**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2 Based on observation, interview and record review, the facility failed ensure an open container of flammable charcoal lighter fluid was properly stored and secured to protect all 75 residents from possible fire and/or inhalation. Findings include: On 6/6/23 at approximately 2:05 PM, a tour of the outside smoking area was conducted with Maintenance/Housekeeping Director (MHD) O. The smoking area was set up in an enclosed courtyard space for both residents and staff. There were several chairs available for residents and staff to sit. Two staff employees were observed outside smoking. A charcoal and gas grill were also observed in the smoking area. Next to the gas grill was a container of charcoal lighter fluid lying on its side. *It should be noted that MHD O did not remove the container during the observation. On 6/6/23 at approximately 2:26 PM, a second tour of the outside smoking area was conducted with the Administrator. The charcoal lighter fluid was again observed lying on the ground near the gas grill. The Administrator picked up the container of lighter fluid and it was observed that the top of the container was not closed, and the container was half full. The Administrator noted that the last time they believed the grills were used was during Memorial Day Weekend (5/27/23-5/29/23) and that the container should not have been left open and on the ground. A review of the facility policy titled, Fire Safety and Prevention (Revised May 2011 ) documented: Policy Statement- All personnel must learn methods of fire prevention and must report conditions(s) that could result in potential fire hazard .Policy Interpretation and Implementation .1. Fire prevention is the responsibility of all personnel, residents, visitors and the general public .2. Whoever identifies a fire hazard .that could develop into a fire hazard, must report the situation .Flammable items .i. Store chemicals, cleaners, etc. as instructed on the containers .7. The Safety Coordinator and Administration will identify and document any hazardous or explosive materials that are stored in locked areas .8. The facility will train personnel on fire prevention methods . Deficient Practice #3 Based on observation, interview and record review the facility failed to ensure extension cords were not used in resident's rooms and ensure sharp and exposed items did not remain in resident room for four (R726, R729 and R727) residents out of five residents reviewed for environment concerns. Findings include: A review of the facility policy titled, Electrical Safety (1/11/21) documented, in part: Policy: It is our policy to provide a safe and healthful environment .Only qualified maintenance personnel are permitted to service, repair, or perform any operation on energized electrical lines or equipment .4. Extension Cord Safety: a. Extension cords shall be used for temporary use only by maintenance personnel. B. Extension cords shall not be used as a substitute for fixed wiring of a structure .g. Extension cords shall be removed immediately upon completion of the purpose for which they were used . On 6/6/23 at approximately 8:32 AM, observations were made in R726 and R729's room. On the wall was a red emergency outlet. Plugged into the outlet was a green extension cord. The cord ran out of the wall and two small fans were plugged into the extension cord. Television cords were also observed plugged into the emergency outlet. On 6/6/23 at approximately 1:50 PM a tour of the facility was conducted with MHD O. MHD O was queried as to the facility policy pertaining to extension cords in resident's rooms. MHD O reported that that extension cords should not be used in resident's room. MHD O reported that they conduct sweeps of resident's rooms to ensure extension cords are not used. MHD O was asked to provide any documentation that would indicate any room audits. No documentation was provided prior to the end of the Survey. On 6/7/23 at approximately 8:50 AM, R727 was observed sitting in a recliner chair. An extension cord was observed plugged into an electrical outlet. The resident's phone charger was wrapped and plugged into the extension cord. R727 reported that a family member had plugged it in for them. MHD O was contacted and again asked if extension cords should be used in resident's room, and they reported they should not. On 6/6/23 at approximately 2:00 PM, R735's room was observed to have a broken window sill on the right side of the window. The area was sharp to the touch. The resident's room had a broken bed with sharp objects on top of it. The room also had a exposed light switch without a cover. MDH O was asked as to why the items remained on the broken bed and why the light switch was not covered. MDH O stated that the resident liked to remove things in the room. On 6/6/23 at approximately 9:30 AM, a second observation of R735's room was conducted with the Administrator and revealed the broken window sill, exposed light switch without a cover remained. They were informed that these observations were brought to the attention during an environmental observation with MHD O on 6/6/23 and remained a concern. This citation has three deficient practice statements. Deficient Practice #1 This citation pertains to intake #s: MI00132356, MI00132528 and MI00133994. Based on observation, interview and record review, the facility failed to provide adequate supervision, effective monitoring and effective search procedures to prevent the elopement of two residents (R707 and R720) of six residents reviewed for elopement, resulting in an Immediate Jeopardy when R707 (who was identified just prior to admission as having exited out of a window from a previous facility and identified as an elopement risk with severe cognitive impairment) exited the building from a window in their room, left the premises and was picked up by local law enforcement, and R720 (who was identified as having moderately impaired cognition and had a legal guardian) exited through a door to the patio area that had been alarming but was shut off by an unknown person, left the premises and was notified by a concerned [NAME] that (R720) they were at the local market on the corner of a highly trafficked six lane road. These deficient practices placed all residents at high risk for further undetected elopements, significant harm, injury and/or death. Findings include: Immediate Jeopardy (IJ): The IJ began on 10/30/22. The IJ was identified on 6/7/23. The Administrator was notified of the IJ on 6/7/23 at 11:10 AM and a plan to remove the immediacy was requested. The immediacy was removed on 6/8/23 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. R707: Review of an allegation