needed, such as when interventions are not effective

This citation pertains to intake MI 868, MI 119 Based on interview and record review, the facility failed to ensure they were free of a significant medication error when the six rights of medication administration were not followed for one (#809) of one resident reviewed for medication errors out of a total of 9 sampled residents, resulting in Resident #809 receiving Resident #20's [MEDICATION NAME] (used to treat anxiety) instead of the [MEDICATION NAME] (used to treat opioid dependence) prescribed and Resident #809 resulting in oversedation and hospitalization . Findings Include: On 9/14/15 at 4:56 PM, during a telephone interview, Witness #1 revealed that Nurse K had administered 11 [MEDICATION NAME] to a resident (Resident #809) and was supposed to administer [MEDICATION NAME]. On 9/15/16 at 10:47 AM, the Director of Nursing (DON) was interviewed about the medication error. The DON stated, Nurse K gave the resident (Resident #809) eleven (11) [MEDICATION NAME] instead of [MEDICATION NAME] medication. Resident (#809) was prescribed [MEDICATION NAME] 110 Milligrams (mg). It comes in 10 mg tablets so she was supposed to give her eleven 10 mg tablets. But she gave her (#809) eleven 1 mg tablets of [MEDICATION NAME] that belonged to Resident #20. We gave the resident (#809) [MEDICATION NAME] and when the ambulance came and they gave her [MEDICATION NAME], too. The resident (#809) complained of not feeling well towards the end of the shift. In summary, Nurse K had administered 11 mg of Resident #20's medication to Resident #809. On 9/15/16 at 10:57 AM, during a telephone interview, Nurse K was asked about the medication errors and explain what happened and how it happened. Nurse K stated, I don't know. It happened. When I pulled the narcotic out of the drawer, I didn't pull it out of the cart. I miss-read the names. Nurse K was asked to further explain how she prepared the medication. Nurse K replied, I don't know how it happened. Nurse K revealed the residents did not reside in the same room neither did Resident #809 and #20 have the same first or last name. Nurse K began to speak in a mumbling low tone of voice and did not answer further questions. On 9/15/16 at 11:10 a.m., a review of the clinical record revealed that Resident #809 was readmitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #809 was cognitively intact and required extensive to total physical assistance from staff to complete activities of daily. A review of the physician orders [REDACTED]. There was no order for Resident #809 to receive [MEDICATION NAME]. A review of the clinical record for revealed that Resident #20 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #20 had moderately impaired cognition and required limited to extensive assistance to complete activities of daily living. The physician orders [REDACTED].#20 was to receive [MEDICATION NAME] 1 mg by mouth three times a day. A review of the Incident Report, dated 8/31/16 no time documented, stated, Resident was laying in bed sweating profusely and showed signs and symptoms of sedation. Resident stated, I feel funny .Resident was sent to the hospital. The Progress note, dated 8/31/16 at 3:30 p.m., stated, Writer observed resident laying in bed sweating profusely and resident stated, I feel funny, Writer went to medication cart and noted wrong medication was given. M.D. notified and resident was given 0.4 mg/ml of [MEDICATION NAME] and was sent to the hospital V/S (Vital Signs) is as followed BP (Blood Pressure) 101/79 P (Pulse)=90, RR (Respiratory)=18, 100% room air. At 11:10 p.m., the Controlled Substance Proof-Of-Use Records for Residents #809 and #20 were reviewed with the DON. A review of the Controlled Substance Proof-Of-Use Record for Resident #809 for [MEDICATION NAME] 10 mg, documented 8/31/16 at 9:00 AM, 11 Error. (Because the medication had not been withdrawn for the package.) A review of the Proof-Of Use Record for Resident #20 for [MEDICATION NAME] 1 mg, documented on 8/31/16 at 2 PM 1 tablet had been removed from the 28 tablets in the package and that 17 was wasted and 16 remained. The DON revealed that Nurse K was supposed to document 11 had been removed from the 28 which left 17. The DON had no explanation why the documentation on the Proof-of-Use sheet was unclear. An interview with Witness #2 from the local hospital where Resident #809 was transferred stated, Resident #809 was very lethargic and out of it. She stayed that way for 24-48 hours. That was a huge medication error. At the most, a person should not get more than 2 mg of [MEDICATION NAME]. On 9/15/16 at 11:27 PM, a review of the facility's policy titled Administering Medications, revised April 2007, stated, Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering medications must verify the resident's identity before giving the resident medications .The individual administering medications must check the label THREE (3) times to verify the right medication, right dosage, right time, and right method of administration before giving the medication. ( )

This citation pertains to intake MI 129: Based on interview and record review, the facility failed to protect the life, health and safety of one (#801) of 3 residents reviewed for neglect out of a total of 3 sampled residents when they failed to implement their Leave of Absence (LOA) policy and did not: (1) Obtain the guardian's consent, (2) Physician's consent, (3) Document who the resident left with and ensure they were educated on how to care for the resident, (4) Document when the resident returned to the facility, (5) Ensure the resident had medications while on the LOA and the side effect, (6) Assess the resident when upon return to the facility, (8) Notify the physician when the resident returned to the facility intoxicated and stated he had been taking drugs and smoking weed (marijuana), resulting in the resident complaining that he was too high, becoming unresponsive, requiring Cardio-Pulmonary Resuscitation (CPR), and being sent to the hospital. Findings include: On [DATE] at 7:40 AM, a review of the nursing notes by Nurse I documented, [DATE] 11:30 PM, Resident is on a LOA, was given information coming on-shift. However, there was no documentation prior to this note of the physician or guardian being called for permission, the condition of the resident when he left the facility, the name/relationship of the person that took the resident out of the facility, or that they were educated on how to care for the resident, or that they had the equipment necessary to care for the resident. A nursing note documented, [DATE] at 10:30 PM, Resting in bed all evening N/V (nausea/vomiting) clear fluids X 4. Resident requesting water & pop, asked to sip it to prevent further episodes of N/V. On [DATE] at 7:42 AM, the clinical record revealed that Resident #801 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #801 was cognitively intact, but required extensive to total physical assistance with all activities of daily living. The MDS further indicated the resident could not ambulate, had limitation in functional range of motion on one side in the upper extremities and both sides of the lower extremities. The review revealed that Resident #801 had a court appointment guardian. The only contacts listed on the face sheet was the guardianship company. There were no family members names listed on Resident #801's face sheet. The clinical record review revealed the resident had a history of [REDACTED].#801 took the following prescribed medications: [REDACTED]. On [DATE] at 9:10 AM, the Director of Nursing (DON) was asked about Resident #801 and the LOA. The DON stated, He had [MEDICAL CONDITION] he was able to communicated and make his needs known. He had contractures (Permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion. Source: 2016 Merriam-Webster Dictionary) almost in fetal position on the right side. He could not sit in a regular wheelchair and was in a geri-chair reclined. He smoked and would get upset if he couldn't smoke .He could not do anything for himself. He was total care. I think he had family. I'm not sure if it was an uncle or brother. There were family dynamics and he would go out on LOA with them too. The DON was asked when Resident #801 left to go on LOA, with whom, and when he returned. And the DON was asked if the visitor had been educated on how to care for Resident #801. The DON revealed she did not know who took the resident out, but that family would bodily lift the resident to move him. The DON revealed she didn't know if the visitor had been education to care for the resident, or what equipment they had at their home. The DON revealed the information might be in Electronic Medical Record (EMR). However, a review of the progress notes in the EMR revealed there were no nursing notes from [DATE] - [DATE]. On [DATE] at 9:59 AM, the guardianship company was called. The company was asked if any of the guardians had been called to grant permission for Resident #801 to go out on an LOA around [DATE]th 2016. The representative could be heard asking others and stated, No one has given Facility Named permission to allow the resident to go out on a LOA. A review of the EMR revealed the following Social Service Progress notes: [DATE] 11:10 Writer made aware of resident returned from visit with family with guardian permission. Resident appeared intoxicated upon return. Nursing monitored resident closely, resident nauseated and feeling light headed. Writer left message informing guardian that family is giving resident alcoholic beverages . [DATE] 11:43 .Resident is one of the younger resident, resident's family come to get resident for outings. Resident does have a legal guardian, which handle all his affairs .There are no plans regarding discharge, but resident does express the fact that he wants to go live with relatives. Resident's guardian expressed that resident has an abusive past in the care of family, and resident will remain in facility long term . At 10:36 AM, Social Worker D was asked about the above social services notes. Social Worker D stated, The nurse told me they got the guardian's permission. Social Worker D revealed she could not remember what nurse told her they had called the guardian. Social Worker D stated, I did not call. Social Worker D stated, A CNA (Certified Nurse Aide) or nurse came to me and said they think he's been drinking. I went in there and he was sleep, but you could smell it. Social Worker D was asked what day Resident #801 went out and came back to the facility. Social Worker D revealed she did not know. Social Worker D was asked about the statement in her note that mentioned Resident #801 had been abused by family. Social Worker D stated, When I first got here they were taking him out, the nephew and sister. The dad is the only one I know of who cannot take the resident out. Social Worker D revealed a letter, dated [DATE], from a previous guardian that stated, Please be advised that (Resident #801) may no longer have unsupervised visit with his father .per order of (Resident #801's guardian), there are to be no unsupervised visit, and all visits must take place in a common area unless otherwise authorized by the guardian . Social Worker D was asked if all visits were limited to the father or included other family members. Social Worker D revealed she had not clarified that. At 11:06 AM, Attending Physician E was called and asked if permission had been given for Resident #801 to go out on an LOA on [DATE]. A brief history/condition of the Resident #801 was given to the physician. Physician E stated, Why was he out on a LOA? Why did he even leave the facility? Did the nurses document a call? I had another doctor covering that facility. They no longer work for me and have moved out of state. But if it wasn't written, it probably wasn't done. Physician E revealed he was not made aware that Resident #801 had come back to the facility intoxicated and vomiting. At 11:15, the DON revealed on [DATE], Nurse B and CNA O had taken care of Resident #801 on the ,[DATE] shift; Nurse H and CNA G had taken care of Resident #801 on ,[DATE] shift, and Nurse I would have taken care of him on the ,[DATE]. On [DATE] (,[DATE]) shift Nurse B and CNA N would have cared for Resident #801. Nurse B, also the nurse that sent Resident #801 to the hospital on [DATE], was called at 9:36 AM and asked about Resident #801. Nurse B stated, He went out on LOA with family I believe. He could not do anything for himself .I don't know when he went out or came back. There was no mention of drugs or alcohol and I did not smell