This citation has two Deficient Practice Statements (DPS). DPS #1 This citation pertains to intakes MI00144702, MI00144797, and MI00144715. Based on observation, interview and record review, the facility failed to provide adequate supervision and implement elopement policies for one (R500) of four residents reviewed for elopement, resulting in a severely cognitively impaired resident being let out of a secured door to the patio by an unknown staff member, unsupervised and was found approximately 36 hours later, about five miles away from the facility. This deficient practice resulted in the likelihood for serious harm, injury, impairment, or death. Findings include: The Immediate Jeopardy (IJ) began on 5/26/24. The Administrator was notified of the IJ on 5/28/24 at 5:18 PM and a removal plan was requested. The State Agency completed onsite verification that the Immediate Jeopardy was removed on 5/29/24, however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On 5/28/24 at 11:17AM an interview was conducted with the Administrator. When asked what happened with R500 and where was R500 found, the Administrator replied R500 was found in Detroit near eight mile and Telegraph road, in a wheelchair. The Administrator further reported R500 didn't state where they were going and the resident was very selective too whom they speak too. The Administrator was then asked about the facility's patio area (where R500 exited) and then explained the patio area had locks but were using it as the front entrance because the main entrance was still under repair. On 5/28/24 at 11:20AM, an interview was conducted with the Director of Nursing (DON). When asked to provide details of where and when R500 was found and when they were first notified that R500 was missing, the DON replied the resident was found at 8:33 PM on Evergreen and Eight Mile Road, about 10 minutes away. The DON further reported the Nurse on Duty on 5/27/24 (Nurse 'B') notified them around 1:30 PM and they arrived at the facility to help with the search. The DON reported when R500 was located, they did not mention an agenda on why they left the facility and R500 was not much of a talker but they did tell their brother that they wanted to go for a walk and get some air. The DON explained the residents are allowed to sit outside on the patio and that staff does not have to physically be out there, but the receptionist is to monitor residents and let them in and out. The DON also reported they keep the gate open because there is no doorbell or buzzer. The DON was asked if there was a log of who goes in and out the building (according to the facility's investigation documentation the receptionist was suspended) and they replied there was no log that keeps track of who goes out to sit in the patio area but they did have a leave of absence (LOA) book. The DON reported at that time, a housekeeper (HK 'C') was covering for the receptionist. When asked about what covering for receptionist entailed, the DON reported a housekeeper can monitor but would have to follow-up to see if they were educated on the responsibilities. On 5/28/24 at 11:47 AM, an interview was conducted with Receptionist (Staff A). When asked about their ability to effectively monitor or supervise the gate, or people out on the patio from their location in the facility, Staff A reported the view was limited and was not able to see the gate or anything behind that area. On 5/28/24 at 12:31 PM, a phone interview was conducted with Nurse B. When asked to recall the events of R500 on 5/27/24, Nurse B reported when they come in every morning, they do walking rounds with the off-going nurse and they did not see R500 in their room, so they assumed that they were outside, or in the dining room where they'd usually be. Nurse B further reported they continued their rounds and started on the medication pass. Nurse B then went back to check on R500 around 1:00 PM, and noticed they still were nowhere to be found and they called a code w (missing resident alert), notified the Administrator and DON, called the family and continued to follow the protocol for a missing resident. Nurse B reported they never laid eyes on (R500) during their shift, the resident doesn't take any medications, and they felt bad because they assumed R500 was there and the off-going (midnight nurse) didn't mention anything about the resident being gone. On 5/28/24 at 12:56 PM, a phone interview was conducted with HK C. When asked to explain what their responsibilities were when they covered the front desk for a receptionist, HKC replied they did not know, and that Maintenance Worker (Staff Q) asked if they could sit in the room for a minute while they went to the basement. HK C reported they were watching the area for all of five minutes, if that. They further reported they were never told that they needed to watch the outside patio and the facility noticed (after the incident) the resident leaving the facility on Sunday 5/26/24 around 9:45 AM and they got it on the security cameras. HK C was then asked about the details and education provided on their suspension and HK C reported they were not aware of any suspensions. On 5/28/24 at 2:28 PM, a phone interview was conducted with Certified Nursing Assistant (CNA E). When asked if they were assigned to R500 on 5/26/24, they reported yes. When asked about R500's routine and when they last saw the resident on 5/26/24, CNA E replied they saw R500 Sunday (5/26/24) at the beginning of their shift when they did morning rounds, and again around 8:00 AM during breakfast. CNA E recalled the resident refused their tray and wanted to eat it with lunch, but that was the last time they saw the resident. CNA E was asked if they should've checked on R500 throughout their shift and replied Yes. On 5/28/24 at 3:00 PM, an observation of the facility's video surveillance from 5/26/24 - 5/27/24 confirmed R500 exited via wheelchair on 5/26/24 at around 9:45 AM, off the property, through the gate of the patio, and returned to the facility via family on 5/27/24 around 9:00 PM (approximately 36 hours later). On 5/29/24 at 9:25AM, an interview was conducted via phone with Family Member G. When asked what happened with the elopement of R500, Family Member G reported the facility never contacted them, but instead called their husband stating they were doing a wellness check. Family Member G then reported they told the facility that R500 does not live with them and they stay at the facility they were calling me from. They further reported Nurse B was the only person who contacted them to tell me what was going on around 2:20 PM on 5/27/24. They told us the Maintenance Director (Staff N) was looking over the cameras and noticed R500 had left the faciity on Sunday (5/26/24) around 9:15 AM. Family Member G then reported they pulled up to the facility the same time the .Police department arrived and told them that R500 used to live in the independent living next door, so the Police were able to go there and view the cameras and confirmed R500 was seen there around 10:00 AM going to their old apartment unit. Family Member G stated they and their family began to search for R500 and even posted they were missing on social media, and that the whole ordeal was very stressful and should never have happened. On 5/29/24 at 2:10 PM, a phone interview was conducted with Nurse I who confirmed they were assigned to R500 on 5/26/24. When asked about their routine during their shift, Nurse I reported upon their shift on 5/26/24 starting at 7:00 AM, they laid eyes on R500, then started their medication pass. They recalled R500 asked them for pull ups around 8:00 AM and after they finished the medication pass they went to try to get R500 pull ups and the staff person that stocks briefs, so they informed the CNA that R500 needed pull ups and to make sure they got some. Nurse I reported they continued rendering care to their other patients at about 9:00 AM, they laid eyes on R500 going to the elevator on Unit 2, by the dining room where the resident would usually be. When they were doing treatments way after lunch, but before dinner they asked the CNA if they had seen R500 and they didn't but we assumed that R500 was outside on the patio. Nurse I was asked if they checked on R500 after they last saw them at 9:00 AM on 5/26/24 and they stated they did not check on them like they should have. Nurse I further reported that was not like R500 to leave the campus, and they were dealing with a difficult resident who wanders all the time so it was just a crazy day. On 5/29/24 at 2:14 PM, an interview was conducted with Nurse J. When asked if they were assigned to R500 during the midnight shift (on 5/26/24, into 5/27/24), Nurse J reported no, they did not take care of R500. They reported when they came onto shift, they got a report from the dayshift nurse that R500 was out somewhere so I didn't follow-up immediately. Nurse J reported they have a resident that wanders, and it was busy and the that resident made their night very busy and chaotic. Nurse J reported the off-going Nurse told them that R500 was outside somewhere. This was their second week so they didn't know how the patients were and how they acted, so they thought R500 was out with a family member and they gave the oncoming nurse the following day the same report. Nurse J reported that nurse took the keys from them, so they did not think anything of it. Nurse J confirmed R500 was not present at the start of their shift on 5/26/24 at 7:00 PM. According to the facility's policy titled, Elopement - For Facilities With a Wander Alert Bracelet System dated 8/2022, revised 5/27/2024: .GUIDELINES FOR STAFF WITNESSING A RESIDENT ATTEMPTING TO LEAVE THE FACILITY: Staff members will report to the charge nurse any resident who tries to leave the facility. If a staff member observes a resident attempting to leave the facility or premises, they should .Get help from other staff members in the immediate vicinity or call for assistance .If the resident leaves the facility: Instruct another staff member to inform the charge nurse or director of nursing that a resident has left the facility or premises while staying with the resident . The Immediate Jeopardy that began on 5/26/24 was removed on 5/29/24 when the facility took the following actions to remove the immediacy: Immediate action(s) taken for the resident(s) found to have been affected include: 1) Resident [Name of R500] on 5/27/2024, it was noted at approximately 1330 that resident was missing in the facility, and after initiating the procedure for a missing resident and searching the facility, the resident could not be located. DON, Administrator, Physician, Medical Director, resident's sister, State of Michigan, and the Southfield police department were notified. It was identified the gate was unlocked and resident wheeled himself through the gate to the sidewalk and left facility premises. The receptionist who was responsible for supervising the resident while on the patio alone was immediately suspended, pending investigation. The resident has been returned to the facility, evaluated, and deemed stable with no negative outcomes. Identification of other residents having the potential to be affected was accomplished by: 1) Residents who reside in the facility who are at risk for elopement have the potential to be affected. A facility-wide audit was conducted and residents in the facility had a elopement assessment completed on 5/27/24 to establish elopement risk, and wander guards were applied to residents as appropriate, with physician orders and care plans updated. 