reported to the state agency on 11/3/22 documented, .Last week a new female admission, Room (occupied by R707), got out the window in her room, which didn't have a screen on it. Complainant doesn't know what happened to the resident. There is no protocol for when a resident gets out of the facility . Review of a Facility Reported Incident (FRI) on 10/30/22 reported the resident (R707) eloped from the facility. Documentation of the facility's Investigation Summary/Actions Taken included: .On 10/30/22, at approximately 7am, Administrator .was informed by Nurse 'CC' that new resident (R707) could not be located at approximately 600am. (R707 was admitted to the facility at approximately 9pm on 10/29). Nurse 'CC' stated he was in communication with R707 at approximately 430am at the nurse's station. At approximately 5am, R707 received ADL (Activities of Daily Living) care from CNA (Certified Nursing Assistant 'DD'). At approximately 6am, Nurse 'CC' stated he went into the resident's room to change the wound dressings and the resident could not be located. Nurse 'CC' noted that the window was open. The emergency elopement code search was initiated to locate R707. Staff searched the surrounding areas, inside and outside the facility, and the resident could not be immediately found. Police and family were notified. The administrator called the daughter at approximately 745am to gather more information about a potential location, a recent photo, etc. However, during the call, the daughter informed the administrator that they received a call from the [local police] that her mother was located and was in police custody. The daughter was in route to pick up the resident. At this time, the daughter also informed the Administrator that her mother has a history of jumping out of windows. The Administrator called the [local police] department and spoke with a dispatcher. The dispatcher stated, I have (R707) right in front of me. Staff were updated that (R707) Was located . The Maintenance Director assessed the window in R707's room. Per his assessment, the Maintenance Director stated that the window's stop lock presented as if someone hit it with force multiple times, forcing it back, causing damage, which loosened the stop lock causing the window to open an additional (approximately) 3 inches. A head count was performed during the emergency elopement code search. All other residents were accounted for. All windows in the resident rooms were assessed by the Maintenance Director to ensure an opening of no larger than 6 inches. All windows were confirmed with an opening of no larger than 6 inches. Two window stop locks were replaced, as they were noted with normal wear and tear. room [ROOM NUMBER], where R707 resided was repaired, ensuring a window opening of no greater than 6 inches. Updated elopement assessments for current residents were updated. Three residents were identified for elopement risk, in which care plans with interventions were reviewed and updated as deemed appropriate. Elopement binders were updated at each nurses station with resident photos and information. Staff were re-educated on the Elopement and Wandering policy. The Admissions Director was educated on identifying elopement risk residents via pre-screening and referral documents . Review of the hospital documentation provided to the facility prior to admission included: .The patient is a [AGE] year old Female .questionable dementia who presented to the ED (Emergency Department) <sic> after being petitioned by her daughter. Patient states that she is in the hospital for high blood pressure and leg pain which she sustained trying to chase after her dog. Patient states that she lives at home with her daughter .however IM (Internal Medicine) H+P (History & Physical), the patient lives in AFC (Adult [NAME] Care) nursing home and was found trying to jump out of a window which ishow <sic> she fell and injured her legs .Date of Service: 10/23/2022 .ER (Emergency Room) consult re: (regarding) petition .pt (patient) with no psych history is petitioned by caregiver who says <sic> pt needs a med adjustment, he also says she has severe dementia, is constantly yelling, jumping from windows, escapingand <sic> fleeing the facility . Review of the clinical record revealed R707 was admitted into the facility on [DATE] and discharged on 10/30/22 with diagnoses that included: end stage renal disease, dependence on renal dialysis, and dementia in other diseases classified elsewhere, severe, with other behavioral disturbance. According to the discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE], the staff assessment for mental status was noted as short-term memory was ok with independent cognitive skills for daily decision making (which conflicted with hospital documentation) and had wandering behavior which occurred 1 to 3 days. Bed mobility/transfers, personal hygiene were not assessed, walking in room and corridor, dressing, eating, toilet use and bathing were noted as Activity did not occur. R720: Review of a FRI on 1/9/23 reported the resident (R720) eloped from the facility. Documentation of the facility's Investigation Summary/Actions Taken included: On 1/8/23 at approximately 445pm, Nurse 'L', notified Administrator .that (R720) left the facility without supervision or notice to staff. (R720) was last seen in the facility around 420pm and was located at approximately 435pm. Nurse 'M' stated a lady arrived to the facility and notified her that a man with missing legs was next door at the market inquiring on how to get to [name of local hospital]. Nurse 'M' immediately walked next door and brought Resident back to the inside of the facility. (R720) was properly dressed for the weather with a winter coat and clothing. Nurse 'M' inquired with (R720) of his reasoning for leaving the facility without notification. (R720) stated that he is ready to discharge. The physician, Guardian, and DON (Director of Nursing) were also notified. The [NAME] Hills Police arrived to ensure the resident arrived inside the facility safely. (R720)'s prior elopement risk assessment was on 10/30/22 and was not identified as an elopement risk. Upon return to the facility, Nurse 'M' did not note any injuries. Nurse 'D' stated that she heard the alarm on the rear door of the facility, however, it was quickly silenced. The doors were verified as working properly with alarms intact. Interview with staff members working in the facility at the time of the incident did not reveal any person(s) that shut the alarm off when it sounded. Staff members are being educated on the elopement policy and the importance of checking outside of the facility when an alarm sounds to ensure a resident has not left the facility unsupervised . On 