anything. I've not seen his family. Other people said he had family . Nurse B revealed the next time she cared for Resident #801 was the day she sent him out to the hospital ([DATE]). CNA O was interviewed at 10:52 AM and 2:47 PM and stated, I was off the day he went on LOA, but the day he went out he would not drink, would not eat, was not wet and he was a heavy wetter. He could not keep his eyes open. He said he was drinking Hennessy (Cognac) and smoking weed. I asked if he took something. He said Yeah but could not get it out. I don't know when he got back. On the 18th they told me that's how he was yesterday, which would have been the 17th .My opinion was that he needed to be sent out. I know my opinion doesn't count because I'm just a CNA. I told Nurse B that he's been taking alcohol and smoking weed. CNA G was interviewed at 12:09 PM. CNA G cared for Resident #801 on [DATE] on the ,[DATE] shift. CNA G stated, He went out with his brother. He did not come back that night. I overheard that when he came back he was sick. He couldn't hold anything down, he was throwing up. He had gone to a party and came back smelling of alcohol. Nurse H was interviewed at 12:36 PM, via telephone. Nurse H would have cared for Resident #801 on [DATE] on the ,[DATE] shift. Nurse H was asked if she had sent Resident #801 out on an LOA on the ,[DATE] PM shift on [DATE]. Nurse H stated, I may have, but I can not remember. Nurse I was interviewed at 12:44 PM. Nurse I would have cared for Resident #801 on [DATE] on the ,[DATE] shift. Nurse I stated, He was gone when I got there and I didn't not see him that shift. CNA Q was interviewed over the phone at 1:35 PM and stated, I took care of him when I got in that afternoon ([DATE] ,[DATE] shift). From what I was told he got back at 7 that morning. He threw up the entire shift. I told Nurse J that I cleaned him up so many times. She (Nurse J) said 'They did not send him out because he was intoxicated from the night before and nobody was going to send him out'. The patient said himself, he had been drinking, took Ecstasy, and Zannies. That came out of his mouth to my ears. He was throwing up every two minutes. I smelled (Alcohol) it on him. At 4:07 PM, CNA Q stated, It was horrible. The liquid (vomit) smelled of it (alcohol). CNA Q was asked who Resident #801 had gone out with. CNA Q stated, He (Resident #801) said it was his brother who had just got out of jail for raping his daughter. I couldn't understand why they would let him go out with him. At 3:48 PM, Resident #802, roommate to Resident #801 was asked about the LOA. Resident #802 stated, He went out 2 days before St. Patrick's day, with the brother who just got out of jail for raping Resident #801's daughter. He was supposed to be gone through St. Patrick's day, but they brought him back early on St. Patrick's day. It was around 6:,[DATE]:00 that morning before Nurse B came on. He was here for breakfast. He was throwing up drunk, sick as a dog, and high as a kite. He said he took drugs .He kept saying 'I'm too high, I'm too high'. Nurse J was called multiple times using three different phone numbers provided by the facility, but was unavailable for interview. On [DATE] at 4:30 PM, Unit Manager F was asked about Resident #801 the morning of [DATE]. Unit Manager F stated, At about 9:30 AM on the 18th, Nurse B told me he was a little lethargic. I told her to call the doctor and that I would send him out to the hospital. I came back from morning meeting about 10 something and she told me he had started drinking more and was better. Unit Manager F revealed the CNA O came and got her 2 in the afternoon and told her Resident #801 was not responding. I went down to the room and he was non-responsive to verbal command and sternum rub. We had to call EMS (Emergency Medical Services) and start CPR and we sent him to the hospital. Unit Manager F was asked if she had been informed that Resident #801 had reported to staff that he had been drinking, popping pills (Ecstasy and Zannies) and smoking weed. Unit Manager F stated, I was told after the fact, after the code and he was sent to the hospital. I was told it wasn't the first time he came back drunk after going out with his brother. Unit Manager F was asked how she knew it was really his brother. Unit Manager F stated, That's what they say. Unit Manager F revealed that EMS was doing CPR as the resident was being taken out of the facility to go to the hospital. At 4:55 PM, Nurse B was called and asked if Unit Manager F had instructed her to call the doctor before she went to morning meeting on the day Resident #801 was found unresponsive. Nurse B stated, Yes. Nurse B was asked if she had called the doctor. Nurse B revealed she did not call the doctor until after they had initiated CPR and Resident #801 was sent out to the hospital. Nurse B was asked if she had been aware that Resident #801 had told staff he had been drinking, popping pills of Ecstasy and Zannies, and smoking weed. Nurse B stated, I don't believe I was given that in report. Nurse B denied that CNAs reported it to her. On [DATE], a review of the facility policy titled Leave of Absence Policy (LOA), revised [DATE] stated, 1. Resident will be evaluated by the physician and clinical team to determine cognitive status, judgement, and ability to make safe decisions while on LOA. 2. Physician will write an order if LOA is safe or not. 3. Resident/responsible part will sign out for an LOA including giving the destination, contact person with an accurate working phone number and time of return. 4 .If we are unable to contact you with-in two hours of the time of return we will contact the appropriate parties including the police. 5. If the LOA is overnight facility must be made aware in advance .9. If the resident has an activated .Legal Guardian; resident must have an escort provided by the responsible party. 12. Facility will complete a full body assessment for all residents on an LOA past 24 hours. 13. Resident must have a pass written by a nurse to leave from the facility. 17. If a resident has supervised LOA the person signing person out must sign the person back in. A review of the facility's Change in a Resident's Condition or Status, dated [DATE], stated, Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . During the exit conference at 5:30 PM, the DON and Administrator was asked if any of the above items mentioned in the facility policy had been located. The DON stated, No. ( )

This citation pertains to MI 979, MI 980, MI 035, MI 233, and MI 059. Based on observation, interview and record review the facility failed to prevent staff to resident physical abuse for one resident (#501) of three residents reviewed for abuse from a total sample of three residents resulting in a left eyebrow laceration, left orbital (eye socket) bone fracture, a nasal fracture, and hospitalization . Findings include: On 6/23/16 at 11:15 am, clinical record review revealed that Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set ((MDS) dated [DATE], Resident #501 had severely impaired cognition and required extensive one person physical assistance with all activities of daily living with the exception of eating. In addition, Resident #501 was noted to have impaired range of motion to both upper extremities (arms). On 6/23/16 at 11:00 am review of the completed investigation file included the following: Review of hospital records dated 6/11/16 at 8:16 PM, note that Resident #501 was taken the hospital with the chief complaint of left eyebrow laceration (3 centimeters in length). After CT scan, dated 6/11/16, Resident #501 was diagnosed with [REDACTED]. Review of the Incident Report dated 6/11/16, revealed Resident observed to have a large laceration over left eye with periorbital [MEDICAL CONDITION] and discoloration. There was no cause of incident noted, however, the report documented that Resident 3501 sustained a laceration that indicated that it was a major injury. The report also noted that Resident #501 was transferred to the hospital for further evaluation. There were no nursing notes for review between 6/6/16 through the discharge date of [DATE]. A statement by CNA 'D' dated 6/11/16 (no time) documented I detained (Resident #501) and took him to his room. After getting him to his room to keep his attention I closed the door and kneeled down in front of him to get a better eye level approach. As he was standing himself up he pounced at me. I restrained the resident but at the same time keeping him form falling. I caught his wrist when he pounced/swung at me. While doing so when he going back into the seat his eye brushed with both my hand and his wrist and it resorted in a gash. I immediately notified the nurse. A statement by Nurse 'A' noted that on Saturday 6/11/16 (no time), This writer observed (CNA 'D') being pushed to room by CNA. CNA closed residents door. When housekeeper (Porter) and writer opened resident's door resident was observed sitting upright in wheelchair with a bloody face. Resident's left upper periorbital area with a deep laceration. Left eye reddened and eye with discoloration and swelling. When writer asked resident what happened resident stated, He hit me in the eye. When writer asked CNA, CNA stated 'I was trying to get him in the bed and he lashed out at me. I held his hands back and he hit himself in the eye. A statement by the Housekeeping Porter 'B' (undated, no time) documented, I seen the resident (#501) being detained by (CNA 'D'). (CNA 'D') took the resident out of the hallways. He said to get him away from others. When the door opened the resident had blood on him. The facility investigation summary (undated, no time, no signature) revealed that CNA 'D' reported being hit in the face by Resident #501 before being taken to his room. On 6/23/16 at 3:00 PM, review of the facility video that pertained to the abuse incident revealed the following: At 11:07 a.m., Resident #501 was observed behind the Nurses Station on the South end of the first floor. At 11:09 a.m., CNA 'D' was observed to pull Resident #501 backwards while seated in a wheelchair, out and away from the Nurses Station. CNA 'D' was then observed to pull Resident #501 down the hall (approximately 100 feet) in a backwards manner. CNA 'D' and Resident #501 entered the residents room and CNA 'D' closed the door at approximately 11:09 a.m As CNA 'D' pulled Resident #501 backward into the resident's room, Porter 'B' and Nurse 'A' were observed in the hallway smiling and talking to one another in front of Resident #501's room. At approximately 11:09 a.m., as Porter 'B' opened the door (per interview) where he and Nurse 'A' had full view of Resident #501 and CNA 'D' inside the room, Nurse 'A's face was observed to change from a smile to her jaw dropping and eyes opening wide. At 11:09 and 54 seconds, Porter 'B' exited Resident #501's room and entered the camera/video view and was observed to drop his head and put his head in his hand. Nurse 'A' entered the room and CNA 'D' was observed to come out of the room and walk down the hallway. On 6/23/16 at 12:30 p.m., Porter 'B' was interviewed regarding the incident that occurred on 6/11/16, that involved Resident #501 and Certified Nurse Assistant (CNA) 'D.' Porter 'B' explained that around 11 a.m., on 6/11/16, Resident #501 hit CNA 'D' in the eye and that he observed CNA 'D' pulling Resident #501 backward down the hall while saying, Why you hit me in my eye, why you hit me in my eye? Porter 'B' then observed CNA 'D' pull Resident #501 into the room and shut the door, I opened the door. When asked why he opened the door, Porter 'B' said, It was just a reaction. When asked, Porter 'B' denied hearing any sounds come from the room. Porter 'B' stated, I opened the door. I saw the man (Resident #501) eye bleeding. The resident was just sitting in the wheelchair and (CNA 'D') was standing in front of him. They were facing each other. On 6/23/16 at 12:45 PM, Housekeeper 'C' was interviewed regarding the incident. Housekeeper 'C' said that she observed Resident #501 behind the Nurses Station picking with items on the shelf. Housekeeper 'C' then explained that she alerted CNA 'D' because he was the only CNA available to get Resident #501 from behind the Nurses Station. She added that CNA 'D' pulled Resident #501 down the hallway in a backward fashion while in the wheelchair and heard CNA 'D' say, He (Resident #501) hit me in my eye. On 6/23/16 at 12:50 PM, CNA 'D' was interviewed regarding the incident and acknowledged that he pulled Resident #501 down the hallway and into his room and closed the door. CNA 'D' explained that he was assisting Resident #501 when he had