2) Facility doors were checked by the Maintenance Department. 3) The facility process changed on 5/27/24 and residents must be attended to on the patio by staff or family. 4) On 5/28/24 the facility gate has been locked and will be observed by 1:1 staff member until a door camera is installed. The gate will remain locked at all times. (It should be noted that this was not verified as implemented adequately until 5/29/24.) Measures put in place and systemic changes you will make to ensure that the deficient practice dose not reoccur: 1) Education was initiated on 5/27/24 for the facility staff by the Director of Nursing, Assistant Director of Nursing, and designee. Staff are educated on elopement policy, procedures for a missing resident, that residents are not allowed on the patio without being attended by staff or family, and that nurses are to complete a head count of their assignment at the start of their shift. Additionally, Nurse Aides and Nurses received and in-service to visualize residents their residents throughout the shift to ensue residents are safe and accounted for. In the event that a resident cannot be located, A staff member will notify the nurse supervisor, administrator, or director of nursing of the possibility that a resident is missing. The supervisor will coordinate and document the search efforts. Any staff member and/or contracted staff who has not been educated will be educated before working their next shift. 2) Patio gate will remain locked and secured. 3) Director of Nursing, or designee, will audit 5x weekly x4 weeks to ensure that residents are not on the patio without being attended by staff or family, and that nurses are completing a head count of their assignment at the start of their shift, to ensure that all residents are in the facility and accounted for. Describe the Quality Assurance & Process Improvement Program that will be put into place (track and trend data over time to ensure action plan met the initially identified goal(s). 1) An Ad Hoc QAPI meeting was held on 5/27/2024 with the Medical Director and QAPI Team 2) QAPI committee will be held weekly for 4 weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. Audits will continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserves the right to modify or extend monitoring times according to outcomes. The Administrator is responsible for the oversight of this plan to ensure ongoing compliance. DPS #2 Based on observation, interview, and record review, the facility failed to adequately supervise and implement effective interventions to prevent wandering into unsafe spaces for one (R502) of four residents reviewed for accidents, resulting in the resident, who had a history of wandering behaviors, using the elevator multiple times to leave the unit and enter the first floor which was a construction zone and off limits to residents. Findings include: On 5/28/24 at approximately 5:15 PM, R502 was observed in the hallway. R502 walked over to the elevator and attempted to enter it. R502 was redirected away from the elevator by a staff member. On 5/29/24 at 9:36 AM, 10:40 AM, and 12:10 PM, R502 was observed sleeping in bed in the same position. A review of R502's clinical record revealed R502 was admitted into the facility on 3/29/24 with diagnoses that included: Huntington's Disease and schizoaffective disorder. A review of R502's Minimum Data Set (MDS) assessment revealed R502 had severely impaired cognition and wandering behaviors. A review of R502's progress notes revealed the following documentation: On 5/9/24, it was documented in a Behavior Note that R502 was exit seeking. On 5/10/24 at 10:10 AM, it was documented in a Social Work note that R502 was exit seeking in addition to other behaviors. It was noted that R502's care plan needed to be updated. On 5/10/24 at 12:49 PM, it was documented R502 was observed walking toward the entrance behind staff .(R502) expressed, 'I'm about to go. I'm going home.' Writer made attempt to redirect her back to her room to retrieve footwear. Upon walking to her room, she tried to get on the elevator. Writer redirected her with staff assist . On 5/10/24 at 4:22 PM, Registered Nurse (RN) 'K documented, Resident was observed on the first floor by maintenance worker ('Q') in the old PT (physical therapy) room. (Maintenance Worker 'Q') brought resident back up to unit and stated that was where he observed her .She has been wandering around the facility, on all of the units .throughout this shift .Writer is placing resident on 15 min (minutes - check on resident every 15 minutes) at this time to ensure the safety of resident. On 5/14/24 at 7:43 PM, RN 'K' documented, Resident made several attempts to enter the elevator this shift . On 5/18/24 at 5:10 PM, RN 'K' documented, .Writer observed resident attempting to get on the elevator, but I was able to re-direct her back to the unit . On 5/19/24 at 4:26 PM, RN 'K' documented, Resident was observed by a couple dietary staff members, walking around on the lower level of the facility. They brought resident back to unit and writer explained to resident that it is not safe for her to go down to the lower level and walk around. Resident did not verbalize understanding and cont (continued) to wander around the facility. After several minutes, I was able to re-direct resident back to the unit, but she cont. to wander off the unit when I was doing my med (medication) pass. On 5/19/24 at 6:33 PM (two hours after the previous progress note), RN 'K' documented, Resident was, once again, observed by staff walking on the lower level of the facility into the kitchen. Writer was called and assigned CNA (Certified Nursing Assistant) went down and brought resident back to the unit. Once again, writer reiterated with resident that it is not safe her her to go down to the lower level of the facility, at this time. Resident did not verbalize understanding. Just prior to resident doing downstairs, she was observed by staff attempting to exit the facility through the current (temporary) facility's maintenance door, per CNA . On 5/28/24 at 7:08 PM, RN 'K' documented, Writer was paged and told that resident was on the lower level, in the kitchen. Writer went down and brought resident back to unit. Wander-guard was on left ankle and did not alarm, due to the fact that she did not walk through the 'double' doors, because she walked through the first kitchen door .Staff had to constantly re-direct resident after this incident so that she would not get on the elevator. Administrator made aware. On 5/29/24 at approximately 9:40 AM, an observation was made of the first floor of the facility. The elevator was accessible from the second floor. Upon exiting the elevator onto the first floor, signage was posted to the left that read Danger. Do Not Enter - Emergency Exit Only. The hallway was partitioned off with plastic. The flooring was removed from that hallway and a fan was installed. Various tools and equipment were observed on the first floor and there were many rooms with open doors. The kitchen was located on the first floor which was accessible from two different doors, one that was accessible after entering through double doors down the hallway. An interview was conducted with Maintenance Director 'N' who explained the first floor was closed off due to a flood that occurred. They were in the process of repairing the damage. On 5/29/24 at 10:37 AM, an interview was conducted with RN 'K'. When queried about R502's wandering behaviors, RN 'K' reported R502 wandered everywhere. When queried about what interventions were in place to prevent R502 from wandering into unsafe spaces, RN 'K' reported R502 had a wander alert bracelet and staff had to supervise and redirect her. RN 'K' explained that she felt R502 required one on one supervision, but due to the way the unit was staffed it was hard to constantly supervise R502 while performing other required duties and caring for other residents. When queried about how R502 got to the first floor on 5/10/24, twice on 5/19/24, and again on 5/28/24 during her shift, RN 'K' reported she did not know R502 went to the first floor until maintenance and dietary staff notified the unit. RN 'K' explained that the wander alert bracelet did not alarm at the elevator and once on the first floor, unless R502 crossed over the sensor at the double doors, it would not alarm. On 5/29/24 at approximately 10:45 AM, an interview was conducted with Unit Manager, Licensed Practical Nurse (LPN) 'P'. When queried about R502's wandering behaviors, LPN 'P' reported R502 wandered all the time in addition to other behaviors. LPN 'P' further reported the elevator was shut down starting at 5:00 PM until 7:00 AM, but it was accessible during the day. LPN 'P' reported R502 required a lot of supervision and she did not feel there was enough staff to watch her. On 5/29/24 at 11:05 AM, an interview was conducted with Maintenance Director 'N'. Maintenance Director 'N' explained that the elevator did not have a sensor for the wander alert bracelets. Maintenance Director 'N' reported that his staff