01/09/23 Administrator .interviewed (R720) about the incident. (R720) was found in a jovial mood with smiles and laughter. He stated that he just wanted some fresh air. (R720) has 4 supervised visits per day, is currently on 30 minute checks, has resumed his normal daily activities and continues to be followed by psych and social services. A head count was provided to ensure all other residents were present inside the facility. Investigation Summary/Actions Taken: .On 1/8/23 at approximately 445pm, Nurse 'L', notified Administrator .that (R720) left the facility without supervision or notice to staff. (R720) was last seen in the facility around 420pm and was located at approximately 435pm. Nurse 'M' stated a lady arrived to the facility and notified her that a man with missing legs was next door at the market inquiring on how to get to [name of local hospital]. Nurse 'M' immediately walked next door and brought Resident back to the inside of the facility. (R720) was properly dressed for the weather with a winter coat and clothing. Nurse 'M' inquired with (R720) of his reasoning for leaving the facility without notification. (R720) stated that he is ready to discharge. The physician, Guardian, and DON (Director of Nursing) were also notified. The [Local Police] arrived to ensure the resident arrived inside the facility safely. (R720)'s prior elopement risk assessment was on 10/30/22 and was not identified as an elopement risk. Nurse 'M' stated that she heard the alarm on the rear door of the facility, however, it was quickly silenced. The doors were verified as working properly with alarms intact. Interview with staff members working in the facility at the time of the incident did not reveal any person(s) that shut the alarm off when it sounded. Staff levels were reviewed and determined to be sufficient. Staff members were educated on the elopement policy and the importance of checking the perimeters or an alarming door before silencing the alarm to ensure a resident has not left the facility unsupervised. An elopement drill has also been conducted since the incident and staff have been instructed on the tasks to be fulfilled in the event of an actual elopement. (R720) has been closely followed by Social Services and psych services since the incident. Social Services has been in contact with [guardian of resident] to start the process of securing safe housing outside of the facility. On 01/09/23 Administrator .interviewed (R720) about the incident. (R720) was found in a jovial mood with smiles and laughter. He stated that he just wanted some fresh air. (R720) has 4 supervised visits per day, has remained on increased supervision and has resumed his normal daily activities and will continue to be followed by psych and social services. A head count was initiated to ensure all other residents were present inside the facility. Doors and alarms have been verified to be in working order. Codes to the doors has also been changed and updated. The elopement event has been substantiated; however (R720) has not sustained any major injuries. Securing safe housing for the resident remains a top priority. (R720) has multiple supervised cigarette breaks per day, has increased supervision and continues to be followed by social services and psych services . Review of the clinical record revealed R720 was initially admitted into the facility on 7/27/22 and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with unspecified complications, long term use of insulin, acquired absence of left leg and right leg above knee, essential hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, adjustment disorder, schizoaffective disorder, depressive type, and COVID-19. According to the MDS assessment dated [DATE], R720 had clear speech, had moderately impaired cognition (scored 12/15 on the brief interview for mental status exam; also had a legal guardian), had no behavioral concerns, required extensive assistance of one person physical assist for transfers, bed mobility, dressing, locomotion on/off unit required only supervision with setup help only, and used a wheelchair for mobility. Review of the care plans included: I have potential to demonstrate behaviors verbally 2/2 (secondary to) adjustment disorder, schizophrenia I will often yell out stating I want to get out of here, or at times I will call the police to get out. I will threaten to elope. I will engage in elopement behavior. This care plan had been initiated on 9/30/22, last revised on 1/9/23. Interventions included: Document my observed behavior and attempted interventions on my POC (Plan of Care). This had been initiated on 9/30/22. Review of the progress notes included: A late entry on 1/8/23 at 5:29 PM from Nurse 'L' read, writer noticed cigarette odor coming from residents room. Writer entered room with cena and addressed resident and removed a half smoked cigarette from his room. Writer then went to the west hall to speak with nurse. At that time we were informed by a bystander who believed one of our residents was outside in the adjourning parking lot. When myself and another nurse went outside, we saw R720 approaching southfield road. We were able to retrieve him an bring him into the building with no further incident . An entry on 1/8/23 at 5:29 PM from Physician 'W' read, Patient was seen by video conferencing .Eloped and ended up in a nearby store? Got out of the door an went in the wheelchair - thinks that he is his own guardian and makes own decision and can go wherever he wants (NOTE: patient has a COURT APPOINTED guardianship .also has been smoking in his room as not allowed to go out due to the low temperatures . An entry on 1/12/23 at 12:34 PM from psych read, .Continues to be easily agitated and angered. When asked how he was doing he replied I want to he there <sic> f-k out of here and go to a shelter. Unable or unwilling to discuss any realistic plans . An entry on 2/6/23 at 10:26 PM from Physician 'EE' read, .He eloped earlier today and as <sic> found in nearby store and brought back to the facility. He has a court-appointed guardian and can not make his own decisions. He states that he wants to go live somewhere else. D/w (Discussed with) pt (patient) that he could do so once he discusses this w/ (with) his guardian and they agree to his request. D/w SW (Social Work) to reach out to his guardian to this regard .Very high risk of elopement . (Per facility, although this note identified R720 eloped earlier today on 2/6/23, there was not another elopement, but is reflective of the elopement from 1/8/23.) An entry on 3/27/23 at 3:38 PM from SW 'T' read, Ombudsman called regarding resident wanting to discharge to less restrictive setting. SW informed her that resident has a guardian, and