to grab Resident #501's wrists because he was swinging at him. He then realized that his hand slightly brushed against Resident #501's face when he suddenly noticed blood. He then reports that he exited the room to get the nurse. However, the video shows that Porter 'B' opened the door where Nurse 'A' had full view of him standing in the room next to Resident #501. CNA 'D' added, (Nurse 'D') immediately accused me and said 'Oh my God. You hit him with something! When asked why he closed the door, CNA 'D' stated, Because I was going to put him into bed. However, Resident #501 was not assigned to CNA 'D' and by CNA 'D's own admission he was not even assigned to work on that unit. When asked if the resident was hostile and aggressive toward him, CNA 'D' explained that Resident #501 was often verbally aggressive and abusive and acknowledged that he struck him this day. When asked if he should have proceeded to assist or work with Resident #501 after Resident #501 struck him in the eye and continued to be verbally aggressive and combative with him, CNA 'D' did not offer any explanation. When asked if Resident #501 fell , or hit his face against any object in the room while he was in the room with him, CNA 'D' stated, No. When asked how did Resident #501 sustain a 3 centimeter laceration to his left eyebrow, a broken orbital bone (eye socket) and a broken nose after he pulled Resident #501 into his room on 6//11/16, CNA 'D' stated, I don't know. I only touched him with my pinky finger and my ring finger. I don't know how that could have caused all that. CNA 'D' added, (Resident #501) scratched me and cut me. I know the Administrator wanted to talk to me but I did not want to come up there (to the facility) because I figure they had the police waiting on me. On 6/23/16 at 1:30 PM, Nurse 'A' was interviewed regarding the incident. Nurse 'A' stated, (Resident #501's) door was closed. The housekeeper and I opened the door and saw (Resident #501's) face. It was bloody. I asked the patient what happened and he said, 'He (CNA 'D') hit me.' I asked (CNA 'D') what happened and he couldn't tell me, he wouldn't tell me. He was just standing there looking puzzled. I wasn't sure what he (CNA 'D') did, the door was closed. All I knew is he was not going to be in the room with him or any other resident. I do remember that as the door opened I heard him say something like 'I f*****d up' or 'That is f****d up. Nurse 'A' added that when the ambulance arrived and they put Resident #501 on the gurney he stated, When I get back I'm gonna beat his ass. On 6/23/16 at 3:30 PM, the Administrator and the Director of Nursing (DON) was interviewed regarding the incident. The Administrator and the DON acknowledged that CNA 'D' was the only person in the room when Resident #501 sustained a facial laceration and facial fractures. The Administrator and the DON were queried regarding CNA 'D' pulling Resident #501 down the hall backwards into a wheelchair and acknowledged that being a form of abuse. The Administrator and DON were queried regarding CNA 'D' working with Resident #501 after Resident #501 had hit him in the eye and acknowledged that Resident #501 should have been left alone and re-approached regarding his behavior by a different staff member. The Administrator and the DON both added that CNA 'D' should have never pulled Resident #501 into his room and closed the door because, (Resident #501) has behaviors and has to be monitored at all times. On 6/23/16 at 4:00 p.m., review of the facility's abuse policy titled, Abuse Program Policy and Procedure (undated) revealed, It is the policy of the facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse by anyone including, but not limited to, facility staff .Physical Abuse: is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. The facility will conduct an analysis of the following: The distribution of staff on each unit in sufficient numbers to meet the needs of the residents and assure that staff assigned has knowledge of individual care needs. The supervisor of staff will identify inappropriate behavior such as using derogatory language, rough handling, ignoring residents during care. Residents exhibiting needs and behaviors that predispose them to have conflict with others or that subject them to neglect by staff such as residents with history of aggressive behaviors. ( )

This citation pertains to MI 598. Based on observation, interview, and record review the facility failed to provide adequate supervision for three (Resident #601, #604, and #605) of five residents reviewed for smoking safety when Resident #601 set her bed comforter and mattress on fire resulting in a smoldering fire and fire damage to the room interior on 5/17/16. This resulted in Immediate Jeopardy (IJ) when the facility failed to monitor Resident #601 and conduct a thorough investigation when smoking paraphernalia was reportedly observed in her room on 5/01/16. On 6/01/16, the facility also failed to adequately supervise residents (#604 and #605) who were observed with smoking paraphernalia on his/her person during a smoking break. This deficient practice had the potential to result in serious harm and/or injury and required immediate corrective action. The (IJ) was identified on 5/27/16, at 1:25 p.m., and the Administrator was notified and provided written notification of the (IJ) on 5/27/16 at 2:25 p.m., and was required to submit a removal plan for the (IJ). The facility provided a plan to remove the (IJ) on 5/27/16. Although the facility provided a plan to remove the (IJ) on 5/27/16, it was determined during the Extended Survey on 6/01/16, that the removal plan to correct the (IJ) had not been fully implemented. Therefore the (IJ) remained in effect and was removed at approximately 12:00 p.m., on 6/01/16. Although the (IJ) was removed, the facility's deficient practice was not corrected and remained isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy (IJ). Findings include: On 5/27/16 at 8:00 am, review of a facility reported incident (MI 598) documented, There was an accidental fire in the facility which was located in a resident room. On 5/27/16 at 8:10 am, Housekeeper 'J' was queried regarding the fire that was started by Resident #601 on 5/17/16. Housekeeper 'J' stated, I wasn't here but I heard that (Resident #601) wanted out of here and she set the bed on fire. On 5/27/16 at 9:40 am, an observation of Resident #601's room along with the Maintenance Director revealed a burned comforter and nearly one half of a burned and blackened mattress. The Maintenance Director stated that the insurance company assessed the damaged and indicated that floor and ceiling tiles were damaged and would need to be replaced. On 5/27/16 at 9:00 am, the Director of Nursing (DON) provided a summary of the investigation regarding the fire. Review of the typed investigation (untitled) dated 5/20/16, documented, On the afternoon of May 17, 2016 about 3:45 p.m., Certified Nurse Assistant (CNA) 'C' smelled smoke coming from (Resident #601's) room alerting (Nurse 'D') who entered the room to remove the resident and requesting (CNA 'E') to get fire extinguisher. Findings: (Resident #601) ignited the comforter in her room that did burn along with the mattress. However, the investigation performed by the facility did not address how Resident #601 obtained the lighter that was reportedly used to set fire to the mattress and bed comforter. At that time the Director of Nursing and the Administrator were asked how did Resident #601 obtain the lighter used to set fire to the comforter and mattress. The Director of Nursing explained, When the fire department arrived (Resident #601) told them, I set the bed on fire with a lighter. When queried how Resident #601 acquired the lighter the Administrator nor the DON were able to explain how Resident #601 obtained a lighter or matches and set her bed on fire. On 6/1/16 at 5:35 p.m., Lieutenant 'N' was interviewed and explained that upon his arrival Resident #601 was hysterical, claimed she wanted to kill herself, and was not able to engage in a conversation. The resident (#601) did not state how she started the fire. I found nothing in her hands or in the room upon inspection that told me how the fire started. On 5/27/16 at 9:20 am, Resident #601's clinical record was reviewed and the following was noted. According to a nurses note dated 5/17/16 (no time), Resident set fire to bed. Resident upset that she was unable to smoke in designated area due to it not being scheduled smoke time. Resident observed sitting in wheelchair in hallway by staff for a few minutes before going to her room. Staff reported resident appeared upset. Further review revealed a nursing note dated 5/1/16 (no time) that documented, Resident had smoking paraphernalia in her room and evidence of cigarette butts, wooden used matches, and ashes on the floor brought to writer's attention by housekeeping. On 5/27/16 at 9:30 am, the Administrator and the Director of Activities were asked if they were aware that Resident #601 had smoking paraphernalia in her room. The Administrator and the Director of Activities both explained that they have not heard of Resident #601 being caught with smoking paraphernalia in her possession. The Administrator was queried what would happen if any resident was found with smoking paraphernalia (to include matches, lighter, and/or cigarettes) and stated, If we (the facility) found someone with smoking paraphernalia then there room has to be searched. On 5/27/16 at 9:35 am, Social Worker 'K' was asked if she was aware that Resident #601 was noncompliant with smoking and was observed to have smoking paraphernalia in her room. Social Worker 'K' explained that she was unaware that staff reported that Resident #601 had smoking paraphernalia in her room. Social Worker 'K' explained that residents were not allowed to have smoking paraphernalia in their possession because it is safety hazard. When queried regarding Resident #601 setting the fire in her room, Social Worker 'K' explained that Resident #601 was aggressive and unpredictable and stated that she knew Resident #601 set a fire in her room because she heard her say, I set this fire because these [***] es won't let me smoke. At this time Social Worker 'K' provided the Petition For hospitalization dated 5/17/16 that documented, (Resident #601) is an immediate threat to self and others. (Resident #601) set fire to her room at nursing facility threatening to harm self and others. On 5/27/16 at 9:40 am, the Housekeeping Supervisor 'L' was queried if he was made aware of smoking paraphernalia found by Housekeeper 'B' and explained that Housekeeper 'B' did not report the findings of smoking paraphernalia in Resident #601's room. If my staff found smoking paraphernalia I expect them to report that to me. Residents are not allowed to have smoking paraphernalia on them at any time. On 5/27/16 at 9:45 am, Nurse 'D' was queried regarding the incident and explained that she pulled Resident #601 out of the room after she set the comforter and mattress on fire. I ran to her room opened the door. I saw a black cloud and red (fire). I had a hard time pulling her out of the room. She was holding onto the pole in her room screaming that she wanted to kill herself. When asked how did she set the comforter and mattress on fire, Nurse 'D' stated, I have no idea. On 5/27/16 at 10:25 am, Guardian 'F' was queried regarding the fire that was set by Resident #601 on 5/17/16. Guardian 'F' stated, The facility did call to inform me that (Resident #601) started a fire in her room and the first thing I asked was where and how did she get matches or a lighter? (Staff Member 'G') said perhaps she got them (lighter or matches) from another resident. On 5/27/16 at 10:30 am, the Director of Nursing (DON) was interviewed. The DON was queried regarding the note written by Nurse 'A' on 5/1/16 that detailed the smoking paraphernalia found by Housekeeper 'B. The DON stated, I just read that note today. I was not aware that they had found smoking paraphernalia on (Resident #601). No resident should have smoking paraphernalia on them at any time. (Nurse 'A') did not follow protocol. She should have done an incident/unusual occurrence report so everyone else would be aware prior to (Resident #601) setting the fire to her bed. (Resident #601) is known for picking up items. If we had known we would have done a room sweep to search for and remove any smoking material. On 5/27/16 at 10:55 am, Security Staff 'H' explained that residents who do not have supervised smoking have to obtain a pass to go outside to smoke. Security Staff 'H' was asked