found R502 on the first floor multiple times and the elevator was turned off from 5:00 PM to 7:00 AM each day. When queried about other times of day, Maintenance Director 'N' reported he was just told (on 5/29/24) to shut the elevator down until we can get rid of the wanderer (R502). On 5/29/24 at 2:10 PM, an interview was conducted via the telephone with CNA 'M'. When queried about how R502 got downstairs to the first floor on 5/28/24, CNA 'M' reported she was unaware that the resident went to the first floor. CNA 'M' reported nobody notified her that R502 went down there. Further review of R502's clinical record revealed a physician's order for a wander alert bracelet started on 4/2/24 and discontinued on 4/22/24. A new order for a wander alert bracelet was ordered on 5/27/24 with a start date of 5/28/24. A review of a Behavior Note progress note dated 5/28/24 at 7:40 PM revealed R502 entered into the activity room and used a pair of scissors and cut off the wander alert bracelet. A review of R502's care plans revealed a care plan initiated on 4/1/24 that noted R502 was exit seeking and an elopement risk. Interventions were initiated on 4/8/24 that included: a wander alert bracelet; distraction with food, activities, conversation, television, and books; and eliciting family input into former routine that might explain attempts to leave unescorted. There were no additional care plans that addressed R502 leaving the second floor unit on the elevator and going to the off limits first floor of the facility that was under construction. There were no additional interventions included on the care plan for exit seeking and elopement after 4/8/24 despite R502 going to the first floor without staff knowledge four times between 5/10/24 and 5/28/24. Further review of R502's progress notes revealed the resident had exhibited exit seeking behaviors since her admission date on 3/29/24. On 5/29/24 at 2:30 PM, an interview was conducted with the Director of Nursing (DON), who started in that position on 5/28/24. When queried about expectations for supervision of residents who wander, the DON reported staff were supposed to redirect residents from wandering, provide diversional activities, attempt to follow the resident's routine, and continue to monitor the resident to ensure they are not in any immediate harm. When queried about what should be done if a resident wandered into an unsafe area, such as the first floor construction zone, the DON reported additional interventions should be implemented. The DON reported the elevator was shut down at 5:00 PM on Monday 5/27/24, but was unsure why as she just started in the DON role one day ago. The DON reported she was unaware R502 got to the first floor on 5/28/24.

This citation pertains to Intake Number(s): MI00137119. This citation contains two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from deprivation of goods and services by staff for sixteen (R's 707, 708, 709, 710, 711, 712, 713, 714, 705, 715, 704, 716, 717, 718, 719, 722) of 24 residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when these residents did not have an assigned licensed or registered nurse for 6 hours and 22 minutes (12:38 AM to 7:00 AM on 5/18/23) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, insulin, blood pressure, seizure, pain, Parkinson, thyroid, diuretic, gastroesophageal reflux disease & potassium, and provided consistent supervision and monitoring; and respond to potential crisis/medical complications, resulting in the increased likelihood of serious harm, serious injury and/or death. Findings include: The IJ began 5/18/23. The Immediate Jeopardy was identified on 7/6/23. The Director of Nursing (DON) was notified of the Immediate Jeopardy on 7/6/23 at 1:37 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 7/6/23 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 deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint submitted to the State Agency (SA) documented the allegation regarding the residents that resided on Unit 3 to not have received their midnight shift medications. Review of the May 2023 Medication Administration Records (MAR) for R704 revealed the following for 5/18/23: 6 AM Levothyroxine Sodium 88 MCG (microgram) for thyroid condition, Enteral Feed Order, Isosource 1.5 ml to be stopped at 6 AM or until goal volume is reached for nutrition, Flush of H20 (water) 45 cc (cubic centimeter) every hour, while pump is running for, Diltiazem HCl 90 MG tablet for high blood pressure, Hydralazine HCl 25 MG (milligram) for high blood pressure, and Isosorbide Dinitrate 40 MG for high blood pressure was not administered and/or monitored. Review of the medical record revealed R704 resided on Unit 3 on 5/18/23, with diagnoses that included: chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, chronic kidney disease (stage 3B), diastolic congestive heart failure, hypertensive heart and chronic kidney disease, type 2 diabetes mellitus, seizures, history of transient ischemic attack, atherosclerotic heart disease and ileus unspecified. Review of the May 2023 MAR for R705 revealed the following for 5/18/23: 6 AM Benzocaine oral analgesic 20% gel for pain, blood sugar level & Novolog Solution per sliding scale was not obtained, administered, or monitored. Review of the medical record revealed R705 resided on Unit 3 on 5/18/23, with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction, speech and language deficits, protein-calorie malnutrition, type 2 diabetes mellitus, hypertensive heart disease with heart failure, chronic respiratory failure, obstructive sleep apnea, and acute kidney failure. Review of the May 2023 MAR for R707 revealed the following for 5/18/23: 6 AM Gabapentin 400 MG, Hydralazine HCl 10 MG for high blood pressure, Keppra 500 MG for seizures was not administered or monitored. Review of the medical record revealed R707 resided on Unit 3 on 5/18/23, with diagnoses that included: hemiplegia and hemiparesis, severe protein-calorie malnutrition, type 2 diabetes mellitus with diabetic neuropathy, critical illness myopathy, encephalopathy, aphasia, hypertension, and epilepsy. Review of the May 2023 MAR for R708 revealed the following for 5/18/23: 6 AM Hydralazine HCl 50 MG for high blood pressure was not administered or monitored. Review of the medical record revealed R708 resided on Unit 3 on 5/18/23, with diagnoses that included: dementia, hemiplegia and hemiparesis following cerebral infarction, hypertensive chronic kidney disease stage 5, end stage renal disease, dependence on renal dialysis, and hyperkalemia. Review of the May 2023 MAR for R709 revealed the following for 5/18/23: 6:30 AM Omeprazole 40 MG not administered or monitored. Review of the medical record revealed R709 resided on Unit 3 on 5/18/23, with diagnoses that included: systolic and diastolic congestive heart failure, longstanding persistent atrial fibrillation, acute respiratory failure with hypoxia, pulmonary hypertension, hypertension heart and chronic kidney disease (stage 3A), dependence on supplemental oxygen and gastroesophageal reflux disease (gerd). Review of the May 2023 MAR for R710 revealed the following for 5/18/23: 6:00 AM Levothyroxine 75 MCG for thyroid condition, Baclofen 5 MG for muscle spasms, Depakote 500 MG delayed release for anticonvulsant, and Tylenol 650 MG for pain (midnight dose as well) was not administered or monitored. Review of the medical record revealed R710 resided on Unit 3 on 5/18/23, with diagnoses that included: toxic encephalopathy, dementia, hypothyroidism, mild cognitive impairment, kidney failure, repeated falls, bradycardia, and epilepsy. Review of the May 2023 MAR for R711 revealed the following for 5/18/23: 6:00 AM Levothyroxine 100 MCG was not administered or monitored. Review of the medical record revealed R711 resided on Unit 3 on 5/18/23, with diagnoses that included: cerebral infarction, epilepsy, type 2 diabetes mellitus, hypertension, hypothyroidism, and chronic kidney disease (stage 3A). Review of the May 2023 MAR for R712 revealed the following for 5/18/23: 6 AM Baclofen 10 MG, Bromocriptine Mesylate 5 MG for antidiabetic & antiparkinson, hydralazine HCl 25 mg for high blood pressure, and Potassium Citrate extended release 20 Meq (milliequivalent) that was not administered or monitored. Review of the medical record revealed R712 resided on Unit 3 on 5/18/23, with diagnoses that included: paralytic syndrome following intracranial hemorrhage, quadriplegia, epilepsy, dementia, asthma, and hypertension. Review of the May 2023 MAR for R713 revealed the following for 5/18/23: Enteral Feed order Isosource, stop time at 3 AM that was not monitored. Review of the medical record revealed R713 resided on Unit 3 on 5/18/23, with diagnoses that included: epilepsy, moderate protein-calorie malnutrition, and heart failure. Review of the May 2023 MAR for R714 revealed the following for 5/18/23: 6:00 AM Novolog Solution per sliding scale and blood sugar level obtained, administered, and monitored. Review of the medical record revealed R714 resided on Unit 3 on 5/18/23, with diagnoses that included: end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, hypertensive heart, systolic congestive heart failure, paroxysmal atrial fibrillation, Parkinson's, and hemiplegia and hemiparesis following cerebral infarction. Review of the May 2023 MAR for R715 revealed the following for 5/18/23: 6:00 AM Carbidopa-Levodopa 25-250 MG for Parkinson's (also the midnight dose) was not administered or monitored. Review of the medical record revealed R715 resided on Unit 3 on 5/18/23, with diagnoses that included: Parkinson's disease, repeated falls, and dementia. Review of the May 2023 MAR for R716 revealed the following for 5/18/23: 6:00 AM Lasix 20 MG for edema, Omeprazole 20 MG for gerd, and gabapentin 800 Mg for neuropathy was not administered or monitored. Review of the medical record revealed R716 resided on Unit 3 on 5/18/23, with diagnoses that included: orthopedic aftercare following surgical amputation, absence of right leg above knee and left leg below knee, type 2 diabetes mellitus, chronic obstructive pulmonary disease, embolism and thrombosis of iliac artery acute kidney failure, hypertension, and gastro-esophageal reflux disease. Review of the May 2023 MAR for R717 revealed the following for 5/18/23: 6:00 AM Gabapentin 