they are aware of his wishes . On 6/6/23 at 1:27 PM, an interview was conducted with CNA 'K' who reported they had been working at the facility since March 2023. When asked if they were aware of any residents on 1 East that were identified as being at risk for elopement, CNA 'K' reported they were not. When asked specifically about R720, CNA 'K' reported no and that R720 was able to independently wheel his wheelchair and went on smoke breaks. On 6/6/23 at 1:50 PM, an interview was conducted with the Maintenance Director (Staff 'O') who reported they had worked at the facility for about a year. When asked about whether the facility utilized a wanderguard alarm system for residents that eloped, they reported they did not. Staff 'O' further reported all of the doors were locked and could be released within 15 seconds or if staff let you out. When asked if a door alarm could be turned off on the outside of the exit door, they reported No. They were requested to provide all elopement drills that had been completed since 10/30/22. Staff 'O' was asked to observe multiple resident rooms, including the room that had been occupied by R707 and currently occupied by R720. Both rooms were located all the way at the end of the hallway on 1 East. Further observation of R720's room revealed there was no screen in the window and the window was opened several inches. Staff 'O' reported they had not been aware of the missing window screen and would replace. When asked who was responsible to monitor the windows as that was identified as an issue when R707 eloped on 10/30/22, Staff 'O' reported staff should've notified them it was missing but had not. When asked if that was something that would've been picked up on room rounds, or if that was part of an environmental audit, Staff 'O' offered no further response. When asked if there were any cameras utilized by the facility, Staff 'O' reported no. On 6/6/23 at 2:10 PM, an interview was conducted with CNA 'P' who reported they had worked at the facility for about eight months. When asked if they were aware of anyone who was an elopement risk on the 1 east wing, CNA 'P' reported they were not and that only the people that could walk would be at risk. CNA 'P' reported the people over here were mostly confused. When asked what they knew about R720, they reported he was alert and having a battle now with pop. On 6/6/23 at 2:15 PM, R720 was observed seated in a wheelchair watching television in the hallway on 1 east. CNA 'P' was observed talking to the resident about not drinking soda pop. R720 was observed to get agitated and began to yell. Further review of the documentation provided by the facility regarding R720's elopement on 1/8/23 revealed several concerns which included: The elopement assessment completed on 1/8/23, 2/5/23 and 5/7/23 revealed conflicting documentation and assessment of R720's risk factors such as diagnoses, other medical conditions, assessment of mobility, and whether the resident made statements regarding desire to leave/wish to go home. Although the assessment on 5/7/23 indicated R720 was not considered an elopement risk, had the assessment been completed as previous assessments with correct indicators, R720 would've been identified as an elopement risk on this assessment. Regardless of this most recent elopement assessment, review of the facility binder at the 1 East Nursing Station identified R720 was currently one of four residents identified as an elopement risk. There was only one elopement drill completed by the facility on 1/12/23 at 2:00 PM which identified concerns with .Problems noted during drill and corrective action taken: No one called Police and it took to <sic> long for them to notice Resident was missing . There were signatures from staff that participated in this drill, however there was no follow-up documentation from the facility on whether any additional elopement drills/education were completed and/or provided to ensure staff responded appropriately. On 6/7/23 at 8:36 AM, a phone interview was conducted with the Southfield Police Department. Although R707 had been picked up by their patrol, there was no documentation as to the details of where R707 was found/picked up. Their facility was approximately four miles from the facility. On 6/7/23 at 8:45 AM, an interview was conducted with the Administrator. When asked to recall the events for R707 and R720, they reviewed the documentation provided by the facility and recounted the same events. The Administrator was asked about whether the facility had identified where R707 had been picked up and they reported the did not. The Administrator reported they had an admission Director and reported they found out after the elopement incident that the information was in the admission documentation and was ignored by Admissions staff. When asked what information the nurse reviewed as part of their admission assessment since the information about R707's history of jumping out of windows, and history of elopement was available for review, the Administrator reported usually for nursing they would review any orders or treatments. When asked if the facility considered where residents that were elopement risk were placed as both R707 and R720 were placed at the end of the hallway, and they reported Someone like that (R707) would not have been admitted to our facility. When asked about R720's current room placement at the end of the hallway, near the exit door, they offered no further response. When asked about the facility's process for how they identified residents were an elopement risk and how direct care staff would be aware, the Administrator reported there were two binders at the nursing station with photos as an extra precaution. If a major elopement risk for instance, the resident would attempt to be sent to a locked facility. The Administrator reported the residents that were currently in the facility were a lower risk. When asked about details of how it had been determined R720 eloped, the Administrator reported R720 got out from the door from the patio (smoking area). When asked about the door alarm and if it had alarmed, how did R720 get out, the Administrator reported it was sounding and he may have already departed before they got it because it was silenced after some time. The Administrator reported if staff silenced a door alarm, the were supposed to go out and check perimeters. When asked if that had been done, they offered no response. When asked if they used any cameras to verify what happened and who may have silenced the alarm, they reported the facility did not use any cameras and they had immediate education with the staff. When asked if all staff were re-educated, or only the staff on duty on 1/8/23, they reported