where the smoking items were maintained. Security Staff 'H' stated, I have the lighter. They (residents) come to me and I light the cigarettes at the door. Security Staff 'H' was asked where resident cigarettes and lighters were kept and Security Staff 'H' explained that the cigarettes and lighters were kept in an unlocked box near the security desk. On 5/27/16 at 11:00 am, Activities Assistant 'I' was queried regarding scheduled smoking times for residents who required supervision and explained that smoking materials are kept in an unlocked cigarette box in the activities room. Activities Assistant 'I' further explained that prior to entering the smoking area residents are given 1-2 cigarettes and staff light the cigarettes. On 5/27/16 at 3:00 am, Housekeeping Staff 'B' was interviewed regarding what she observed in Resident #601's room on 5/1/16. Housekeeping Staff 'B' explained that while sweeping up Resident #601's bedroom floor (Resident #601 resided in a private room) she saw a cigarette butt with ashes on the floor like someone put the cigarette out with their foot. Housekeeping Staff 'B' demonstrated by placing the ball of her foot on the floor while making a sweeping motion and then stated, I found a used match stick next to it. I didn't smell smoke but I swept up the smoking paraphernalia and showed it to the nurse. The smoking paraphernalia was in the dust pan. She (Nurse 'A') told me she would make a note of it and put it in the Behavior Log. On 5/27/16 at 3:40 p.m., Social Worker 'K' provided the facility 'Behavior Logs. The Behavior Log for 5/1/16 was reviewed. There was no note that indicated that Resident #601 was observed to have smoking paraphernalia in her room and therefore no notification for that behavior/incident to be addressed. When queried, Social Worker 'K' stated, That should have been reported. That is significant! There is a log at every nursing nursing station to report that type of behavior. On 6/1/16 at 11:45 am, Nurse 'A' was queried regarding Resident #601. Nurse 'A' acknowledged that she documented that Housekeeping Staff 'B' reported the smoking paraphernalia. Nurse 'A' stated, That incident happened over the weekend. We don't have any Supervisors to report to. We are the supervisors. I knew the incident was significant so I documented the incident in the nurses notes. I thought they (Unit Manager or Director of Nursing) would look at the notes to see what happened over the weekend. On 6/1/16 at 9:15 am, during the facility's first scheduled smoking time, Resident #604 was observed smoking in the supervised area (porch) with Activity Assistants (AA) 'I' and 'M.' At 9:25 am, Resident #604 was observed to stand up and walk to the facility entrance where a green-colored lighter was observed in the Resident's left hand. AA 'M' was informed that Resident #604 exited the supervised smoking area with a lighter in his hand. At that time AA 'M' asked AA 'I' if she had seen Resident #604 with the lighter. AA 'I' stated, I saw him. AA 'M' stated, We will report it to (Activities Director) and she will handle it. On 6/0/1/6, at 9:25 am, Resident #605 was observed to wheel himself up to the door with a cigarette hanging from his mouth. Resident #605 entered into the porch area where supervised smoking occurred. (Staff did not give Resident #605 a cigarette from the cigarette box observed on the table.) When queried AA 'M' stated, I don't know where he got that from. This is the first smoke break for the day. We (facility) can't figure out how they (residents) get cigarettes or lighters. On 6/1/16 at 10:25 am, the Activities Director was queried regarding the incidents that were observed to occur during the supervised smoke break. The Activities Director reported that AA 'I' informed her that during the smoke break Resident #604 pulled a lighter out from his shoe. The Activities Director denied being informed that Resident #605 had a cigarette prior to coming out onto the porch for the smoke break and stated, (Resident #605) refused to sign the smoking policy. On 6/1/16 at 10:45 am, the Administrator, the Second Floor Unit Manager, and the Director of Nursing were informed that Resident #604 re-entered the facility with the lighter in his hand. The Administrator and the Second Floor Unit Manager stated, I didn't hear that part of the story which indicated that the Administrator, Unit Manager, and the DON were unaware that Resident #604 had a lighter, unsupervised, and unmonitored within the facility at the time of interview (one hour and 15 minutes since the smoke break ended). When queried regarding Resident #605, the Administrator nor the DON were able to explain why why Resident #605 presented onto the supervised smoking area with a cigarette in his mouth. At that time the DON was asked if residents who smoke should have care plans related to smoking. The DON explained that all residents who smoke should have a care plan regarding smoking to assist staff and residents in smoking in a safe environment in order to prevent fires and any potential for injury. On 5/27/16 at 1:00 p.m., review of the facility policy titled Smoking Policy revised 10/2/15, documented Residents are NOT allowed to have any smoking paraphernalia on them or room. #8. Residents who smoke must sign the resident smoking policy. #10. Residents are NOT permitted at ANY time to maintain in their possession any smoking material. All materials must be returned to designated staff (indicating that residents who smoke are allowed to have smoking materials in their possession at some time.) #11. Violation of #10 may result in loss of smoking privileges or involuntary discharge from the facility. However, the policy does not state how residents are supervised or monitored for smoking materials, the policy does not delineate what staff should do if they encounter a resident with smoking paraphernalia, the policy does not address how staff should handle a resident found with smoking paraphernalia, the policy indicate who staff should notify or report to if residents are found with smoking paraphernalia, nor does the policy address individualized smoking care plans for residents who are deemed safe to smoke. Resident #601 On 5/27/16 at 1:00 p.m., further clinical record review revealed that Resident #601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] Resident #601 was able to make her needs known and had impaired cognition. Smoking Assessment dated 2/3/16 revealed that for safety Resident #601 was not to light her own cigarette, that Resident #601 required supervision, that (Resident #601) needed facility to store lighter and cigarettes. In addition the assessment indicated that a, Plan of care is used to assure resident is safe while smoking. However, Resident #601 had no smoking plan of care to ensure the resident's personal safety or the safety of other residents. Resident #604 On 6/1/16 at 8:35 am, clinical record review revealed that Resident #604 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #604 had intact cognition, was independent with ambulation and transfers and required minimum to extensive physical assistance with dressing and bathing. According to the Smoking Assessment dated 3/1/16, for safety Resident #604 required the facility to store lighters and cigarettes, the assessment indicated a plan of care to assure resident is safe while smoking was needed, and that Resident #604 will smoke with supervision. Resident #604 had no plan of care that addressed how Resident #604 was to safely smoke. Resident #605 On 6/1/16 at 8:40 am, clinical record review revealed that Resident #605 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent MDS, dated [DATE], Resident #605 had intact cognition, required supervision to extensive care with activities of daily living. A Smoking Assessment dated 7/17/15 noted that Resident #605 was Safe to smoke with supervision and that Resident #605 needs facility to store lighter and cigarettes, and that a Plan of Care is used to assure resident is safe while smoking. The following Plan of Correction to remove the immediate jeopardy was submitted by the facility to remove the IJ: Element #1 The resident of concern is no longer a resident in the facility. On 5/27/16, the facility screened the total census of 97 residents for smoking. There were currently 30 smokers out of the 97 total census of residents. Nurse A has been terminated for failure to communicate incident that was documented in the resident of concern ' s clinical record without informing Director of Nursing and or Administrator. Element #2 New admits to the facility will be screened for smoking and be provided the smoking policy and informed of consequences if the smoking policy is violated. This will be in the admission packet. Element #3 Smoking policy was revised to include licensed nursing staff to complete incident report of any residents who violate the smoking policy or incidents of unusual occurrence relevant to violating the facility ' s smoking policy and notify director of nursing and administrator. Residents who go out of the facility on a LOA (Leave of Absence) will be subject to inspection of bags and packages upon reentry to the facility. LOA policy was reviewed to include that packages upon return to the facility are subject to inspection upon reentering the building. Policy on incident reporting was reviewed with all staff. All staff in-servicing has started for (Licensed nurses, CENAs, Housekeeping, Dietary, Activities, Laundry, Maintenance and therapy) on 5/27/16 and will be completed by 6/3/16. All employees that are on vacation or on leave of absence will be in-serviced prior to return to work. All incidents of noncompliant smokers will be discussed with interdisciplinary team for further evaluation and recommendations daily as the incident occurs. All smoking residents were informed of the revisions to the smoking and LOA policies and guardians will be informed starting on 5/27/16 and completed by 6/3/16. Element #4 All residents rooms will be monitored 3 times a week by the unit managers and or designee and all findings will be presented to the administrator and or director of nursing for further evaluation and recommendation. All audit findings will be forwarded to the QA committee for further recommendations. The Administrator will be responsible for sustained compliance. ( )

This citation pertains to intake number MI 306 Based on observation, interview and record review, the facility failed to implement appropriate safety measures for one (#705) of four sampled residents reviewed for falls from a total of six sampled residents, resulting in the Certified Nursing Assistant rolling the residents away from her during the provision of care. As a result, the resident fell off of the bed and sustained facial bruising and a fractured wrist. Findings include: On 6/10/14 at 9:54 a.m., during a tour of the facility, Resident #705 was observed in her room sitting in a wheelchair at the side of her bed watching television. Resident #705 was observed to have a hard permanent cast to her left forearm that was resting on a pillow and on the arm of the wheelchair. The resident had a darkened area to the left side of her face. Resident #705 was asked what happened to her arm and face and stated, "I fell out of the bed and hit my head and broke my left arm. It still hurts, (points to her left forearm). My face was swollen. I went to the hospital. Before the fall, I was just beginning to walk good." When asked to recall the details of her fall, Resident #705 stated, "She jerked the blue pad and I fell on the opposite side of the bed on the floor. They called for an x-ray but my son told them to send me to the hospital. I had a soft cast on at first. Now I have a hard cast on." A review of the facility's "Unusual Occurrence Report" dated 5/14/14, revealed that on 5/14/14 at 8:30 a.m., Resident #705 was in her room in her bed. It was documented that Certified Nursing Assistant (CNA) "B" stated, "I was cleaning Resident #705 up because she had a bowel movement. I rolled her over on her right side using the pad underneath her, at the same time Resident #705 attempted to roll herself as well, which at that time Resident #705 rolled out of the bed on the right side of the bed onto the floor." The report documented that the resident complained of pain to left face and left lower arm. X-rays and pain medications were ordered and the resident as sent to the emergency room . X-rays were obtained on 5/14/14 and the findings were as follows: 1. "...Face/Orbits: No fracture or intraosseous lesion. Sinuses and mastoid air cells as well as nasal cavities are clear." 