300 MG for neuropathy, and Propranolol HCl 20 MG for hypertension was not administered or monitored. Review of the medical record revealed R717 resided on Unit 3 on 5/18/23, with diagnoses that included: frontal lobe and executive function deficit following cerebral infarction, hemiplegia and hemiparesis, dysphagia, type 2 diabetes mellitus, acute kidney failure, hypertension, and epilepsy. Review of the May 2023 MAR for R718 revealed the following for 5/18/23: 6:00 AM cleanse s/p (suprapubic) site with ns (normal saline) apply split 4x4 gauze and give prn (as needed) BP (blood pressure) medication prior to dialysis if SBP (systolic blood pressure) is above 150 was not obtained, provided, or monitored. Review of the medical record revealed R718 resided on Unit 3 on 5/18/23, with diagnoses that included: paraplegia, dependence on renal dialysis, type 2 diabetes mellitus, end stage renal disease, hypertensive chronic kidney disease (stage 5), displacement of indwelling urethral catheter, retention of urine, legal blindness, and bradycardia. Review of the May 2023 MAR for R719 revealed the following for 5/18/23: 6:00 AM Oxybutynin Chloride 5 MG for urinary issues and 6:30 AM obtain blood sugar before meals for glucose monitoring was not obtained, administered, or monitored. Review of the medical record revealed R719 resided on Unit 3 on 5/18/23, with diagnoses that included: chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, insomnia, hypertension, overactive bladder, and repeated falls. Review of the May 2023 MAR for R722 revealed the following for 5/18/23: 6:30 AM Insulin Lispro solution pen-injector per sliding scale and obtained blood sugar level was not obtained, administered, or monitored. Review of the medical record revealed R722 resided on Unit 3 on 5/18/23, with diagnoses that included: acute respiratory failure with hypoxia, systolic congestive heart failure, type 2 diabetes mellitus, hypotension, and cardiomyopathy. The facility failed to ensure a nurse was assigned to all of the above residents from 12:38 AM to 7:00 AM on 5/18/23. Review of a census report dated 5/18/23 documented 24 residents in total resided on Unit three. Review of the facility staff sheet dated 5/17/23 documented the facility Census as 74. Further review of the staffing sheet, time sheets for facility employees, invoices for agency staff provided by the facility revealed the following for the 7 PM to 7:30 AM shift: Unit 1- Licensed Practical Nurse (LPN) A was assigned to 27 residents. LPN A worked from 7:30 PM on 5/17/23 to 7:45 AM on 5/18/23 on Unit 1. Unit 2- LPN B was assigned to 15 residents. LPN B time sheet was requested from the DON, but not provided. Unit 3- Registered Nurse (RN) C (agency nurse) was assigned to 24 residents. RN C worked from 6:54 PM on 5/17/23 to 12:38 AM on 5/18/23 on Unit 3. Unit 4- LPN D was assigned to nine residents. LPN D worked from 7:19 PM on 5/17/23 to 8:58 AM on 5/18/23. On 7/6/23 at 8:54 AM, LPN A was contacted via telephone for an interview. A message was left for LPN A to return the call. At 3:36 PM, LPN A returned the call and when asked about the nightshift on 5/17/23 to 5/18/23, LPN A stated LPN B informed them the Agency nurse (RN C) went home early. LPN A stated LPN B was upset because they had just returned back to work from being suspended and recently demoted. LPN A stated they asked LPN B who counted (the narcotics and cart) with RN C before they left the facility, LPN B replied another nurse (later identified as LPN E) instructed RN C to put the keys (for the medication and narcotic box) in the book (medication book). LPN A was asked who LPN E was and if they were on duty that night and LPN A stated they think LPN E was a unit manager and stated LPN E was not on duty that night. LPN A stated they told LPN B to let a manager know that RN C went home and that the nurses have a pretty heavy workload so that someone can come in to help. LPN A stated at that time they were under the impression that LPN B was contacting the DON to inform them of the situation so that a nurse will be assigned to come on duty to help. LPN A stated they saw LPN B a little later in the shift and asked if they had notified the DON and what directive the DON gave to LPN B. LPN A stated LPN B said they called the DON, and the DON did not answer their phone. LPN A stated at that time they asked LPN B to call the DON in front of them. LPN A explained that the facility has a box that is supposed to go on Unit 2 when there is no supervisor in the building. LPN A stated the nurse assigned to Unit 2 is supposed to call around to try and get someone to come in or call in a manager to help if something happens or the facility is short staffed with nurses. LPN A stated they were trying not to step on LPN B toes because LPN B was the assigned nurse on Unit 2, and it was their responsibility to ensure a manager was notified of RN C going home early and Unit 3 not having nurse coverage. LPN A stated LPN B went on the phone and acted as if they called the DON however stated the DON did not answer and LPN E is going to handle the situation. LPN A stated it was getting closer to 7 AM, so they asked LPN B again if they counted the narcotics with RN C before they left, and LPN B laughed and stated their (facility administration staff) are not going to use me when they need me. LPN A stated they asked LPN B to come with them to Unit 3 to count the narcotics on the cart and LPN B refused. LPN A stated they asked LPN B to split the workload (for Unit 3) with them, but LPN B stated they could not go over to Unit 3. LPN A explained a resident on Unit 3 made a complaint against LPN B and LPN B was not allowed to work with that resident. LPN A stated they told LPN B they would take the resident and LPN B would be assigned to another group of residents on Unit 3 and LPN B refused. LPN A stated there was another nurse LPN D assigned to Unit 4, however Unit 4 is downstairs, and that nurse has to stay on their floor for their whole shift to ensure a nurse is on the first floor with the residents. LPN A stated they called LPN E and the DON themselves and neither answered their phones. LPN A stated those residents (on Unit 3) missed their morning medications unnecessarily, we (LPN A and LPN B) could have split that unit to ensure the residents received their medications, however LPN A stated it was poor communication and LPN A was not forth coming with the information or what duties they did or did not do and who they informed of the situation and talked to. On 7/6/23 at 9:14 AM, LPN D (the nurse assigned to Unit 4) was interviewed and asked about the midnight shift on 5/17/23 7PM to 5/18/23 7AM and if they knew anything about a nurse leaving in the middle of their shift. LPN D stated they remember hearing about the nurse that left, but they worked downstairs and when you work on Unit 4 the nurse has to stay on that unit. LPN D stated they heard that no one counted her (RN C) out and took her keys (to the medication cart and narcotic box). LPN D stated no one asked them to help out on Unit 3 and they did not find out about the incident until the end of their shift. LPN D stated it was a big commotion when the dayshift came into the facility. On 7/6/23 at 9:28 AM, a phone interview was attempted with RN C, a message was left on their voicemail to return the call. A return phone call was not received by the end of the survey. On 7/6/23 at 10:02 AM, a phone interview was attempted with LPN B, a message was left on their voicemail to return the call. A return phone call was not received by the end of the survey. At the time of this survey the DON informed the surveyor that LPN B was terminated due to this incident. On 7/6/23 at 10:10 AM, the DON was interviewed and asked what the facility's protocol is when a nurse has to leave their assignment mid shift and the DON stated they (staff) are supposed to call around to replace that nurse. The DON stated the other two nurses on the second floor could also split the unit to cover the house. The DON stated the unit manager come in at 6AM and can take over and make sure that everything is good. When asked if they were aware of RN C leaving their shift early on 5/18/23, the DON stated they were aware that RN C had an issue with their child and had to leave. The DON stated they didn't find out until 6 AM the morning of 5/18/23. The DON stated LPN B had left a message on their phone. The DON confirmed LPN B was terminated due to the incident on 5/18/23. The DON stated they put all of this information in a binder. The DON was asked to provide the binder to the surveyor for review. On 7/6/23 at 10:33 AM, the Medical Director (MD) H was interviewed and asked if they were aware of Unit 3 to not have nursing coverage for six hours and twenty-two minutes on 5/18/23 and MD H stated they believe they were informed by their colleague. MD H explained at that time their colleague was the Medical Director of the facility and they were transitioning into the position. MD H stated there is no long-term consequence for the residents missing one dose of their medications, however the incident was awful . terrible and should have never happened. MD H went on to say how it was unacceptable, however believed with the new management in place the facility is now moving in the right direction. On 7/6/23 at 10:46 AM, the DON was asked for the second time to provide the binder with the investigation from the incident on 5/18/23. A third request for the binder was made at 11:08 AM. Review of the binder provided by the DON contained the following staff statements: RN C statement (dated 5/18/23) documented in part . I (RN C name) had an emergency. My one-year-old son had a very high Temp (temperature) of 103.7. I was notified by his caretaker. I called 2 different nurses' station but no answer. I walked over to another unit and explained to the nurse at the station my situation and asked her to call the DON. She did however, there was no answer She then called a unit manager named (LPN E name). She explained the situation. Due to the fact that the . nurse at the station saying she could not count the cart with me. The unit manager and other nurse said to count my cart and leave key in book. I counted the cart but then went back to the nurse and pleaded with her to count with me. She said no they demoted