it was done with staff that were involved with the elopement drill. When asked to explain more about the elopement drill, the Administrator reported there was a drill done on 1/12/23 and they were a part of the team to conduct that. They further reported you have the drill, and go through formalities of what went well and what went wrong. When asked if that was done for the employees who were not working that day, or if any additional elopement drills should have been completed since there were concerns identified and that was done only four days following R720's elopement, they reported they would conduct another drill at another time, but that had not been done. The Administrator was informed of current concern in regard to staff's lack of awareness of R720's elopement risk, inaccurate/consistent elopement risk assessments and acknowledged the concerns. On 6/7/23 at 9:36 AM, the Administrator provided documentation of a past non-compliance (PNC) for R707's elopement and was informed that due to ongoing, current concerns, there was no sustained compliance to consider an acceptance of a PNC. On 6/7/23 at 10:36 AM, a phone interview was conducted with R707's daughter. When asked if they could provide any additional information as to where R707 was found/picked up, or what the resident had been wearing at the time of the elopement, they reported they were unable to provide any details and R707 remained living with them since then. Removal Plan for IJ for Elopements: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 10/30/22 and 01/08/23) R720 1/8/23 On 1/8/23, a nursing assessment including a Skin Sweep was completed on R720 upon return to the facility - no identified deviations from baseline. On 1/8/23, the facility Medical Director performed a video conference with R720. On 1/8/23, a licensed nurse reevaluated R720 for risk for elopement and revised resident care plan, as applicable related to identified risk areas. Social Services performed wellness checks on the days following the event for R720. On 01/8/23, the Administrator verified all doors were in working order and would alarm if the appropriate code was not entered. R707 10/30/22 As of 10/31/22 R707 discharged from the facility (resident did not return to facility warranting further resident interventions) On 10/30/22, all windows were checked to verify openings of no larger than 6 inches. New window locks were purchased for rooms [ROOM NUMBERS], as the locks were identified with normal wear and tear. Upon review of the window lock in room [ROOM NUMBER] (where the elopement of R707 occurred), it was noted as having intentional-appearing damage. The window lock in room [ROOM NUMBER] has been replaced. On 10/30/22, the Admissions Director was re-educated on necessary efforts to identify elopement risk residents at pre-screening. The facility Medical Director was notified of the event. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 06/08/23) For both identified events, the DON/designee(s) re-evaluated all residents for risk for wandering/elopement using an elopement risk assessment tool to identify any updated residents for elopement/wander risk. For the incident involving R707, all residents were assessed on the date of the incident 10/30/2022. For the incident invo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of a Facility Reported Incident (FRI) reported to the State Agency (SA) documented in part, . Incident Summary on 02/09 . (R723 name) made contact with Resident (R713 name) via her right hand to the right side of Resident (R713 name) face . (R723 name) was attempting to turn off Resident (R713 name) overhead light however (R713 name) told (R723 name) no. (R723 name) then proceeded to make contact with Resident (R713 name) via her right hand . On 6/8/23 at 11:27 AM, a telephone interview was conducted with R713 (who no longer resided in the facility). When asked about the incident that involved R723, R713 replied in part . it was daytime, and I was reading my stuff and she (R723) was turning off my light. I was shaking my head no and said you don't have to. She opened up her hand and slapped me. The person came in to help me and I told him (name of staff), and he asked the resident (R723) and she said yes she did slap me . Review of the medical record revealed R713 was admitted to the facility on [DATE], with diagnoses that included: multiple sclerosis, contracture of left and right hands, and quadriplegia. Review of the census revealed R713 was moved into the room with R723 on 1/31/23 only a few days before the alleged incident on 2/9/23. Review of the medical record revealed R723 was admitted to the facility on [DATE] with diagnoses that included: developmental disorder of speech and language, deaf nonspeaking and difficulty walking. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9 (indicating moderately impaired cognition). On 6/9/23 at 10:38 AM, R723 was observed sitting in their wheelchair tending to their plant on their windowsill. Communication was conducting via pen and paper. When asked, R723 admitted to slapping R713. When asked why, R723 pointed to the light above their roommate's bed. R723 denied having any other incidents or concerns with any residents in the facility. Review of a facility policy titled Abuse, Neglect and Exploitation reviewed/revised 4/23, documented in part . It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Abuse means the willful infliction of . intimidation, or punishment with resulting physical harm, pain, or mental anguish . R730 and R731 A FRI was reported to the SA on 5/1/23. The facility indicated that on 2/11/22, R730 struck R731 on the head. A review of the facility Incident/Accident report documented, in part: .Date of Alleged Event: 2/11/23 .Facility incident report received via online submission on: 5/1/23 .Incident Summary in review of R730's record, it was noted R730 made contact with R731 via his hand on 2/11/23. Administrator interviewed Nurse N. Nurse N stated that she was informed by Certified Nursing Assistant (CNA) P that R730 made contact with R731 on 2/11/23 .CNA P informed the Administrator that the event occurred and she immediately reported it to Nurse N .Administrator interviewed Nurse N who stated she was informed by CNA P of the event . A review of R730's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: psychotic disorder, anxiety disorder and Alzheimer's Disease. Review of the residents MDS indicated the resident was severely cognitively impaired. Continued review of the resident's clinical record documented, in part: 2/10/23 -Psychiatric Service Progress Note: New admission .is noted to have profound confusion .throwing self out of chair unsafely . 2/10/23 - Behavior Notes (11:03 PM): Please describe the behavior that was observed .Agitation, restlessness, constantly getting up to work with instability .Prior History of Aggression or Violence? YES . 2/11/23 - Nursing Progress Note (7:49 PM): Mistaken Entry .Resident very violent. Hitting R731 in the head three times. Trying to get out of chair and swinging at RCS's refusing to take his medication and swinging at nurse.(Authored by NurseN) *This progress note was struck out. There were no further notes regarding the incident. R731 A review of R731's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, osteoarthritis and Alzheimer's Disease. Review of R731's MDS noted the resident was severely cognitively impaired. A review of R731's clinical record revealed no documentation that indicated R730 struck the resident. There was no assessment completed on 2/11/23 to determine R731's medical status. On 6/8/23 at approximately 11:45 AM, R730 was observed sitting near the Nurse's station. The resident was alert, but not able to answer most questions asked. R731 was also sitting near the Nurse's station. R731 was not able to answer most questions asked. Nurse N was then asked as to whether they were aware of any incident involving R730 and R731. Nurse N stated they had no recollection of the incident. On 6/8/23 at approximately 1:42 PM, an interview was conducted with CNA P. CNA P was queried as to the incident involving R730 and R731 on or about 2/11/23 or 2/12/23. They reported that R731 was sitting in the hallway near the nurse's station eating dinner and R730 was walking nearby and struck R731 in the head. CNA P reported that R731 was pretty shook up after the incident. When asked if they were familiar with R730, CNA P reported that the resident was fairly new to the facility but showed signs of anxiety, irritation and was not easily directed. On 6/8/23 at approximately 1:43 PM, an interview and record review were conducted with the Administrator/Abuse Coordinator. When queried as to the reporting of the incident that occurred between R730 and R731, the Administrator reported that the incident did occur on 2/11/23. They noted that they were doing audits of the resident's charts and discovered that the incident occurred. When asked if any assessments were completed for R731, they reported not on that date. This citation pertains to intake #MI00131483, MI00131513, MI00132356, MI00136470, MI00134873, MI00136407. Based on observation, interview and record review, the facility failed to protect R704's right to be free from physical and verbal abuse. This deficient practice resulted in an Immediate Jeopardy to the health and safety of R704 when staff members witnessed a Certified Nursing Assistant (CNA) abusing R704 physically and verbally (which included slapping R704's rear end, pressing hand on R704's neck and squeezing while threatening, punching R704's hand, placing their foot on R704's hand and bending the residents right thumb while repeatedly saying stop f****** playing with me; while attempting to get R704 off the ground into a sling the CNA began punching R704's hand twice, then placed their foot on R704's hand and bending R704's right thumb while repeating keep f****** playing with me). The physical and verbal abuse resulted in serious harm and/or injury to the resident using the reasonable person concept for a resident with impaired cognition. Additionally, the facility failed to ensure that resident to resident physical abuse did not occur for four (R's 730, 731, 713 and 723) of 14 residents reviewed for abuse. Findings include: Immediate Jeopardy (IJ): The IJ began on 9/12/22. The IJ was identified on 6/7/23. The Administrator was notified of the IJ on 6/7/23 at 4:07 PM and a plan to remove the immediacy was requested. The immediacy was removed on 6/7/23 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a facility policy titled, Abuse, Neglect and Exploitation dated 4/2023 documented: .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Verbal Abuse means the use or oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents .regardless of their age, ability to comprehend, or disability .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment .Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed on 9/12/22 at 4:30 PM, .(Name of Nurse 'AA') informed (Name of Administrator) of an alleged event that includes CNA 'A' and (Name of R704). Per Nurse 'AA': CNA 'B' informed her that while assisting R704 from a floor mat, the resident was holding really tight to the floor mat. CNA 'A' placed her foot on the hand of R704 in order for the resident to release his hand. CNA 'B' further stated (per Nurse 'AA') that CNA 'A' pulled back the fingers of R704 due to him holding on tightly to release his grasp . Review of a complaint submitted to the State Agency by local Law Enforcement (Officer 'BB') included, .On 9/12/2022, (R704) had fallen to the floor. An employee of (Facility Name), CNA 'A', placed her right hand on R704's neck, squeezed, pressed his face to the floor mattress, punched R704 twice in the hand (to make him let go of an object), and she bent his thumb backwards . Review of a police report documented: .Report of: Vulnerable Adult Abuse .FOLLOW UP ON 9/29/2022 I followed up with (Name of Administrator) .who stated that she was conducting her own investigation into the matter to send to the State of Michigan. Additionally, I spoke to (R704), who stated the alleged events documented in this report, did in fact happen. I asked if (CNA 'A') had pressed his face into the mat and he shook his head yes; I asked if she had punched his hand, and he shook his head yes; I asked if she had pulled his thumb back and he shook his head yes .I asked (Name of Administrator) if there was an issue between (CNA 'A', CNA 'B' and CNA 'E') and she stated that (CNA 'A') said the other two were upset with her because she reported them for not doing their work. When I asked (CNA 'B') if this could be the case, she stated that would be impossible because they hadn't worked together previously. (Name of Administrator) stated that there is no record or (CNA 'E' and CNA 'B') making such a complaint. FOLLOW UP ON 10/4/2022 I spoke to (CNA 'A'), who stated that she wanted to talk to me regarding the issue .stated she would come in to talk with me at 12:00 pm. She did not show up or answer my phone calls afterward. I spoke to (CNA 'E') who stated she would take a poly if asked to. She stated everything she said in her statement is correct and she would not mind assisting in the investigation. (CNA 'B') stated she would come to the station to complete a witness statement (hers was deleted by [Facility Name] staff). FOLLOW UP ON 10/5/2022 I spoke to (CNA 'A') who stated she would be at the station at five to give her statement on today's date, however she never showed up again for the meeting. (CNA 'B') came into the station to make a statement. She stated the same details that (CNA 'E') said. She stated that (R704) is now afraid of (CNA 'A') and would not talk to staff and would only talk to staff after dark because he knows that (CNA 'A') does not work at night. She said (R704) is verbal and probably did not want to speak because he was afraid that he would be hurt again. SUMMARY On 9/19/2022 [local police department] PD was notified of an assault that had taken place at [Facility Name] nursing home .Upon arrival, officers spoke to the facility manager (Name of Administrator) who stated an employee, (CNA 'A') had been accused of assaulting a patient named (R704) on 9/12/2022. Witnesses to the incident (CNA 'E' and CNA 'B') stated they were walking by (R704's) room .when they observed him on the ground face down on a mat next to his bed. They stated that they went to get (CNA 'A') to assist him off the ground. When (CNA 'A') arrived to (R704's) room, it was observed that (R704) had a bowel movement while on the floor. (CNA 'A') proceeded to change (R704's) clothes, but left him without new clothes on, leaving him exposed on the ground. While exposed, (CNA 'A') continuously slapped (R704) on the rear end. (CNA 'B', CNA 'E' and CNA 'A') attempted to lift (R704) off the ground but were not able to because (R704) was too heavy. They went to get more help to try and lift (R704) off the ground and as they came back into the room, they observed (CNA 'A') placing her right hand on (R704's) neck pressing down and squeezing his neck while saying stop f****** playing with me. A lift assist tool (sling) was brought in to help get (R704) off the ground at this time. While attempting to get (R704) off the ground and into the sling, he began grabbing the sling strap and not letting go. (CNA 'B' and CNA 'E') state that (CNA 'A') began punching (R704's) hand attempting to get him to let go of the sling. They state (CNA 'A') punched his hand twice. (CNA 'A') then placed her left foot on (R704's) right wrist and pulled the sling from his hand. Once they rolled (R704) over (CNA 'A') had (R704's) right thumb in her hand and she was bending it back, while she kept repeating keep f****** playing with me. (R704) asked (CNA 'A') if she was going to break his finger and (CNA 'A') stated yes. Both (CNA 'E' and CNA 'B') stated that (R704) is afraid to talk to staff in fear of being hurt again by someone, and that could be the reason he did not speak to me and only used head and hand signs during the conversation. They stated that they believed (R704) denied any abuse allegations because he was fearful for retribution. (CNA 'A') was asked several times to come in for an interview and she stated yes she would like to come and talk to me however every time I would set an interview time, she would not show up for the appointment . FOLLOW UP ON 11/9/2022 Warrant was received . Included with this police report were handwritten statements from CNA 'B' and CNA 'E' and a warrant for CNA 'A' dated 10/6/22 which read, .being a person who directly cares for or has physical custody of a vulnerable adult, did intentionally cause physical harm to (R704), a vulnerable adult .VULNERABLE ADULT ABUSE - THIRD DEGREE . The statement from CNA 'E' dated 9/13/22 read, On Sept. 12, 2022 towards the end of the shift (CNA 'B') and I we're <sic> doing rounds. I was heading to a room with (CNA 'B') when the housekeeper seen that room (R704's room) was on the floor on his mattress face down. She told (CNA 'B') and I , I went into the room and (CNA 'B') called out for (CNA 'A'), because she was his CNA. We all prepared to get him off the floor, but I noticed his sheet was soild <sic> she (CNA 'A') cleaned him up. (CNA 'B', CNA 'A' and myself) tried to pick him up, but he was too heavy. I don't remember which one went out to get more help, but before going to get help (CNA 'A') placed her right hand on (R704's) neck and pressed as she squoze <sic> his neck and face down in the materss <sic>, as she was this she saying to him stop f****** playing with me (CNA 'D') came into the room after one of them wen <sic> to get help, (CNA 'A') was the help. (CNA 'A') left out the room to get the hoyer sling, because all four of us tried to get him up, and he still was too heavy. (R704) was grabbing the matterss <sic> and (CNA 'A') was punching his hand, she punched his hand twic <sic> and was his right hand. Once we started to put the sling in place (R704) grabbed it and wouldn't let go (CNA 'A') placed her left foot on (R704's) right wrist and pulled very hard the sling from out of his hand. Once we rolled him over (CNA 'A') had (R704) right thumb in her hand and she was bending it back, (CNA 'A') kept repeating Keep f****** playing with me, (R704) asked are you going to break my finger, and (CNA 'A') said yes. We finally got him safe into the bed using the hoyer. He gave me a thumbs up and thanked me for helping him. Also when waiting on (CNA 'D') to bring the hoyer lift and sling (CNA 'A') was smacking (R704) on the behing <sic> repeatedly. (R704) kept covering himself with the cover. The statement from CNA 'B' dated 10/5/22 read, .I was working it was almost the end of shift me and (CNA 'E') was walking down the hall and I seen (R704) on the floor I called (CNA 'A') because he was her resident me and (CNA 'E') told (CNA 'A') we will help you put him back in bed. When we go in the room (R704) had his cover I asked him to let it go and he did. (CNA 'A') put her hand on the back of (R704) neck and pushed his face in mattress and told him to stop f****** playing with her. She left out the room and came back (CNA 'D') came back in with (CNA 'A'). (CNA 'A') took her foot and stomp (R704) hand then took her hand and punched his hand. As we got (R704) turned over on his back to get him up (CNA 'A') bent his finger back and (R704) asked (CNA 'A') are you breaking my finger and she said yes. Me and (CNA 'E') went and told the unit manager. Then I told the DON and wrote a stament <sic> as well. An unannounced, onsite investigation was conducted from 6/6/23 through 6/9/23. On 6/7/23 at approximately 1:25 PM, R704 was observed laying in bed leaning to the right side of the bed with part of their right torso over the edge of the bed. When queried if they were comfortable, R704 stated they were and they preferred to be positioned like that. When asked if they could recall an incident with staff being rough during care, swearing, or making threats, R704 reported oh you mean with (Name of CNA 'A'). R704 reported that incident was probably reported by Nurse 'C' and CNA 'E'. R704 started to report staff went to change