2. "...Left forearm: Acute complete non-angulated and nondisplaced transverse fracture of the distal radial metaphysis (wrist) with intact proximal radius and entire ulna (forearm). Soft tissue swelling at fracture site." Review of the Hospital "Discharge Instruction" paperwork, dated 5/15/14 revealed, "Discharge [DIAGNOSES REDACTED]." Norco (Narcotic) 5 milligrams/325 milligrams one tablet by mouth every four hours as needed for pain-moderate." On 6/10/14 at 11:22 a.m., during an interview, the Physical Therapist was queried about the amount of physical assistance Resident #705 required during performance of activities of daily living (ADL's) and stated, "She (Resident #705) only needed one person assist during ADLS." When asked about the proper way to position a resident when rendering ADL care, the Therapist reported, "You should always roll the resident toward you. You should never roll the resident away from you in order to prevent falls." On 6/10/14 at 1:58 p.m. during an interview with the Director of Nursing (DON) about the incident, the DON stated, "It was my understanding that CNA "B" was standing in the wrong position. CNA "B" pulled the pad that was underneath Resident #705 and propelled the resident in the opposite direction. It was my understanding that CNA "B" turned Resident #705 away from her." On 6/11/14 at 9:32 a.m. CNA "B" was interviewed about the resident's falling from bed while she was providing care and stated, "...I was washing her up. I was standing on her left side. I pulled her blue pad toward me and I turned her on her right side away from me. She had a bowel movement and I had to wash that area. As I was cleaning her she moved because she said I was rubbing too hard. She fell out of bed and landed on the floor. She landed on the left side of her body. She turned completely over. I should have pulled her towards me instead of away from me. She should have been facing me and not facing away from me." On 6/11/14 at 11:52 a.m., during a follow up interview, the DON was asked the facility's procedure during incontinence care and the facility's protocol when a resident complained of discomfort during care and reported, "The CNA should stop the care and report it to the nurse. They shouldn't just continue." A review of The Facility's "Perineal Care/Incontinence Care" policy (undated) revealed, "Instruct or assist the resident to turn on her side, be sure to have the resident towards you. If using a draw pad, do not roll the resident away from you." Review of the clinical record on 6/10/14 at 1:30 p.m. and 6/11/14 at 10:30 a.m. revealed that Resident #705 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #705 had no cognitive impairments for decision making and required extensive physical assistance of staff with all activities of daily living (ADLS) including bed mobility, transfers, dressing, hygiene, bathing and toileting. A review of Resident #705's "Self Care Deficit" care plan updated 4/1/14 revealed, "impaired physical mobility, weakness, extensive assistance with dressing and personal hygiene. Floor mats for safety." A review of Resident #705's "Pain assessment" dated 5/15/14, revealed that Resident #705 was able to communicate and articulate pain and complained of "dull throbbing pain daily, cause: fracture Left arm pain related to fracture. "Resident had a fall this am (morning) with complaints of pain to left arm "acute" pain." ( )

This citation pertains to MI 279 Findings: Based on observation interview and record review, the facility failed to adequately assess, monitor and implement its' bowel protocol to help prevent fecal impaction for one resident of one sampled resident (#403) identified at risk for constipation and reviewed for fecal impaction from a total sample of eight, resulting in a fecal impaction and the resident being hospitalized . Findings: On 10/08/2013, at 10:00 a.m., a telephone interview was conducted with resident #403's family member. During the interview the family member reported on 8/04/2013 at 4:20 p.m., the family of resident #403 took the resident out of the facility and drove her directly to a local hospital due to complaints of abdominal pains and constipation. The family member stated, "... I kept telling them (the nurses, no name given) she was constipated--they didn't do anything, so I took her (resident #403) to the hospital". An unannounced on- site abbreviated survey was conducted on 10/08/2013 through 10/11/2013. During a tour of the facility at 9:00 a.m., resident # 403 was observed in her room seated in a wheelchair. on 10/08/13 at 11:00 a.m., resident # 403 ' s clinical record was reviewed. A "sign-out sheet: Resident leave of absence" (LOA) form dated 8/04/2013 revealed the resident left the facility at 4:20 p.m., with a family member and was taken to a local hospital. A local hospital emergency department report dated, 8/04/2013, at 8:28 p.m., revealed resident #403 had been brought to the hospital by a family member for complaints of abdominal pain. The hospital reports revealed the an abdominal X-ray dated 8/04/2013 (conducted for abdominal pain and distention) stated: Three views of the abdomen were obtained. " ...There is significant increased stool within the sigmoid colon and rectum. This results in increased gas with distention of the remainder of the colon. There was no significant small bowel distention. There is elevation of the right hemi-diaphragm ... " Impression: "...Significant fecal impaction within the sigmoid colon and rectum ... " Resident #403 was admitted to the hospital, according to the hospital transfer document, on 8/05/2013, with the chief complaint: "altered mental status and abdominal pain..." A Computed Tomography (CT) of the abdomen and pelvis performed in the hospital was as follows: Indication: Upper abdominal pain. "...there is a large amount of retained stool throughout the colon with a marked amount seen in the rectum. Findings are consistent with fecal impaction ... Impression: large amount of retained stool throughout the colon with a marked amount seen in the rectum. Findings are consistent with fecal impaction ... " A hospital physician progress notes [REDACTED]. Altered mental status likely is secondary to abdominal fecal retention and severe dementia ... 2. abdominal pain likely secondary to fecal impaction ...disimpaction was attempted in ER (emergency room ) but patient did not tolerate ... " A consulting physician progress notes [REDACTED]. A physician ' s progress note dated 8/12/2013, 10:55 a.m., stated, " ...we disimpacted her (resident #403) and gave her medication for constipation ... " The hospital patient discharge summary dated, 8/13/2013, revealed resident #403 was discharged from the hospital back to the facility with a [DIAGNOSES REDACTED]. The facility 's nursing admission assessment, dated 8/13/2013, revealed resident #403 was readmitted back into the facility with a [DIAGNOSES REDACTED]. The facility ' s ADL (activity of daily living) flow sheet was reviewed for July and August 2013, for resident #403 and the ADL sheet revealed resident # 403 did not have good bowel movement before being admitted into the hospital for abdominal pain and distention. Small bowel movements were documented on July 22, 23, 24, 25, 26, and 29. No bowel movement was documented on July 27, 28, 30, 31, August 1, 2 and 3. The ADL flow sheets further revealed staff failed to assess, monitor and document resident # 403 ' s bowel status on the following shifts: July 22, 23, 24, 26, 27, 28, 29, 30, and 31 on the midnight shift (11pm-7am); July 25, 30, 31, on afternoon shift (3pm-11pm). A nursing plan of care, "risk for constipation", indicated resident #403 was at risk for constipation related to decreased mobility and a history of constipation. Intervention included, notify physician of constipation, and administer medication (stool softeners, laxatives, suppositories, enema as ordered). A medication review for resident #403 revealed resident received [MEDICATION NAME] 0.5 mg (milligram) every day at bedtime for a [DIAGNOSES REDACTED].# 403 at increased and at an additional risk for constipation. On 10/09/2013 at 11:00 a.m., the facility's "Bowel Check Protocol" (initially undated) and reviewed on 10/09/2013, was reviewed and stated the following: " ...Procedure: 1. The charge nurse will do a bowel check q (every) three days for all residents with the following condition: a. [DIAGNOSES REDACTED]. Impaired mobility (bed bounds), d. All other residents who are at risk for impaired bowel function related to medical condition or medication side effect. 2. Bowel checks will be done q 3 days by the Midnight nurse, written in the MAR (medication administration record) and signed accordingly. Abnormal findings must be documented. 3. The following interventions must be done: a. Give mom (milk of magnesium) 30 cc (cubic centimeters) PO (by mouth), if still no BM (Bowel movement) for 3 hours give, b. [MEDICATION NAME] suppository, if still no BM, do, c. Manual evacuation, d. Refer to MD (Medical Doctor) as needed, e. Document effectiveness of interventions. 4. The Nurse Managers will ensure staff compliance..." The July and August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] revealed the facility's bowel protocol had not been implemented for resident # 403 when resident had no bowel movement on the aforementioned days in July and August 2013. The face sheet record dated, 9/17/2013 revealed, resident # 403 was originally admitted into the facility on [DATE] and recently readmitted on [DATE]. Resident #403 had [DIAGNOSES REDACTED]. The most recent minimum (MDS) data set [DATE] revealed resident # 403 was severely impaired in cognitive skills for daily decision making, non-ambulatory and required limited to extensive assistance with activities of daily living. Resident #403 was incontinent of both bowel and bladder and requires staff assistance for toileting. On 10/09/2013, at 11:00 a.m., an interview was conducted with unit manager (A) regarding following and implementing the facility's bowel protocol for resident #403 in the absence of bowel movements on the aforementioned days in late July and early August 2013. Unit manager (A) reported it was up to the unit manager to ensure staff compliance with the bowel protocol, but was unable to explain why the facility's bowel protocol had not been followed and implemented for resident #403 to help prevent fecal impaction. On 10/09/2013, at 3:00 p.m., the DON acknowledged, she was aware resident #403 left on LOA with a family member who transported the resident to a local hospital, where the resident was admitted with a [DIAGNOSES REDACTED].# 403 to help prevent fecal impaction. On 10/10/2013, at 3:30 p.m., an interview was conducted with charge nurse (G) regarding resident #403 leaving the facility on LOA with a family member and the failure to implement the facility's bowel protocol for resident #403 to help prevent fecal impaction. Nurse (G) reported she (nurse) was the nurse on duty when resident #403 left the faciity on LOA with a family member. Nurse (G) further reported that the family member informed her (Nurse G) that she (family member) was taking resident #403 to the hospital for abdominal pain. However, nurse (G) had no explanation why resident #403 was not assessed and treated in the facility for fecal impaction. ( )