me cause of a resident named (resident name) and this is on them. They should have a supervisor on duty now look at them. You have to go, and I understand that. I asked her about the other nurse on duty. She said (LPN A name) is on break and I don't know what time she is coming back. Go ahead we will take care of everything. I then messaged my agency and messaged (the facility name) through my app before leaving. The other nurse signed me out on my app by using her signature (LPN B). She almost didn't want to do that. She said I'm not a supervisor. I then showed her that she could cause it only says, staff signature. I would never just leave any patients without trying to do all I could to find relief. She signed me out and confirmed she would handle things. I had no choice . This statement contained the signature of RN C. LPN F statement (dated 5/18/23) documented in part . arrived on unit at around 7 AM . No MN (midnight) nurse on unit . ask for supervisor . When supervisor get to unit 3 . count narcotics . LPN E statement (dated 5/19/23) documented in part . I received a call after midnight regarding a Nurse (RN C) leaving to tend to her sick child. Nurse (LPN B name) stated The nurse is leaving. She does not have the black box. She is no longer manager and will not go on the unit. I informed (LPN B name) that we cannot hold her (RN C), but someone will have to count down the narc (narcotic) box and pass meds (medications) at 6am. She (LPN B) stated I am not doing it. (DON name), told me my license was on the line and I am not allowed to go on the unit (Unit 3) for my safety. I am not taking those keys. (DON name) isn't answering and did not respond to the text. I asked where the others <sic> staff nurses were. She (LPN B) stated she (LPN A) was missing in action. I then explained they are staff; the meds have to be passed. Attempt to call (DON name) again . This statement contained the signature of LPN E. UM G statement (not dated) documented in part . I came in at 6:15 AM and went to my office to begin my day. At approx. (approximately) 6:35 Nurse (LPN B name) reported to me that the MN (midnight) Agency nurse left around midnight d/t (due to) family emergency. I questioned nurse (LPN B name) about the events and if the medications had been given. According to Nurse (LPN B name) the 0600 medications had not been given. When asked why she stated she was banned from Unit 3 because of (resident name) and nurse (LPN A) wouldn't go. She (LPN B) stated she called the DON but did not get an answer. I texted the DON for direction and to make her aware. The midnight nurse (RN C name) called me to explain what happened. She told me she tried to get nurse (LPN B name) to sigh out . LPN A statement (not dated) documented in part . Around 0100 AM, I returned from break. I returned to my unit, checked in with my aids <sic> then did a wellness check by walking the unit. I then came over to unit 2, (LPN B name) the assigned nurse asked if I received the medication from pharmacy. I confirmed I did. She said, Oh girl the nurse on Unit 3 left. I asked if she counted her out (counted the narcotics and took the cart keys), and did she notify management. She said (LPN E name) was notified. The nurse left the keys in the book, her child was sick. I asked who was going to go over to Unit 3, she said she wasn't the manager anymore. (LPN E name) went back to sleep. She (LPN B) then said she isn't allowed over on Unit 3. I asked if it was only one patient, she couldn't have? She said No, I'm not allowed over their <sic>. I then returned to give care to my unit. I then see (LPN B name) on unit 2 in hall, I asked if she would call (DON name). She said ok, she came over to unit one and walked in the clean utility. I then wanted to hear from (DON name) myself. I followed her. I walked after her. She literally held the door shut after I put the code in, she opened it and stated she (DON) didn't answer. After 0700 AM (LPN B name) came over to unit one and said (DON name) was now notified. I asked who needs to pass the meds she said she is no longer the manager, and they can't use her at there <sic> convenience and walked away . Further review of the binder revealed an education titled Medication order & timely administration of medication that was completed with the facility nursing staff as a result of the incident that occurred on 5/18/23 with RN C leaving mid-shift and Unit 3 to not have nursing coverage. On 7/6/23 at 11:37 AM, the DON was interviewed and asked what the nurses (LPN B and LPN A) was supposed to do when RN C left mid shift and they (the DON) was not answering their phone on 5/18/23. The DON stated LPN B was supposed to call around to get coverage and/or LPN B and LPN A could have split the unit to ensure Unit 3 had nursing coverage. The DON was asked why they didn't answer their phone when staff attempted to notify them of RN C leaving the facility and what the facility's protocol is when they (the DON) don't answer their phone or return the staff's phone calls and the DON stated they did not know why their phone didn't ring because they had it on their bedside by them all night. The DON stated they did not receive a call. The DON stated the staff could have reached out to the Administrator or whoever they could get a hold of. The DON was asked if the facility only educated the staff on medication orders & timely Administration and the DON confirmed the only education provided to the facility staff after the 5/18/23 incident was the medication order & timely administration of medication policy. The DON then stated they gave directive to Unit Manager (UM) G to give the residents on Unit 3 their morning medications on 5/18/23 when UM G came into work at 6 AM that morning and UM G notified them (the DON) that there was no nursing coverage on Unit 3 when RN C left the facility. When asked why UM G didn't administer the medications to the residents on Unit 3 the DON stated they did not know why UM G did not administer the medications to residents on Unit 3 which resulted in UM G to receive a written counseling. The DON was then asked besides the medication administration, who ensured Unit 3 had nursing coverage for the residents basic nursing needs, nursing assessment and nursing services if a crisis or medical complication had arisen and the DON did not have a response. On 7/6/23 at 1 PM, LPN F (the nurse who was assigned to Unit 3 on 5/18/23 for the dayshift) was interviewed via telephone. When asked who they received the Unit 3 medication and narcotic keys from, LPN F stated they received it from the unit manager (UM G). LPN F stated they obtained the keys from UM G and counted the Unit 3 narcotics and one of the narcotics was off by a pill. LPN F stated when they looked at the Unit 3 MARs on the computer all of the residents were red (which indicated they had medications that were overdue). LPN F stated the Administration staff was aware that the midnight shift medications were not administered. LPN F stated when they came on to Unit 3 there was only two CNA's (Certified Nursing Assistants) on the unit. The aides stated they didn't have a nurse on nightshift, but they didn't have any falls or anything. LPN F was asked if they ever came on duty to a Unit that didn't have a nurse assigned to them for the previous shift before at the facility and LPN F stated they had never had that happen to them at any facility until 5/18/23. On 7/6/23 at 12:05 PM, UM G was interviewed and when asked about the morning of 5/18/23 when they came on duty at 6 AM, UM G stated they came on duty and was made aware that Unit 3 did not have nursing coverage due to RN C leaving because of a family issue. UM G stated they notified the DON. When asked if the DON gave them directive to administer the residents on Unit 3 midnight shift medications, UM G stated the DON did not give them the instructions to administer the medications. UM G explained that they did not want to take the keys for Unit 3 medication and narcotic cart because there was no nurse to do the count of the cart/narcotic medications at that time. UM G stated when LPN F came on duty on the morning of 5/18/23 (to unit 3) they counted the narcotics with them, and the count was off. When asked, UM G could not remember the resident or the medication whose count was off. UM G explained they were following standard nursing practices and the facilities policy to complete the count with another nurse before resuming the duties of the medication cart/narcotic medications. UM G explained because they followed professional nursing standard practices and the policy, they were given a written counseling for not resuming the medication cart, without counting with a nurse to administer the medications to the residents on Unit 3. On 7/6/23 at 4:11 PM, a follow-up interview was conducted with the DON. The DON was asked to clarify LPN E position and why staff called LPN E at home regarding RN C leaving the facility mid shift and the DON stated LPN E was previously a manager, however they were not a manager at that time and the DON stated they were unsure on why staff called LPN E for further directive on 5/18/23. At the start of the survey the facility's Administrator was on vacation, however entered the building once the Immediate Jeopardy was served to the facility. Review of a facility policy titled Abuse revised 4/13/23, documented in part . Residents have the right to be free from . neglect . The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . Neglect . Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . DPS #2 Based on observation, interview, and record review the facility failed to prevent a resident-to-resident abuse incident for two (R's 701 and 702) of three residents reviewed for Abuse. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) documented in part, . Incident Summary Resident (R702 name) allegedly assaulted resident (R701 name) on 05/16/2023 in their shared room . at approximately 3:30pm . On the afternoon of 05/16/23 the nurse, (Licensed Practical Nurse- LPN I name), was alerted to a disturbance coming from the room shared by (R701 name and R702 name). When she went to investigate, she observed (R702 name) lying on the floor between the two beds yelling and kicking (R701 name) in his back. The blows did make contact with (R701 name) . The nurse asked (R702 name) to stop kicking (R701 name) and at that point (R702 name) became aggressive with the staff nurse and other staff members who responded . On 7/5/23 at 1:22 PM, R701 was observed sitting in the community room in their wheelchair watching television. When asked, R701 stated that (R702) was a nut and stated the resident came into the room and started kicking him in the back. When asked, R701 stated they did not feel safe around R702. Review [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00131469, MI00131551, MI00131999, and MI00131552. Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from deprivation of goods and services by staff for nine (R28, R57, R14, R36, R45, R24, R68, R60, and R7) of 13 residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when these residents were not assigned a licensed or registered nurse for 12 hours (7:00 PM on 9/22/22 until 7:00 AM on 9/23/22) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, pain, cardiac disease, blood clots, psychiatric disorders, diabetes, and post kidney transplant therapy; did not provide wound treatments and catheter care; complete nursing assessments for pain and blood sugar monitoring; provide supervision; and respond to potential crisis/medical complications. This resulted in R28 and R60 calling 911 due to unrelieved pain and experiencing anxiety due to nobody being available to check their vital signs when they experienced blurry vision. Because there was no nurse willing to provide nursing care to these residents, it increased the likelihood of serious harm, serious injury and/or death. Findings include: The IJ began 9/22/22. The Immediate Jeopardy was identified on 3/30/23. The Administrator was notified of the Immediate Jeopardy on 3/30/23 at 1:30 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 9/23/22 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint submitted to the State Agency on 9/23/22 revealed the following allegations: Last night, 9/22, there was no nurse and the midnight supervisor refused to pass medications on Unit 2. Resident called the police because medication was not being passed. Medication was still not passed even after the police was called . Review of a second complaint submitted to the State Agency on 9/23/22 revealed the following allegations: .Patient (R28 - who is quadriplegic) called police at 3am (3:00 AM) because he needed his pain medication and there is no nurse able to give it to him .The person in charge at that time is (Nurse 'FF'). She says she is responsible for Unit 1. (R28) is in Unit 2 and they have no nurse to hand out any medication until the day nurse comes in at 6AM (6:00 AM). (Nurse 'FF') said she was not going to be responsible for another unit's med (medication) cart. Unit 2 consisted of many beds, possible 30+ (more than 30) patients. (R28) said this situation occurs regularly . Review of a third complaint submitted to the State Agency on 9/23/22 revealed the following allegations: .(R28) is bedridden .(facility name) is short on staff. There are two aides at the facility who cannot administer medication. None of the patients are getting their medication. The supervisor, (Nurse 'FF'), is capable of administering medication to the patients but is refusing to do so. (R28) is supposed to get pain medication every six hours but have not received pain medication for 11 hours since day shift. This has occurred multiple times a week . Review of a Case Report from the local police department revealed the following: .Subject .Cruelty/Neglect .Report Date/Time 09/23/2022 02:41 (2:41 AM) .Occurrence Date/Time 09/23/2022 02:41 .Dispatched Offense .Welfare Check .Verified Offense .Cruelty/Neglect . .Suspect .(Nurse 'FF') .Victim .(R28) . .Officers were dispatched to (facility name) to check on (R28). We made contact with (R28) in (room number). (R28) said he has not received his medication since 5pm the previous day, which was almost 11 hours prior. (R28) said he is supposed to get his pain medication every 6 hours .(R28) said the medication neglect has been an on going issue with (R28), the only supervisor in the building when officers were on scene. (R28) said not getting his meds through the night has been happening several times a week. Officer spoke with staff on scene. There were two nurses on the floor near (R28's room). Offers inquired about medications. They said they did not have the ability of giving medication. I could hear numerous rooms complains that they did not get their medication. The nurses were just telling the patients to go to sleep. I asked the floor nurses why everyone was asking for meds. They said the <sic> do not have enough staff and the only person that could give medication is (Nurse 'FF'), the supervisor on scene. The nurses took us to (Nurse 'FF')'s office. When we opened the door (Nurse 'FF') was just sitting in the room listening to music on her phone. (Nurse 'FF') said she is the staffing manager. She said they have 4 wings and only 3 nurses that can give medication so the wing with (R28) on it will not get medication until day shift comes back to work. I noted that 15 plus patients will not be receiving any medication from approx. (approximately) 7pm to 7am on this date. (Nurse 'FF') is an LPN (Licensed Practical Nurse). When we were interviewing her she said she can give medications but she is not willing to take responsibility of signing out the medication cart and giving meds. (Nurse 'FF') said her boss is (former Director of Nursing, DON 'II')and gave us her phone number. I tried to call several times and (Officer name) tried to call her several times as well, with no response .(Officer) .filed a complaint about (facility) and the negligent medical care they are providing . On 3/28/23 at 10:12 AM, R28 was observed lying in bed. R28 appeared to have limited use of their arms and reported they were unable to move the lower half of their body. When queried about any time when they called the police, R28 reported they did call 911 before because there was no nurse to pass medications and they did not receive their pain medication for approximately 12 hours. R28 reported there was not enough staff to take care of the residents, but the facility continued to admit new residents. On 3/30/23 at 1:49 PM, R60 was interviewed. When queried about whether there was any time when a nurse was not available to provide nursing care or pass medications, R60 reported there was a night when they did not have a nurse. R60 explained it was several months ago. R60 reported they did not receive their pain medications and they were having trouble with blurry vision which they said they were instructed to have their blood pressure monitored if that happened. R60 further explained they tried to get a nurse, but there was nobody to come help them. R60 called the front desk from their cellular phone and nobody answered. They called their family to call the front desk and they did did not get anyone on the phone. R60 reported they called 911 and EMS (emergency medical services) came and took their blood pressure. R60 stated, After they left, I thought my nurse was going to get my medicine and we never got any meds that night. Review of a Grievance Documentation, Investigation & Follow-Up Form dated 9/23/22 revealed R28 filed a grievance on that date. The nature of the concern was documented as follows: Res (resident) stated it has been 2 nites <sic> of not receiving 9p (9:00 PM) and 6a (6:00 AM) meds due to no nurse on Unit 2. Res. stated that he used light multiple times and sent cena (CNA) to nurse who never came so he called 911. Police came out. Res. stated the police spoke with (Nurse 'FF') and said 'she is not doing it'. Police filled out a victim's report. Res. also stated that police came due to multiple calls. The signature of the person who received the grievance was illegible and the facility was unable to identify who signed it. The following was documented in the investigation section: Nurse suspended. Investigation indicates that she failed to supervise or pass medications on Unit 2. Termination paperwork pending. The investigation section was signed by the former Administrator, (Administrator 'JJJ). The following was documented in the Action Taken section: Nurse responsible, (Nurse 'FF'), suspended. Nurse was terminated .(the rest of the handwriting was illegible). That section was signed by former DON 'LL'. Review of a resident census for the date of 9/22/22 revealed all residents listed on the census did not receive nursing services, including medication administration, treatments, assessments/monitoring, and supervision on the 7:00 PM to 7:00 AM shift. Review of R28's Physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for September 2022 revealed they did not receive the following physician ordered treatments, medications, and assessments on 9/22/22 and 9/23/22: 1. Percocet (a narcotic pain medication), was given at 7:10 AM on 9/22/22 and was not given again until 12:10 PM on 9/23/22. According to R28, this medication was needed the night on 9/22/22 which is why they called 911. 2. Acetaminophen Tablet (medication used to treat pain) 9:00 PM dose. 3. Pain Assessment during second shift (7:00 PM-7:00 AM). 4. COVID-19 Screen for symptoms during second shift. 5. COVID-19 Screen to monitor vital signs during second shift. 6. Monitor catheter anchor during second shift. 7. Midodrine HCl (a medication to treat low blood pressure) 10:00 PM dose on 9/22/22 and 6:00 AM dose on 9/23/22. 8. Docusate Sodium (stool softener) 9:00 PM dose. 9. Assessment of heels and sacral areas which were ordered to be done during the evening shift. 10. Suprapubic catheter care ordered to be done every night shift. 11. Bowel movement monitoring during second shift. 12. Colostomy care during second shift. 13. Irrigation of suprapubic catheter during second shift. 14. Wound care to the sacro-coccyx area on second shift. Further review of R28's clinical record revealed R28 was admitted into the facility on 7/25/22 and readmitted on [DATE] with diagnoses that included: quadriplegia, stage 4 pressure ulcers, cervical spinal cord injury post gun shot wound, hypertension, morbid obesity, compression of the brain, and contractures of the right and left upper arms. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R28 had intact cognition, was totally dependent on staff for all activities of daily living (ADLs), had an indwelling catheter and a colostomy, had multiple pressure ulcers, and frequent pain. Review of R60's Physician's Orders, MAR, and TAR for September 2022 revealed they did not receive the following physician ordered treatments, medications, and assessments on 9/22/22 and 9/23/22: 1. Lidocaine to rectum 9:00PM dose. 2. Pain Assessment during second shift. 3. Calmoseptine Ointment to sacrococcyx, ordered to be done at 9:00 PM. 4. COVID-19 Screen for symptoms during second shift. 5. COVID-19 Screen to monitor vital signs during second shift. 6. Monitor catheter anchor during second shift. 7. Hydrocodone-Acetaminophen (a narcotic pain medication) 10:00 PM dose on 9/22/22 and 6:00 AM dose on 9/23/22. The medication was ordered to be administered every 8 hours. 8. Tizanidine HCl (a medication to treat muscle spasms) 10:00 PM dose on 9/22/22 and 6:00 AM dose on 9/23/22. 9. Assessment of heels and sacral areas which were ordered to be done during the evening shift. 10. Biscodyl Suppository (to treat constipation) due at 9:00 PM which was ordered every day at bedtime. 11. Bowel movement monitoring during second shift on 9/22/22 and first shift on 9/23/22. 12. Monitoring of urine output from indwelling catheter during second shift on 9/22/22 and first shift on 9/23/22. 13. Wound care to bilateral legs/feet/toes, 9:00 PM. 14. Catheter care during evening and night shift. Further review of R60's clinical record revealed R60 was admitted into the facility on 7/21/22 with diagnoses that included: quadriplegia, neuralgia (severe pain due to damaged nerves), type 2 diabetes mellitus, constipation, and neuromuscular dysfunction of bladder. Review of a MDS assessment dated [DATE] revealed R60 had intact cognition, required extensive physical assistance from staff for bed mobility, transfers, and all ADLs, had an indwelling urinary catheter, and experienced frequent pain. Review of a Staffing Assignment sheet for 9/22/22 revealed the facility census was 73 on that date. Further review of the staffing assignment sheet, time punches for facility employees, an invoice from a staffing agency used by the facility that indicated who worked in the facility, and MARs for residents who resided on the second floor on 9/22/22 revealed the following: The following nurses were scheduled and/or worked in the facility on 9/22/22 during the 7:00 PM to 7:00 AM shift: Nurse 'GG' worked from 7:00 PM until 7:15 AM and was assigned to Unit 3. Nurse 'HH' worked from 7:00 PM until 8:31 AM and was assigned to Unit 2. Nurse 'YY' was assigned to Unit 4 according to the assignment sheet, but there was no time punch for that day. Review of MARs for residents who resided on Unit 4 revealed Nurse 'GG' administered medications to those residents on the 7:00 PM-7:00 AM shift on 9/22/22. Nurse 'FF' was assigned to Unit 1 according to the assignment sheet, but there was no time punch for that day. Review of the MARs for residents who resided on Unit 1 on 9/22/22 revealed Nurse 'FF' administered medications on that day which indicated they did work. Five Certified Nursing Assistants (CNAs 'AA', 'BB', 'CC', 'ZZ' and 'AAA') worked the 7:00 PM to 7:00 AM shift according to the assignment sheet and corresponding time punches provided by the facility. Review of MARs for residents who resided on Unit 3 revealed Nurse 'HH' administered medications to residents on Unit 3 on the 7:00 PM-7:00 AM shift on 9/22/22. Review of MARs for residents who resided on Unit 1 revealed Nurse 'GG' administered medications to residents on Unit 1 on the 7:00 PM-7:00 AM shift on 9/22/22. Based on the time punches and documentation in the clinical record, there was no indication that Nurse 'YY' worked on 9/22/22. On 3/29/23 at 12:56 PM, a telephone interview was conducted with CNA 'AA'. CNA 'AA' reported she did not remember police coming to the building or the building being without a nurse. On 3/29/23 at 12:58 PM, CNA 'BB' who was assigned to work on Unit 1 on 9/22/22 was interviewed. CNA 'BB' was not available for interview prior to the end of the survey. On 3/29/23 at 12:34 PM, a telephone interview was conducted with CNA 'CC' who was assigned to Unit 2, the unit documented on the police report as not having an assigned nurse and residents who complained of not getting their medications. When queried about the night of 9/22/22, CNA 'CC' reported they did not remember that night. When queried about the police being called because residents were not getting their medications, CNA 'CC' reported they would not know if a resident did not get medications because they were not a nurse and further explained that they remembered police coming a couple of times. On 3/29/23 at 1:27 PM, a telephone interview was conducted with Nurse 'DD' who was the outgoing nurse on 9/22/22 at 7:00 PM and the incoming nurse on 9/23/22 at 7:00 AM. When queried about any knowledge of a set of residents not getting medications or nursing services and police response during the night shift, Nurse 'DD' reported they did not have any specific information, but that used to happen a lot because they cut one of the night shift nurses out. Nurse 'DD' reported when that occurred they would be coming in at 6:00 AM instead of 7:00 AM to pass medications. Nurse 'DD' further explained the nurse assigned to Unit 1 and the nurse assigned from Unit 3 would split Unit 2. When queried about who they counted the Unit 2 narcotics with when they left their shift on 9/22/22, Nurse 'DD' could not remember. When queried about what happened if a nurse did not show up to relieve them from their medication cart, Nurse 'DD' reported the narcotics were counted with the afternoon/night supervisor and keys to the cart were handed over to the supervisor. When queried about any time they arrived for their day shift and residents had not received medications from the previous 12 hour shift, Nurse 'DD' could not remember. When queried about what they would do if they discovered that happened, Nurse 'DD' reported they would report it to the unit manager or DON and stated, But, it is my word against the nurses. They will ask me who told me that and if I say it was the resident, then it's the resident's word against the nurse. They have to investigate. Review of Nurse 'FF's personnel file revealed the following: An Employee Personal Change Form that documented Nurse 'FF' was hired as a LPN - supv (supervisor) on 8/18/22. A Personal Change Form that documented Nurse 'FF' was discharged effective 9/27/20 (confirmed with Human Resources Director - HR 'C' that the date was 9/27/23). It was documented Nurse 'FF' was not recommended for re-employment in the same department or in other departments. In the remarks section the following was documented: Terminated first 90 days not taking cart. The form was not signed. An Employee Counseling & Corrective Action Record for Nurse 'FF' documented they were suspended (not terminated) on 9/29/22 and the form was signed by former Administrator 'JJJ' and former DON 'LL'. On 3/29/23 at 3:08 PM, an interview was conducted with the current DON of the facility. When queried about why Nurse 'FF' was terminated and/or suspended on 9/27/22 or 9/29/22, the DON reported she was not aware of the reason. On 3/29/23 at approximately 3:45 PM, the current Administrator was interviewed. The Administrator, who was also the Abuse Coordinator for the facility, reported they began working in the facility on 12/5/22. When queried about any investigation into the grievance provided for R28 from 9/23/22 regarding Nurse 'FF' and medications and care not being administered, the Administrator explained that was before they started working in the facility and they did not find an investigation. When queried about what was the protocol if a nurse refused to pass medications or there was nobody available or willing to pass medications or care for a set of residents, the Administrator reported it was fully investigated and the physician was called about missed medications. The Administrator reported they did not know anything about this incident. On 3/29/23 at 4:32 PM, a telephone interview was conducted with Nurse 'HH'. Nurse 'HH' reported they worked at the facility two times and was contracted through a staffing agency. When queried about whether they recalled if police came to the facility when they were working, Nurse 'HH' reported they recalled one night EMS came because there was a patient that wanted pain medicine and the young lady that was supervising would not pass medications. Nurse 'HH' explained that Nurse 'FF' sent a nurse home at the start of the night shift on 9/22/22 and that left the building short of nurses (three instead of four). Nurse 'HH' reported that they worked on Unit 3 on second shift. Nurse 'HH' further explained when they went upstairs, a resident was very upset because he had not yet received pain medication. Nurse 'HH' looked for Nurse 'FF', the nurse supervisor, to assist the resident. Nurse 'HH' stated, I found her (Nurse 'FF') in the cubby hole and told her that the resident needed pain medication. She was sitting there, with no socks or shoes on, eating candy, and on her phone. When Nurse 'HH' informed Nurse 'FF' that the resident needed medication, Nurse 'FF' told Nurse 'HH', Well do you want to give it to him? Nurse 'HH' explained that she did not acquire the keys to that cart and did not count the narcotics on the cart and was not comfortable. Nurse 'HH' further explained that they were assigned to 20-30 patients on the other side of the floor. Nurse 'FF' accused Nurse 'HH' of refusing an assignment and Nurse 'FF' remained in the cubby for the shift eating candy and sitting on her phone. Nurse 'HH' explained they did not pass medications to any residents on Unit 2 and either did Nurse 'FF' who was the supervising nurse. When queried about if they contacted anybody to report that there was nobody to take care of the residents on Unit 2, Nurse 'HH' reported that she told her manager at the agency, but did not contact anyone at the facility. On 3/30/23 at 8:32 AM, Nurse 'FF' was interviewed. When queried about why the police came to the facility on 9/22/22, Nurse 'FF' reported there was a situation where they did not have a nurse scheduled for a particular unit. When queried about what was done about that, Nurse 'FF' reported they contacted the DON, but the DON did not return the phone call and they were given no directives. When asked if they were a nurse supervisor, Nurse 'FF' stated, The position I had was not specific of my title. I was more of a working supervisor or charge nurse. I just made CNA assignments. When queried about who acquired the keys from the Unit 2 medication cart at the beginning of second shift on 9/22/22, Nurse 'FF' reported the keys were in the cart and they reported to the DON that another nurse was needed. When queried about their interaction with the police, Nurse 'FF' reported the police asked what was going on and they told them they were working on a whole other unit and the DON was notified. When queried about any interaction with other nurses who were working to ensure all residents were cared for, Nurse 'FF' reported there was interaction but one of the nurses concerns was that it was unsafe to assign them to Unit 2 when they were already working on Unit 3 because of how the floor was designed. When asked if they took the medication cart on Unit 2 in the absence of another nurse due to being the supervisor, Nurse 'FF' reported they did not because I had a whole other cart. Nurse 'FF' explained they did not pass medications or provide any nursing care to the residents on Unit 2 for the entirety of second shift and they told the police they would have to wait until the day shift (first shift) came in at 6:00 AM. When queried about whether there was any disciplinary action taken due to them not providing medications, treatments, and assessments on Unit 2, Nurse 'FF' reported they were taken off the schedule while the facility investigated and then they brought them back to work. Nurse 'FF' reported the DON 'II' stopped coming to work and never returned after that night. On 3/30/23 at 9:04 AM, a telephone interview was attempted with former DON 'II'. There was no response from DON 'II' prior to the end of the survey. On 3/30/23 at 9:34 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried about whether they were aware of the reason for termination/suspension of Nurse 'FF' in September 2022, the ADON reported they were informed by the previous Administrator that Nurse 'FF' refused to pass medications when staffing was short. When queried about what the proper protocol would be, the ADON reported Nurse 'FF' was the second shift supervisor and had access to the medication cart. In the absence of another nurse, Nurse 'FF' would have been responsible to pass medications, provide treatments, and do assessments on the residents without an assigned nurse. In addition, the nurse supervisor was responsible to contact the contracted staffing agencies to find a nurse to come in and then contact the DON and/or on call managers if there was one assigned. and DON should be contacted. When queried about what should be done if a staff member became aware that a set of residents did not have an assigned nurse, the ADON reported the DON and Administrator would be contacted. On 3/30/23 at 9:42 AM, a telephone interview was attempted with the Medical Director, Physician 'JJ'. There was no response from Physician 'JJ' prior to the end of the survey. On 3/20/23 at 10:26 AM, a telephone interview was conducted with former Administrator 'KK'. Administrator 'KK' reported they were the former interim Administrator in the facility and their last day at the facility was 11/18/22. When queried about any knowledge of what occurred on 9/22/22 when the police came to the facility, Administrator 'KK' reported they remembered the police coming to the facility because there was a resident who said they did not get their medications and the nurse would not administer them. Administrator 'KK' did not have any further details and reported she thought there was an investigation, but it might have been done by Administrator 'JJJ'. Administrator 'KK' reported there were several different DONs and Administrators within a six month period. On 3/30/23 at 10:32 AM, a phone interview was conducted with former DON 'LL'. DON 'LL' reported they worked at the facility as a consultant for two months and left the first week of October 2022. DON 'LL' could not remember details of what occurred on 9/22/22 with R28 and Nurse 'FF' and stated, There were several times when nurses had to split a unit and staffing was such a problem. When queried about whether they recalled being contacted and they could not remember. Review of the residents who resided on Unit 2 on 9/22/22 revealed a total of 21 residents total did not receive medications, treatments, assessments, and/or supervision by a licensed nurse between the hours of 7:00 PM and 7:00 AM (on 9/23/22). Review of R45's clinical record revealed R45 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), osteoarthritis, anxiety disorder, hyperlipidemia, lymphedema, chronic kidney disease, and depression. Review of a MDS assessment dated [DATE] revealed R45 had intact cognition, was totally dependent on staff for transfers, bed mobility, and most ADLs, and experienced frequent pain. Review of R45's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R45 was not administered their 9:00 PM dose of melatonin (a medication used to treat insomnia, trazadone (a medication used to treat depression), sertraline ( a medication used to treat anxiety and depression), erythromycin ointment (a medication used to treat eye inflammation), meloxicam (a medication used to treat pain), hydralazine HCl ( a medication used to treat high blood pressure), and tramadol (a medication used to treat pain). In addition, R45 was not administered their 6:00 AM dose of tramadol on 9/23/22. R45 was not assessed on second shift according to physicians orders for COVID-19 symptoms and vital signs and their blood sugar was not checked at 9:00 PM according to physicians orders. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R45. R57's clinical record was reviewed and revealed R57 was admitted into the facility on 1/12/22 and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus, end stage renal disease (on dialysis), kidney transplant status (on immunosuppression therapy), anemia, hypothyroidism, hyperlipidemia, heart failure, peripheral vascular disease, major depressive disorder, hypertension, pleural effusion, constipation, and insomnia. Review of a MDS assessment dated [DATE] revealed R57 had intact cognition and required set up and supervision with most ADLs. Review of R57's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R57 was not administered their 9:00 PM dose of tacrolimus (an immunosuppresive medication used to prevent organ rejection after a transplant), mycophenolate mofetil (a medication used to prevent organ rejection after a transplant), insulin glargine-yfgn (a medication used to treat diabetes), clonidine (a medication used to treat high blood pressure), hydralazine HCl, isosorbide dinatrate (a medication used to treat chest pain), amlodipine (a medication to treat high blood pressure), atorvastatin (a medication used to treat high cholesterol), levothyroxine ( medication used to treat underactive thyroid), remeron (a medication used to treat depression), carvedilol (a medication used to treat heart failure and high blood pressure), and colace (a medication used to treat constipation). In addition, R57 was not assessed for COVID-19 symptoms and vital sign monitoring according to physicians orders, pain was not assessed, and orthotic splints and ace wraps were not applied. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R57. Review of R68's clinical record revealed R68 was admitted into the facility on 6/15/22 with diagnoses that included: COPD, bipolar disorder, major depressive disorder, thrombophilia (a blood clotting disorder), chronic pain disorder, spinal stenosis, and constipation. Review of a MDS assessment dated [DATE] revealed R68 had intact cognition, required set up and supervision for ADLs, and had frequent pain. Review of R68's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R68 was not administered their 9:00 PM dose of allergy medication, antifungal medication for itching, atorvastatin, trazodone, diclofenac sodium gel (a topical medication used to treat pain), eliquis ( a medication used to prevent blood clots), acetaminophen (a mediation used to treat pain), their 10:00 PM dose of baclofen (a medication used to treat muscle spasms) on 9/22/22 and their 6:00 AM dose on 9/23/22, their 10:00 PM dose (9/22/22) and 6:00 AM dose (9/23/22) of gabapentin (a medication used to treat nerve pain), and their 12:00 AM and 6:00 AM dose of tramadol on 9/23/22. In addition, R68 was not assessed for pain, COVID-19 symptoms, or vital sign monitoring according to physician's orders. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R68. On 3/30/23 at 1:45 PM, R7 was observed seated in a wheelchair in their room. When queried about any time when he did not receive medications, R7 reported they remembered a few months ago not getting medications at night, but could not recall if the police came. R7 reported he had seen police in the building before though. Review of R7's clinical record revealed R7 was admitted into the facility on 9/14/22 with diagnoses that included: wedge compression fracture of lumbar vertebra, cardiomyopathy, atrioventricular block, hypertension, type 2 diabetes mellitus, dementia, anemia, and depression. Review of a MDS assessment dated [DATE] revealed R7 had severely impaired cognition, required extensive assistance with ADLs, transfers and bed mobility, and experienced frequent pain. Review of R7's physicians orders, MAR and TAR from September 2022, and progress notes revealed the following: On 9/22/22, R7 was not administered their 9:00 PM dose of atorvastatin, melatonin, seroquel (a medication used to treat psychosis), enulose (a medication used to treat constipation), lidocaine patch (a patch used to treat pain), and acetaminophen. R7 did not receive insulin lispro at 12:00 AM and 6:00 AM on 9/23/22. In addition, R7 was not assessed for pain, COVID-19 symptoms, or vital sign monitoring according to physician's orders. There were no progress notes written to indicate a physician was contacted regarding the missed medications for R7. Review of R14's clinical record revealed R14 was admitted into the facility on 6/28/22 with diagnoses that inc[TRUNCATED]