their adult brief, became visibly upset and did not want to continue the interview or review any further details. When asked if there had been any further issues since the alleged incident with CNA 'A', R704 shook their head no. Review of the clinical record revealed R704 was admitted into the facility on 8/3/20 and readmitted on [DATE] with diagnoses that included: encephalopathy, acute kidney failure, psychotic disorder with delusions, other seizures, dysphagia, contracture of muscle left hand, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic pulmonary edema, major depressive disorder single episode mild, and delirium. According to the Minimum Data Set (MDS) assessment dated [DATE], R704 had no communication concerns, had moderately impaired cognition (scored 11/15 on brief interview for mental status exam), required extensive assistance with two or more people with bed mobility, transfers, dressing, and toilet use; was occasionally incontinent of bladder, and was always incontinent of bowel. Review of the progress notes included: An entry on 9/12/22 at 9:37 PM read, Cena reported to administrator of an alleged fall/abuse event. Writer assessed resident and found no injuries. Writer noted a small old bruise on the base of the index finger of the left hand . An entry on 9/12/22 at 9:35 PM, by Physician 'W' read, .Patient was seen by video conferencing-with help of the nurse on duty .small abrasions noted on left hand - associated tenderness / partially contracted at baseline .Assessment and plan Lt (Left) hand injury/Fall/gait disturbance-fall .X-ray of the left hand to rule out any occult fracture . An entry on 9/18/22 at 12:57 AM, X-Ray Result: Hand 2 views, Left Scapholunate ligament disruption (when the scaphoid and lunate bones in your wrist move apart). No acute fracture identified . An entry on 9/18/22 at 12:52 AM from Physician 'W' read, .Left hand x-ray/changes in the scapholunate ligament noted likely chronic .Assessment and plan Scapholunate subluxation - radiologically but clinically without any problems/patient does not use the left arm/hand due to paralysis . It should be noted that the statements from staff identified concerns regarding R704's right hand, but there was no evaluation of the right hand, only the left. Attempts to contact CNA 'A', CNA 'D', and CNA 'E' were unsuccessful by the end of the survey. On 6/7/23 at 1:01 PM, a phone interview was conducted with Nurse 'C' who reported they no longer worked at the facility since 4/27/23. When asked what they could recall regarding the alleged incident with R704 and CNA 'A', they reported it was reported to them by one of the CNAs that had been providing care to R704. Nurse 'C' reported they had reported it to the Administrator. They reported at that time, they were kinda in charge since there were many DON (Director of Nursing) changes, so they were kind of like the Unit Manager, DON, and Wound Manager. They reported the CNA 'A' had been suspended immediately and had not been allowed to return to work following that day. On 6/7/23 at 1:30 PM, an interview was conducted with the Administrator and Regional Director of Operations (Staff 'F'). When asked about the FRI with allegations of physical abuse, the Administrator reported the facility had not substantiated R704's allegation since the resident denied it initially. When asked what they had done when they received additional information in the police report (noted as Created on 12/14/2022 12:14 PM per the documentation included in the facility's investigation file under Police Report in which documentation identified law enforcement's interviews with staff and R704 had substantiated and matched R704's initial allegations, the Administrator did not offer any further explanation other than they had kept in contact with police, but were not aware of anything further yet. When asked if the facility had reported CNA 'A's certification to the appropriate licensing department, the Administrator reported they had included that with the initial FRI which they had unsubstantiated. When asked once they received the police report with substantiated allegations, was anything else done, such as notifying appropriate licensing department, they reported nothing further had been done. The Administrator further reported they kept in contact with police, but was not aware of any other details. It was reported that the facility believed the warrant was issued due to CNA 'A' not cooperating with law enforcement. On 6/8/23 at 12:10 PM, a phone interview was conducted with the Director of Public Safety (Chief 'I'). Chief 'I' provided additional investigation details which included a warrant issued for CNA 'A' for vulnerable adult abuse. Chief 'I' reported CNA 'A' had not been arrested as of this time and continued to evade interaction with law enforcement. When asked to clarify if the warrant issued was due to CNA 'A's lack of cooperation with law enforcement, Chief 'I' reported it was not, it was for suspected criminal act and was the reason for issuance of a criminal bench warrant. Removal Plan for IJ for Abuse: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 09/16/22) On 9/12/22, a nursing assessment, including a skin assessment was completed on R704 - no identified deviations from the baseline. On 9/12/22 the facility Medical Director performed a video conference with R704. Neurochecks and an x ray of the left hand was ordered. X-ray results returned on 09/17 and did not reveal any fractures related to abuse per MD (Medical Doctor). On 9/16/22 neurochecks were completed - no identified abnormalities. The guardian was notified of the event. On 09/16/22, the police was notified of the incident.by the NHA. On 09/12/22, the identified CNA was suspended pending investigation. The identified CNA has not had access to the resident since 09/13/22 and was terminated on 09/16/22. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 06/07/23) On 06/07/23, the Regional Director of Operations reviewed the Abuse, Neglect and Exploitation policy and deemed it appropriate. On 06/07/23, the NHA was re-educated on reporting abuse allegations and the subsequent follow-up of all like residents. The NHA (nursing home administrator) was educated previously on 11/16/22. On 06/07/23, the NHA was educated on reporting staff licensures to the license agency for substantiated abuse accusations. On 06/07/23, The NHA reported the CNA certification to the licensing agency for the substantiated abuse allegation. On 06/07/23, like residents were interviewed for abuse. All facility reported incidents will be brought to QAPI (Quality Assurance Process Improvement) for review. The facility asserts the likelihood of immediate harm has been mitigated since 06/07/23.