This citation pertains to intake numbers MI 475 and MI 485. Based on observations, interviews and record reviews, the facility failed to provide adequate, appropriate supervision to prevent elopements for 2 (#205 and #206) of 5 residents reviewed for elopement from a total sample of 10, resulting in Immediate Jeopardy for Resident #205 who eloped from the facility unbeknownst to facility staff and was missing from the facility for more than four hours. Also, the facility failed to prevent the attempted elopement of Resident #206, when she opened a second floor window and tried to climb out. As a result of the facility's failure to supervise and implement appropriate safety devices (secured doors and windows), 13 other residents identified as wanderers were placed at risk for elopement, resulting in the potential for physical harm, injury or death. Findings include: Resident #205: On 4-18-2012 at 9:00 A.M., the Administrator and Director of Nursing (DON) were interviewed regarding a report that Resident #205 had been missing from the building for more than 4 hours on 4-16-2012. The facility-initiated investigation for Resident #205 was reviewed. The Unusual Occurrence Form and nurses' notes, dated 4-16-2012 at 8:00 P.M., were reviewed. According to this documentation, Resident #205 was last seen on 4-16-2012 at 3:30 P.M. by Certified Nursing Assistant (CNA) #1. At 4:30 P.M., a family member came to visit Resident #205 and was unable to find him in his room. Nursing staff members checked both the first and second floors and were unable to find the resident. The nurse supervisor initiated the full elopement protocol and the search expanded outside the facility and surrounding area by all available nursing staff. The police were contacted, but did not arrive at the facility until 8:00 P.M. on 4-16-2012, when resident #205 was returned to the facility by a family member. The family member informed the facility that the resident had been found at a friend's home in the resident's old neighborhood, the exact location was not identified on the Unusual Occurrence Form. According to the Unusual Occurrence Form, the resident was examined and had no injury. The responsible party and physician were notified of the elopement. The physician ordered one-to-one supervision for Resident #205 and the placement of a WanderGuard bracelet (a device that transmits a signal which activates an alarm when the signal is received, usually at a doorway) to the resident's wheelchair. Resident #205's clinical record was reviewed. Resident #205 was admitted to the facility on [DATE] and had an appointed legal guardian. Resident #205's [DIAGNOSES REDACTED]. The nursing home resident assessment and care screening, dated 2-26-12, identified that Resident #205's cognitive skills were severely impaired. The resident exhibited memory loss and impaired decision making. The resident required limited-to-extensive assistance with activities of daily living. On admission, the resident was identified as an elopement risk with physician's orders [REDACTED]. However, after the resident removed the bracelet several times, the intervention was discontinued on 10-31-2011. According to the Interdisciplinary Team note, dated 11-29-2011, Resident #205 remained identified as a wanderer and at risk for elopement. Additionally, according to the facility's wanderer list (undated), known as the "travelers club," Resident #205 was known to be a "wanderer." It was noted he did not wear a WanderGuard. However, despite the fact that Resident #205 was at risk for elopement, further review of the clinical record revealed that the facility had no wandering or elopement plan of care in place, until after Resident #205 eloped on 4-16-12. The assigned CNA for Resident #205 on 4-16-12, CNA #4, was not available for interview. CNA #4's written statement, dated 4-16-2012 at 5:30 P.M., noted, "I came in at 3:00 P.M. I went to one north to get my assignment. I did my rounds at 3:30 P.M. and I saw Resident #205 in his room." On 4-17-2012 at 3:40 P.M.,. Resident #205 was interviewed. The resident was observed lying in bed with CNA #5 (assigned to provide one-to-one supervision for Resident #205) sitting in the room. The resident was verbal, loud and angry during the conversation. He stated, "I am not being taken good care of here. I do not want to be here." When the resident was asked about leaving the facility, he stated, "I went out the door. I caught a cab and went by my friend's house and to my house. I then came back." During an additional interview on 4-18-2012 at 2:00 P.M., Resident #205 changed his story, saying he got a ride from a stranger down the street with a pick-up, and paid him to take him to the casino, where he ate, played slots and then paid someone else to take his to his friend's house. The resident repeatedly became agitated, loud and angry during the interview. On 4-17-2012 at 4:00 P.M. CNA #5 was interviewed. He reported that Resident #205 was doing well and had made no attempts to leave the facility. On 4-18-2012 at 1:00 P.M., Resident #207 was interviewed. According to Resident #207, "I was coming back from the store. It was between 3:30 P.M. and 4:00 P.M. I was rushing to go watch television. I was inside the first door when (Resident #205) was coming out the inner door behind a young lady and her son. He was alone in his wheelchair, so I held the door as he came out. I said (to Resident #205), so you (#205) are on your way, because earlier in the day he (#205) had informed me that he was going somewhere with his son. I did not see his son but as he went by me, (Resident #205) said he had someone waiting." Resident #207 went on to say that upon entering the inner door of the facility, people were moving about, but he (#207) did not recall seeing anyone sitting at the nursing desk. On 4-18-2012 at 4:00 P.M. Nurse #3 (nurse on duty) was interviewed by phone. She stated, "I worked both the day and afternoon shift. I attempted to pass medications at 1:00 P.M. and (Resident #205) refused. When (Resident #205) went out to smoke under staff supervision between 1:30 P.M. to 2:00 P.M., he was normal, laughing and talking. He always refuses medications. His son came in at around 4:30 P.M. and asked about his whereabouts. I informed him that if he was not in his room he could be upstairs (second floor). When he was not located, we immediately began searching and initiated the elopement protocol. The resident returned to the facility with one of his sons. I assessed him with no injury identified. The resident would not say how he left, but said he went to the casino and to a friend's house. It was during shift change when he exited. I have never experienced something like this before. I helped in the search and did not want anything to happen to him." On 4-19-2012 at 2:00 P.M., Psychologist #6 was interviewed by phone. He stated, "I assessed and evaluated Resident #205 on 4-18-2012. The resident was highly agitated and intermittently confused. The resident exhibited paranoid thinking. He is an elopement risk. He was angry and wanted to initiate an altercation so I remained soft and calm. I referred the resident for medication intervention." The policy and procedure entitled "Management of Wandering Residents," dated 4/2012, was reviewed. According to this policy, "It is the policy of (facility name) to maintain the safety of a wandering resident and prevent elopement from the facility. Procedure: 1. The elopement assessment will be completed by nursing upon admission to identify if a resident wanders or is an elopement risk. The assessment is renewed by nursing at least quarterly. 2. If the resident is identified as an elopement risk a wander-guard is obtained and placed on the resident." It was unclear why facility staff failed to follow this policy. According to nurse's notes, dated 4-16-12, "Resident was last seen at 3 p.m. Searched facility, unable to locate resident. . .son brought resident back at 8 p.m." Resident #205 left the building and was unsupervised and unattended on the inner city streets of Detroit. This situation put resident #205 at high risk for serious physical harm, injury or death. On 4-20-2012 at 2:42 P.M., the Administrator and Director of Nursing were informed of the Immediate Jeopardy that began on 4-16-12 as a result of the facility's failure to supervise and implement safety devices to prevent the elopement of resident #205, placing 13 other residents identified as at risk for elopement at a potential risk for serious physical harm, injury and/or death. On 4-23-2012 the surveyor confirmed that the facility had implemented the following to remove the Immediate Jeopardy: 1. Resident returned to the facility on [DATE] at 8:00 P.M. and a full body assessment was performed by the charge nurse. No ill effects were noted related to the occurrence. 2. The resident was placed on one-to-one supervision upon return to the facility on [DATE] at 8:00 P.M. 3. Resident #205 was educated on 4-16-2012 at 8:15 P.M. regarding the process of the leave of absence. The Leave of Absence Policy was presented to the resident and he verbalized understanding. 4. Facility security hours were immediately increased by 8 hours on 4-16-2012 to cover first and second shift, and security is stationed at the front door. The elopement incident occurred on the day shift. Previous security hours were from 4:00 P.M. to 12 midnight. New hours are first shift: 8:00 A.M. to 4:00 P.M., second shift: 4:00 P.M. to 12:00 midnight. 5. A wander-guard bracelet was placed on Resident #205's wheelchair on 4-18-2012. Placement will be checked by the charge nurses and signed off every shift in the MAR (Medication Administration Record). 6. Staff in-service training was initiated on elopement and wandering policy on 4-16-2012. The in-service is on-going to capture 100% of employees. An Elopement and Missing Person audit tool will be initiated by nursing and will be done three times a week for one month or until compliance is achieved. Findings will be reported to the Quality Assurance (QA) committee. 7. Elopement assessments were initiated on 4-16-2012 for thirteen other residents who were previously identified as at risk for elopement. Their care plans were reviewed and updated as of 4-16-2012. Elopement assessments are ongoing until all residents are reassessed. The Immediate Jeopardy (IJ) which began on 4-16-2012 was removed on 4-18-2012. The facility remained out of compliance at a scope of "isolated" and severity of "no actual harm with potential for more than minimal harm that is not immediate jeopardy" until sustained compliance can be verified by the State Agency. ( ) Resident #206: On 4-18-2012 at 10:00 A.M., the Administrator and Director of Nursing were interviewed regarding a report that on 4-17-12, Resident #206 had attempted to climb out of a second-floor window. The facility-initiated investigation for Resident #206 was reviewed. The investigation identified that Resident #206 did not go out the window. The facility had previously installed security windows throughout the facility that opened no more than six inches. However, Resident #206 figured out how to release the security latch allowing the window to open. Resident #206 was able to open the second floor window, but was redirected by nursing staff. It was noted that the resident was being closely monitored and had a one-to-one sitter since admission. The Incident Report and nurse's notes, dated 4-17-2012 at 12:20 P.M., were reviewed. Resident #206 was observed attempting to get out the window. The staff nurse stopped the resident from doing it. On the nurse assessment the resident had no identified injury. The physician and responsible party were notified. The Director of Nursing and managers were notified. Corrective measures taken, as noted by the Incident Report, were to notify maintenance to check windows to ensure safety and close monitoring with a one-to-one sitter. According to the nurse's notes, the resident was experiencing increased agitation and scheduled psychotropic medications were administered with the medication being temporarily effective. The nurse's notes went on to say that the resident was constantly redirected away from windows and doors. Resident #206's clinical record was reviewed. Resident #206 was admitted on [DATE], with [DIAGNOSES REDACTED]. The nursing home resident assessment and care screening, dated 3/9/12, identified that Resident #206's cognitive skills were severely impaired. The resident exhibited memory loss and impaired decision making. The resident required supervision to limited assistance with activities of daily living. The resident had behavioral concerns that included wandering. The care plan for falls and injury, dated 3/20/12, noted that the resident verbalized that she wanted to "leave the building." Interventions included the use of a one-to-one sitter and application of a wander-guard bracelet. On 2-18-2012 at 1:00 P.M. Resident #206 was observed in dining room with one-to-one supervision. The resident was appropriately dressed and groomed with no marks, bruises or injury observed. The resident was verbal on approach but moving back and forth. She stated, "Yes I get good care, but right now I am going upstairs to see about my husband." The resident was confused and disoriented when she exited the dining room with staff. On 4-18-2012 at 2:35 P.M. CNA #7, the assigned certified nurse aide was interviewed by phone. She stated, "I worked the day shift on 4-17-2012. I was not in the room. I had gone on break at 12 noon and the nurse (employee #8) was covering. I returned and was informed that (resident #206) had opened the window in her room and went through it. Everyone was there (in the room) when I returned. The resident never tried to go out the window when I was monitoring. She was just moving from place to place, wandering." On 4-18-2012 at 3:00 P.M. employee #8, the nurse on-duty, was interviewed by phone. Employee #8 stated, "The resident was observed trying to climb out the window. The window in the resident's room was half open and she had raised the screen. The resident's upper body went through the window. I had been outside the door. The door was open. The resident's sitter had gone on break and I was covering. I was doing something at the nurse's cart. I did not know she would do that, it was out her character. The resident became agitated and started attaching me as I redirected from the window. She was saying let me go. The resident remains on one-to-one monitoring and continues to wander back and forth looking for her husband." Employee #8 did not explain why she (#8) was at the nurse's cart, when she (#8) was supposed to be providing one-to-one supervision to Resident #206 while employee #7 was on break. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER (S): MI 315, MI 349 BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ADDRESS COMPLAINTS OF PAIN RESULTING FROM A FRACTURE OF UNKNOWN ORIGIN FOR ONE (#501) OF THREE RESIDENTS REVIEWED FOR INJURIES AND FALLS, FROM A TOTAL OF THREE SAMPLED RESIDENTS, RESULTING IN THE DELAYED IDENTIFICATION OF A FRACTURE OF UNKNOWN ORIGIN AND SUBSEQUENT DELAY OF TREATMENT, UNMET CARE NEEDS AND UNRELIEVED PAIN. FINDINGS INCLUDE: ON 9/27/11 AT 10:25 A.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #501 WAS OBSERVED IN HER ROOM SITTING IN A GERI CHAIR (RECLINING/POSITIONAL CHAIR). RESIDENT #501 WAS WEARING A SLING TO HER RIGHT ARM. RESIDENT #501'S DOCTOR WAS IN TO PERFORM A PHYSICAL EXAMINATION. PER THE DOCTOR, RESIDENT #501'S RIGHT ARM HAD "...SLIGHT SWELLING AND DISCOLORATION..." RESIDENT #501 MOANED DURING THE EXAMINATION. ACCORDING TO THE ADMISSION RECORD, RESIDENT #501 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #501 HAD SEVERELY IMPAIRED DECISION MAKING AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, HYGIENE, BATHING AND TOILET. A COMPLAINT AND FACILITY REPORTED INCIDENT ON FILE ALLEGED THAT RESIDENT #501 HAD SUSTAINED AN INJURY OF UNKNOWN ORIGIN. A REVIEW OF THE FACILITY'S "UNUSUAL OCCURRENCE FORM" DATED 9/6/11, REVEALED THAT AN INCIDENT OR ACCIDENT OCCURRED ON 9/6/11 INVOLVING RESIDENT #501 "...RIGHT SHOULDER RIGHT HUMERUS ACUTE MILDLY DISPLACED [MEDICAL CONDITION] SHAFT OF THE HUMERUS. I WAS NOTIFIED BY THE MIDNIGHT NURSE OF RESIDENT #501'S YELLING OUT IN A SOUND OF PAIN WHILE ADLS (ACTIVITIES OF DAILY LIVING) WERE BEING PERFORMED, IMMEDIATELY PHONED THE DOCTOR TO GET AN OKAY FOR X-RAYS..." A physician's orders [REDACTED].M., REVEALED "...STAT (IMMEDIATELY) X-RAY OF THE RIGHT ARM AND SHOULDER, HUMERUS AND FOREARM..." AN X-RAY REPORT OF RESIDENT #501'S RIGHT ARM, DATED 9/6/11, REVEALED "...FINDINGS: THERE IS A [MEDICAL CONDITION] NECK OF THE HUMERUS WITH MEDIAL DISPLACEMENT OF THE HUMERAL SHAFT..." ON 9/27/11 AT 1:56 P.M., DURING AN INTERVIEW, CERTIFIED NURSING ASSISTANT (CNA #1) REPORTED "...ON 9/3/11 AT ABOUT 6:30 A.M., I WAS WASHING UNDER HER (#501) RIGHT ARM AND SHE SCREAMED SO I REPORTED IT TO THE NURSE (LPN #1). LPN #1 ASSESSED HER AND SAID IT LOOKED DIFFERENT. SHE (LPN #1) SAID SHE WAS GOING TO PUT IT IN THE X-RAY BOOK..." CNA #1 FURTHER REPORTED "...I WAS OFF THE WEEKEND, BUT THE NEXT NIGHT I WORKED, LEADING INTO THE MORNING OF 9/6/11, I CALLED LPN #2 BECAUSE SHE (#501) WAS IN PAIN AND DOING THE SAME THING AS I WAS PROVIDING CARE. SHE WAS SCREAMING OUT IN PAIN. SHE (LPN #2) SAID SHE WOULD CALL FOR AN X-RAY BUT I DON'T KNOW IF SHE DID..." CNA #1'S WRITTEN STATEMENT CONTAINED IN THE FACILITY'S INVESTIGATIVE FILE WAS CONSISTENT WITH THE STATEMENT GIVEN DURING HER INTERVIEW. ON 9/27/11 AT 2:20 P.M., DURING AN INTERVIEW, LPN #1 REPORTED, "...CNA #1 INFORMED ME THAT RESIDENT #501 WAS YELLING OUT. I WENT TO CHECK IT OUT AND LIFTED HER ARM AND I FOUND NOTHING. I GOT ANOTHER NURSE TO CHECK IT OUT WITH ME AND WE FOUND NOTHING..." WHEN ASKED IF SHE (LPN #1) NOTIFIED THE DOCTOR REGARDING CNA #1'S REPORTS OF RESIDENT #501'S YELLING OUT WHEN RECEIVING CARE, LPN #1 SAID "...NOT AT THAT TIME BECAUSE THERE WAS NO EVIDENCE. I ONLY KNEW WHEN LPN #2 INFORMED ME ON THE MORNING OF 9/6/11. LPN #2 ASKED ME IF THE CNA INFORMED ME OF RESIDENT #501'S COMPLAINTS OF PAIN SO I SAID YES BUT I FOUND NOTHING..." WHEN ASKED WHAT INITIATED THE ORDER FOR AN X-RAY, LPN #1 SAID, "...BECAUSE I HEARD THAT SHE (#501) COMPLAINED OF PAIN AGAIN AND BECAUSE LPN #2 BROUGHT IT UP AGAIN. THAT'S WHAT PROMPTED ME TO CALL THE DOCTOR. I WANTED TO BE ON THE SAFE SIDE..." WHEN ASKED WHY THE DOCTOR WAS NOT NOTIFIED FOR THE INITIAL COMPLAINT OF PAIN ON 9/3/11 IN ORDER TO BE ON THE SAFE SIDE, LPN #1 SAID "...BECAUSE HER VITAL SIGNS WERE NORMAL..." ON 9/27/11 AT 2:41 P.M., DURING AN INTERVIEW, LPN #2 REPORTED, "...CNA #1 INFORMED ME THAT RESIDENT #501 WAS SCREAMING OUT IN PAIN AND THAT HER RIGHT ARM WAS SWOLLEN. I WAS IN THE MIDDLE OF A MED (MEDICATION) PASS SO I DIDN'T GO RIGHT THEN. I WENT IN AND CHECKED IT OUT AND SHE SCREAMED. SHE WAS KNOWN TO SCREAM AT TIMES BUT THIS SCREAM WAS DIFFERENT AND HER RIGHT ARM WAS OUT OF ALIGNMENT..." LPN #2 FURTHER REPORTED, "...I LEFT TO FINISH MY MED PASS AND WHEN I GOT TO HER, I GAVE HER A PAIN PILL. THE DAY SHIFT NURSE (LPN #1) CAME IN AND I WAS INFORMING HER ABOUT #501'S ARM AND SHE (LPN #1) SAID SHE REMEMBERED CNA #1 REPORTING THE SAME FINDINGS TO HER SO SHE (LPN #1) CALLED THE DOCTOR AND GOT THE X-RAY. I (LPN #2) WAS GOING TO CALL BUT I HAD TO FINISH MY MED PASS..." WHEN ASKED WHY SHE FAILED TO NOTIFY THE DOCTOR IMMEDIATELY ONCE SHE (LPN #2) DISCOVERED THAT RESIDENT #501'S RIGHT ARM WAS OUT OF ALIGNMENT AND THAT SHE WAS SCREAMING OUT IN PAIN, LPN #2 SAID, "...I WAS GOING TO AFTER I FINISHED MY MED PASS. I ONLY HAD A COUPLE MORE PEOPLE TO PASS MEDS TO BEFORE I FINISHED AND GOT TO HER (#501)..." LPN #2 COULD NOT EXPLAIN WHY SHE FAILED TO NOTIFY THE DOCTOR RIGHT AWAY ONCE SHE DISCOVERED THAT RESIDENT #501'S RIGHT ARM WAS OUT OF ALIGNMENT AND THAT RESIDENT #501 WAS SCREAMING OUT IN PAIN. A physician's orders [REDACTED]. TAKE ONE TABLET EVERY 6 HOURS AS NEEDED." A physician's orders [REDACTED]. A REVIEW OF RESIDENT #501'S "ROUTINE MEDICATIONS" SHEET FOR THE MONTH OF SEPTEMBER 2011 REVEALED THAT RESIDENT #501 RECEIVED HER PRESCRIBED PAIN MEDICATION ([MEDICATION NAME]) ON 9/6/11 AT 10:30 A.M. FURTHER RECORD REVIEW REVEALED THAT RESIDENT #501 HAD NOT RECEIVED ANY PAIN MEDICATIONS ON 9/3/11 WHEN SHE INITIALLY COMPLAINED OF PAIN AND HAD NOT RECEIVED ANY OTHER PAIN RELIEF MEDICATION PRIOR TO 9/6/11. ON 9/27/11 AT 2:50 P.M., THE FACILITY ADMINISTRATOR SAID, "...SHE (LPN #1) SHOULD HAVE ADDRESSED IT ONCE SHE BECAME AWARE..." UPON FURTHER RECORD REVIEW, IT WAS REVEALED THAT THERE WAS NO DOCUMENTATION OF RESIDENT #501'S INITIAL COMPLAINTS OF PAIN ON 9/3/11 IN THE CLINICAL RECORD. THE LAST ENTRY IN THE NURSE'S NOTES PRIOR TO 9/3/11, WAS IN JULY OF 2011 FOR AN UNRELATED CONCERN. WHEN QUERIED ABOUT THE LACK OF DOCUMENTATION, THE ADMINISTRATOR SAID, "...THAT'S ONE OF THE THINGS WE'RE WORKING ON..." ON 9/27/11 AT 3:40 P.M., DURING AN INTERVIEW, WHEN ASKED ABOUT THE STAFF'S FAILURE TO PROPERLY ADDRESS RESIDENT #501'S COMPLAINT'S OF PAIN AND THE MALALIGNMENT OF HER RIGHT ARM, THE DIRECTOR OF NURSING (DON), REPORTED, "...I FEEL BAD FOR THE RESIDENT (#501) BECAUSE SHE HAD TO WAIT..." A REVIEW OF THE FACILITY'S "CHARTING AND DOCUMENTATION " POLICY REVISED APRIL 2008, REVEALED: "...ALL OBSERVATIONS, MEDICATIONS ADMINISTERED, SERVICES PERFORMED, ETC., MUST BE DOCUMENTED IN THE RESIDENT'S CLINICAL RECORDS..." "...ALL INCIDENTS, ACCIDENTS, OR CHANGES IN THE RESIDENT'S CONDITION MUST BE RECORDED..." A REVIEW OF THE FACILITY'S "PAIN ASSESSMENT POLICY AND PROCEDURE" REVISED AND UPDATED 9/09, REVEALED: "...RESIDENTS WHO ARE OBSERVED WITH GRIMACING, CLENCHED JAW, FROWNING, TEARING, MOANING, CRYING, SCREAMING, CURSING, BITING, RUBBING BODY PARTS, KNEES PULLED UP, PACING, HAND WRINGING, IRRITABILITY, OR COMBATIVE WITH CARE, THE PHYSICIAN WILL BE NOTIFIED OF ANY CONCERNS..." "...THE NURSE WILL OBSERVE AND DOCUMENT THE LOCATION OF PAIN AND INTENSITY..." "...COGNITIVELY IMPAIRED RESIDENTS' PAIN WILL BE ASSESSED THROUGH SIGNS AND SYMPTOMS OF PAIN..." "...THE PHYSICIAN WILL BE NOTIFIED REGARDING CONCERNS RELATED TO THE RESIDENT'S CURRENT PAIN MANAGEMENT PROGRAM AND ANY RESIDENT WHO HAS BEEN NEWLY IDENTIFIED AS HAVING PAIN..."

THIS INTAKE PERTAINS TO MI 537 BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THAT 1 OF 4 SAMPLED RESIDENT (#501) RECEIVED ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS RESULTING IN AN INJURY WITH HARM (FRACTURED LEG) WHEN THE WHEELCHAIR TAB ALARM WAS NOT APPLIED. FINDINGS INCLUDE: REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #501 REVEALED ON THE FACE SHEET THAT HE HAD MULTIPLE [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT THE RESIDENT REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH TRANSFERS AND USED A WHEELCHAIR FOR MOBILITY. A FALL RISK ASSESSMENT FORM DATED OCTOBER 2010, INDICATED A TOTAL SCORE OF 14 WITH A SCORE OF 10 OR HIGHER REPRESENTING A HIGH RISK FOR ACCIDENTS. REVIEW OF RESIDENT #501'S COMPREHENSIVE CARE PLAN DATED 9/21/10, INDICATED FALL RISK AS A PROBLEM ASSOCIATED WITH SYMPTOMS OF "SYNCOPE AND IMPAIRED BALANCE RELATED TO GENERALIZED WEAKNESS". THE CARE PLAN INDICATED THAT RESIDENT #501 USED A WHEELCHAIR AS HIS PRIMARY MODE OF LOCOMOTION. THE CARE PLAN FURTHER INDICATED FALL RISK INTERVENTIONS THAT INCLUDED, "TAB ALARM IN WHEELCHAIR. CHECK FOR PLACEMENT AND FUNCTION EVERY SHIFT". FURTHER REVIEW OF RESIDENT #501'S CLOSED CLINICAL RECORD REVEALED IN THE MONTHLY PHYSICIAN ORDERS [REDACTED]. REVIEW OF AN ACCIDENT REPORT DATED 12/18/10, INDICATED AT APPROXIMATELY 5:30 P.M., RESIDENT #501 WAS FOUND ON THE FLOOR IN THE CORRIDOR ON THE SECOND FLOOR. THE RESIDENT WAS DISCOVERED ON THE FLOOR BY TWO CNA'S (CERTIFIED NURSING ASSISTANTS) KNOWN AS EMPLOYEES "A" AND "B". THE RESIDENT WAS ASSESSED BY THE LPN (LICENSED PRACTICAL NURSE) KNOWN AS EMPLOYEE "C". THE ACCIDENT REPORT INDICATED THAT RESIDENT #501 IMMEDIATELY COMPLAINED OF PAIN IN THE RIGHT LEG. FURTHER REVIEW OF THE CLINICAL RECORD REVEALED ON A DOCUMENT ENTITLED, "REHAB SERVICES SCREENING FORM" DATED 12/20/10, "RESIDENT (RESIDENT #501) ALREADY HAS BEEN PROVIDED WITH A TAB ALARM IN W/C (WHEELCHAIR) BUT IT WAS NOT THERE WHEN FALL HAPPENED". THIS DOCUMENT WAS COMPLETED BY THE PHYSICAL THERAPIST ALSO KNOWN AS EMPLOYEE "D". ON 1/20/11, AT 2:30 P.M., INTERVIEW WITH EMPLOYEE "D" VERIFIED THAT SUBSEQUENT TO RESIDENT #501 FALL INCIDENT SHE INTERVIEWED NURSING STAFF WHO INFORMED HER THAT RESIDENT #501 WHEELCHAIR TAB ALARM HAD NOT BEEN APPLIED AS OUTLINED IN THE PLAN OF CARE AND ORDERED BY THE PHYSICIAN. ON 1/20/11, AT 1:00 P.M., INTERVIEW WITH EMPLOYEE "A" REVEALED THAT AT APPROXIMATELY 5:30 P.M., SHE RESPONDED TO YELLING BY RESIDENT #501 WHO WAS LAYING ON THE FLOOR IN THE CORRIDOR ON THE SECOND FLOOR OUTSIDE OF THE DOORWAY TO HIS ROOM. EMPLOYEE "A" STATED THAT THE WHEELCHAIR TAB ALARM WAS NOT ATTACHED TO RESIDENT #501 AND HIS WHEELCHAIR. ON 1/21/11, AT 3:00 P.M., INTERVIEW WITH EMPLOYEE "B" REVEALED THAT AT APPROXIMATELY 5:30 P.M., SHE ALSO RESPONDED TO YELLING BY RESIDENT #501 WHO WAS LAYING ON THE FLOOR IN THE CORRIDOR ON THE SECOND FLOOR OUTSIDE OF THE DOORWAY TO HIS ROOM. EMPLOYEE "B" ALSO STATED THAT THE WHEELCHAIR TAB ALARM WAS NOT ATTACHED TO RESIDENT #501 AND HIS WHEELCHAIR. ON 1/21/11, AT 11:30 A. M., INTERVIEW WITH EMPLOYEE "C" REVEALED THAT AT APPROXIMATELY 5:30 P.M., SHE RESPONDED TO YELLING BY RESIDENT #501 WHO WAS LAYING ON THE FLOOR IN THE CORRIDOR ON THE SECOND FLOOR OUTSIDE OF THE DOORWAY TO HIS ROOM. EMPLOYEE "C" ALSO REPORTED THAT THE WHEELCHAIR TAB ALARM WAS NOT ATTACHED TO RESIDENT #501 AND HIS WHEELCHAIR. EMPLOYEE "C" FURTHER REPORTED THAT SHE ASSESSED RESIDENT #501 FOR INJURIES AND HE IMMEDIATELY COMPLAINED OF PAIN IN HIS RIGHT LEG SAYING "MY LEG IS BROKE". EMPLOYEE "C" REPORTED THAT SHE IMMEDIATELY NOTIFIED THE PHYSICIAN AND X-RAYS WERE ORDERED. RESIDENT #501 WAS SUBSEQUENTLY TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. FURTHER REVIEW OF RESIDENT #501'S CLOSED CLINICAL RECORD REVEALED ON A RADIOLOGICAL REPORT DATED 12/21/10, "EXAM OF RIGHT HIP, RIGHT FEMUR" WITH FINDINGS OF EVIDENCE OF AN "ACUTE COMMINUTED MINIMALLY DISPLACED SUPRACONDYLAR FRACTURE OF THE RIGHT DISTAL FEMUR". FURTHER REVIEW OF THE HOSPITAL RECORD INDICATED ON AN ORTHOPEDIC SURGICAL PHYSICIAN REPORT THAT RESIDENT #501 REQUIRED AN ORIF (OPEN REDUCTION INTERNAL FIXATION) OF THE RIGHT DISTAL FEMUR. IN SUMMARY, THE FAILURE BY NURSING STAFF TO ATTACH THE WHEELCHAIR TAB ALARM TO RESIDENT #501 PLACED HIM AT HIGH RISK FOR A FALL ACCIDENT AND CONSEQUENTLY RESULTED IN HARM OUTCOME THAT WAS AVOIDABLE.

BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT 1 OF 6 SAMPLED RESIDENTS (RESIDENT #201) FROM ELOPING FROM THE FACILITY, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #201 AS A RESULT OF THE FACILITY'S FAILURE TO SUPERVISE AND IMPLEMENT SAFETY DEVICES (WANDERGUARD, LOCKED AND ALARMED EXIT DOORS) TO PREVENT THE ELOPEMENT OF RESIDENT #201, PLACING 16 OTHER RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK AT A HIGH RISK FOR ELOPEMENT WHICH COULD HAVE RESULTED IN PHYSICAL HARM, INJURY OR DEATH. FINDINGS INCLUDE: ON ENTRANCE, 10-28-2010 AT 2:30 P.M. THE DIRECTOR OF NURSING WAS INTERVIEWED. THE FACILITY UNUSUAL OCCURRENCE FORM, NURSE NOTES AND INVESTIGATION FINDINGS WERE REVIEWED. THE UNUSUAL OCCURRENCE FORM DATED 10-24-10 AT 4:30 P.M. STATED THAT THE RESIDENT LEFT THE FACILITY WITHOUT INFORMING THE STAFF MEMBER. A CERTIFIED NURSE AIDE HEARD THE DOOR ALARM. THE FACILITY CONDUCTED SEARCHES OF THE FACILITY AND SURROUNDING AREA. THE CERTIFIED NURSE AIDE FOUND THE RESIDENT STANDING IN LINE IN A CHINESE RESTAURANT (SHOPPING AREA IN THE NEXT BLOCK). THE RESIDENT WAS BROUGHT BACK TO THE FACILITY. THE RESIDENT WAS EXAMINED AND SHOWED NO INJURY. VITAL SIGNS: BLOOD PRESSURE 136/78, TEMPERATURE 98.1, RESPIRATION 16, PULSE 83. THE RESPONSIBLE PARTY AND PHYSICIAN WAS NOTIFIED. THE FACILITY ELOPEMENT MISSING RESIDENT POLICY AND PROCEDURE WAS REVIEWED. IT IS THE POLICY OF THE FACILITY THAT ALL EFFORTS TO PREVENT ELOPEMENT WILL BE IMPLEMENTED. ELOPEMENT IS DEFINED AS LEAVING THE FACILITY PREMISES WITHOUT FOLLOWING THE FACILITY POLICY AND PROCEDURE FOR LEAVE OF ABSENCE. FACILITY FOLLOWED THE GUIDELINES OF THE ELOPEMENT POLICY AND PROCEDURE (ELOPEMENT OCCURS WHEN A RESIDENT WHO NEEDS SUPERVISION LEAVES A SAFE AREA WITHOUT SUPERVISION). RESIDENT #201'S CLINICAL RECORDS WAS REVIEWED. THE RESIDENT WAS admitted [DATE] FROM ANOTHER FACILITY AND HAD A LEGAL GUARDIAN. [DIAGNOSES REDACTED]. ELOPEMENT RISK assessment dated [DATE] NOTED THAT THE RESIDENT IS AN ELOPEMENT RISK. THE NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING DATED 8-16-10 IDENTIFIED COGNITIVE SKILLS THAT WERE MODERATELY IMPAIRED. THE RESIDENT COMMUNICATION PATTERNS NOTED THAT HE USUALLY UNDERSTOOD AND USUALLY UNDERSTANDS OTHERS. SUPERVISION WAS REQUIRED WITH ACTIVITY OF DAILY LIVING SKILLS AND SELF PERFORMANCE. A PLAN OF CARE WAS IN PLACE THAT INCLUDED POTENTIAL FOR ELOPEMENT RISK RELATED TO IMPAIRED COGNITION, DEPRESSION AND PSYCHOSIS. THE RESIDENT WAS DELUSIONAL AND EXHIBITED PARANOID BEHAVIORS. THE APPROACH INCLUDED MONITORING RESIDENT BEHAVIORS AND WHEREABOUTS AND THE USE OF A WANDER GUARD ALARM. ON 10-28-2010 AT 3:00 P.M. RESIDENT #201 WAS INTERVIEWED. THE RESIDENT WAS OBSERVED IN ROOM LYING IN BED WITH EMPLOYEE IN ROOM PROVIDING ONE TO ONE MONITORING. THE RESIDENT WAS APPROPRIATELY DRESSED AND GROOMED WITH MO MARKS, BRUISES OR INJURY EVIDENT. THE RESIDENT STATED, "I WAS GOING TO THE STORE AND BACK HERE. NO I DID NOT TELL ANYONE. I WANT TO GO BACK HOME TO INKSTER. I HAVE BEEN HERE LONG ENOUGH. I WENT DOWN THE HALLWAY AND THE ALARM DID NOT COME ON, I EXITED." ON 10-28-2010 AT 3:15 P.M. THE CERTIFIED NURSE AIDE (ASSIGNED) WAS INTERVIEWED. SHE STATED "I SAW HIM IN HIS BEDROOM AND HAD HIM JOIN US IN THE DINING ROOM FOR DINNER (APPROPRIATELY 4:10 P.M.) I WENT TO ASSIST ANOTHER RESIDENT AND RETURN TO FINE HIM GONE. I BEGAN LOOKING FOR HIM BECAUSE FOR HIM TO GET UP AND LEAVE IS NOT A NORMAL ROUTINE (APPROXIMATELY 4:30 P.M.). I WENT TO HIS ROOM AND LOOKED IN OTHER ROOMS. I COULD NOT FIND RESIDENT #201 ON THE SECOND FLOOR SO I INFORMED THE CHARGE NURSE, WHO BEGAN TO LOOK. I HEARD AN ALARM SOUND, MORE LIKE A CHAIR ALARM I THOUGHT. THE DOOR HAD BEEN DISARMED WHEN I CHECKED. I INFORMED SECURITY THAT WHEN I OPENED THE DOOR THE ALARM DID NOT GO OFF. I WENT DOWN THE STAIRS AND THE EMERGENCY DOOR WAS CLOSED. I GOT IN MY CAR AND DROVE UP SCHAEFER. I ENTERED INTO THE SHOPPING AREA AND STARTED SEARCHING STORES. I WENT INTO A CHINESE RESTAURANT AND OBSERVED RESIDENT #201 STANDING IN LINE TO MAKE A PURCHASE. HE STATED HE WAS HUNGRY. I DIRECTED HIM BACK TO MY CAR WITH NO PROBLEM. I ASKED HIM HOW HE EXITED THE FACILITY AND HE SAID THROUGH THE EMERGENCY DOOR. I HAD CHECKED THE DOOR AND THE ALARM DID NOT GO OFF." THE EMPLOYEES WRITTEN STATEMENT FOR THE FACILITY INVESTIGATION WAS REVIEWED. ON 11-1-2010 AT 10:30 A.M. THE MAINTENANCE DIRECTOR WAS INTERVIEWED. HE STATED, "THE DOOR BATTERY WAS DEAD. THE DOOR ALARMS ARE CHECKED MONTHLY AND THE BATTERY CHANGED EVERY 6 MONTHS." WE CHECKED THE DOOR ALARMS (FIRST AND SECOND FLOOR SOUTH EXITS) THE SOUNDING ALARM WAS LOUD AND PIERCING TO THE EAR DRUM. ON 11-1-2010 AT 10:45 A.M. THE NURSE (ON DUTY 10-24-10 AFTERNOON SHIFT) WAS INTERVIEWED. SHE STATED, "I CAME OUT A RESIDENT ROOM AND THE ELOPEMENT CODE WAS IN PROCESS. THEY HAD SEARCHED THE FACILITY AND I VOLUNTEERED TO GO OUTSIDE TO SEARCH. I HAD BEEN ON THE FIRST FLOOR AND I DID NOT HEAR AN ALARM. I LEFT WITH THE ASSIGNED CERTIFIED NURSE AIDE. WE WENT NEXT DOOR TO THE SHOPPING CENTER AND EACH BEGIN LOOKING IN A STORE. I ASKED THE RESIDENT WAS HE OKAY. HE SAID HE WAS COMING BACK. I DID NOT SAY MUCH MORE DID NOT WANT TO AGITATE HIM. THE CERTIFIED NURSE AIDE SAID HE HAD BEEN A LITTLE APPREHENSIVE. WE CALLED THE FACILITY TO INFORM THAT THE RESIDENT WAS FOUND. WE TOOK HIM TO THE NURSE WHO COMPLETED A NURSING ASSESSMENT. WE BEGAN THE SEARCH AT ABOUT 5:00 P.M. AND FOUND HIM 10 TO 15 MINUTES LATER." THE EMPLOYEES WRITTEN STATEMENT FOR THE FACILITY INVESTIGATION WAS REVIEWED. ON 11-1-2010 AT 1:00 P.M. THE SECURITY GUARD WAS INTERVIEWED. HE STATED, "I WAS ON THE SECOND FLOOR WHEN APPROACHED BY THE CERTIFIED NURSE AIDE. SHE SAID THAT THE RESIDENT MAY HAVE GONE DOWN THE STAIRS. I DID NOT HEAR AN ALARM FOR THE STAIRS SO I PROCEEDED TO CHECK THE FLOORS (SECOND, FIRST AND BASEMENT). I THINK THE STAIRWAY DOOR MUST HAVE BEEN ON CHIME, BECAUSE THE ALARM WAS NOT SOUNDING. IT MUST BE CODED TO TURN OFF WHEN ALARMING. I WENT TO THE EMERGENCY EXIT DOOR AND REALIZED THAT THE DOOR WAS AJAR (APPROXIMATELY THREE MINUTES AFTER STARTING THE SEARCH). I OPENED THE DOOR AND LOOKED OUT THEN LOCKED THE DOOR AND ALERTED THE NURSE. I GOT IN MY CAR AND BEGAN TO CHECK THE NEIGHBORHOOD. I RECEIVED A CALL THAT HE WAS FOUND AT THE CHINESE RESTAURANT ORDERING FOOD." THE SECURITY GUARD NOTED THAT HIS SHIFT STATED A 3:00 P.M. THAT HE HAD NOT HAD A CHANCE TO CHECK THE DOORS, BUT INDICATE THAT IT IS A PART OF HIS DUTIES. A WRITTEN STATEMENT FOR THE FACILITY INVESTIGATION WAS REVIEWED. RESIDENT #201 WAS UNSUPERVISED AND UNATTENDED ON THE INNER CITY STREETS OF DETROIT FROM 4:30 P.M. TO 5:15 P.M. AT HIGH RISK FOR SERIOUS PHYSICAL HARM, INJURY OR DEATH. ON 11-3-2010 AT 11:00 A.M. THE ADMINISTRATOR AND DIRECTOR OF NURSING WAS INFORMED OF THE IMMEDIATE JEOPARDY AS A RESULT OF THE FACILITY'S FAILURE TO SUPERVISE AND IMPLEMENT SAFETY DEVICES (WANDERGUARD, LOCKED AND ALARMED EXIT DOORS) TO PREVENT THE ELOPEMENT OF RESIDENT #201, PLACING 16 OTHER RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK AT A HIGH RISK FOR ELOPEMENT. ON 11-3-2010 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 10-24-10 THE RESIDENT WAS RETURNED TO THE FACILITY AND A FULL BODY ASSESSMENT WAS PERFORMED BT THE CHARGE NURSE. NO ILL EFFECTS WAS NOTED RELATED TO THE OCCURRENCE. 2. THE RESIDENT WAS PLACED ON 15 MINUTE CHECKS UPON RETURN AND ON 10-26-10 PLACED ON 1:1 SITTER UNTIL THE RESIDENT EXPRESSES NO DESIRE TO LEAVE THE FACILITY. 3. ON 10-25-10 A WANDER GUARD WAS PLACED ON THE RESIDENT AND IS BEING MONITORED BY THE NURSES, SIGNED OFF EVERY SHIFT IN THE MAR (MEDICATION ADMINISTRATION RECORD). 4. ON 10-26-10 THE RESIDENT WAS EDUCATED REGARDING LEAVING THE BUILDING WITHOUT ESCORT AND VERBALIZED THAT HE UNDERSTOOD. 5. ON 10-27-10 ACTIVITY STAFF REASSESSED THE RESIDENT FOR TAKING HIM TO THE STORE AS AN OUTING; THE CARE PLAN WAS REVISED AND UPDATED. 6. ON 10-31-10 THE DIETARY DEPARTMENT REASSESSED THE RESIDENT FOR LIKES AND DISLIKES RELATED TO THE RESIDENT ' S DESIRE FOR CHINESE FOOD. 7. ON 11-2-10 16 OTHER RESIDENTS WERE IDENTIFIED AS AT RISK FOR ELOPEMENT. THEY WERE REASSESSED, CARE PLANS REVIEWED AND INTERVENTIONS UPDATED. 8. ON 10-27-10 AND 10-28-10 THE EMPLOYEES WERE REEDUCATED ON ELOPEMENT POLICY. ABOUT 75% OF THE EMPLOYEES WERE IN-SERVICED AS OF 11-3-10. THE IN-SERVICE IS ON-GOING TO CAPTURE 100% OF THE EMPLOYEES. NO EMPLOYEE WILL BE ALLOWED TO ON THE SCHEDULE UNTIL THEY HAVE ATTENDED THE ELOPEMENT IN-SERVICE. 9. ON 10-26-10 THE MAINTENANCE DIRECTOR CHECKED ALL THE ALARMS AND FIRE EXIT DOORS. THIS PROCESS IS DONE ON A DAILY BASIS. 10. ON 11-3-10 MAINTENANCE REPLACED THE ALARM SYSTEM ON THE STAIRWELL DOORS TO ENSURE THAT THE STAIRWELL IS MORE SECURE. THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED ON 11-3-10. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAVE NOT BEEN IN-SERVICED AND SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )