Every finding on record at Argentine Care Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:Resident 1 A review of Resident 1's medical record revealed an admission into the facility on 2/4/26 with diagnoses that included sepsis, diabetes, gastro-esophageal reflux disease, and chronic duodenal ulcer. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 12/15 that indicated moderate impaired cognition. On 3/24/26 at 11:08 AM, an interview was conducted with Resident 1, who answered questions and engaged in conversation. The Resident was laying on their bed in their room. When asked about any issues with the care received from the facility, the Resident reported issues with food services. The Resident reported poor taste of some of the foods, the way the food was cooked and the food not at a palatable temperature. The Resident stated, Half the time it's cold. The Resident reported items that came too cold were not enjoyable. The Resident reported eating in their room and that any of the meals might arrive too cold when it should be hot. When asked for examples, the Resident reported that for breakfast they get scrambled eggs often and the eggs were usually cold. The Resident reported occasionally they will get something else and stated, I got French toast, but it was cold too and the bacon was burnt, and reported the oatmeal does not come warm enough. On 3/25/26 at 2:03 PM, an observation was made of Resident 1 sitting in their room. The lunch meal remained in the room and was partially consumed. When asked how the temperature of the food was, the Resident reported, It was OK, could have been better. On 03/24/2026 at 8:50am conducted initial kitchen tour with Certified Dietary Manager (CDM) H. On 03/24/2026 at 9:13am the wiping cloth sanitizer bucket was tested with quat strips and the result was zero. During this observation, CDM H was interviewed on what range the quat sanitizer should be and stated, at least 200 and the bucket is changed out every 8 hours or as needed. According to the FDA 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit. On 03/24/2026 at 9:32am observed yellow brownish residue on the interior walls of the ice machine located in the clean storage room. During this observation, CDM H was interviewed on how often the ice machine is cleaned and she said maintenance cleans the ice machine. On 03/24/2026 at 9:33am observed two coolers stored inside the clean storage room near the ice machine. The interior of the coolers had water pooling at the bottom and water droplets on the interior walls. Observed black splotches on the interior of one of the cooler lids. During this observation, CDM H was interviewed on what the coolers are used for, and she stated she wasn't really sure what the coolers are used for, but the coolers are ran through dishwasher in the kitchen for cleaning. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the FDA 2022 Food Code, 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment, and utensils: Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food. On 03/24/2026 at 11:50am during lunch observation, cottage cheese was observed sitting on a food preparation table. The cottage cheese was temped at 47 degrees F using a thermometer probe. During this observation, CDM H was interviewed on what temperature the cottage cheese should be while cold holding, and she stated it should be below 41 degrees F. On 03/24/2026 at 11:51am observed several plates of food sitting on the food prep table behind the steam table, covered with lids. One of the plates held pizza and it was temped at 102 degrees F using a thermometer probe. Observed grilled cheese on a separate plate and it was temped at 83 degrees F. During this observation, [NAME] I was interviewed on why the pizza was sitting out on the table, and she stated they will put it in the microwave later to warm it up. CDM H was interviewed on what temperature food should be hot holding at and she stated 135 degrees F or above. On 03/24/2026 at 12:04pm observed a fly above the tray line. According to the FDA 2022 Food Code, 6-501.111 Controlling Pests, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by .Routinely inspecting incoming shipments of food and supplies .Routinely inspecting the premises for evidence of pests .Using methods, if pests are found, such as trapping devices or other means of pest control . Eliminating harborage conditions. On 03/24/2026 at 12:05pm observed [NAME] I touch trash can lid after washing her hands to throw away a paper towel and then proceeded to glove hands before prepping food. According to the FDA 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single -use articles and . After engaging in other activities that contaminate the hands. On 03/24/2026 at 12:12pm observed an unlabeled spray bottle with a yellowish liquid inside the bottle, sitting on the windowsill above the food prep area. During this observation, CDM H was asked what was in the bottle and she said she didn't know and asked [NAME] I what was in the bottle, and neither of them knew what the liquid was. According to the FDA 2022 Food Code, 7-201.11 Separation, Poisonous or toxic materials shall be stored so they can not contaminate food, equipment, utensils, linens, and single-service and single-use articles by.Separating the poisonous or toxic materials by spacing or partitioning.Locating the poisonous or toxic materials in an area that is not above food, equipment, utensils, linens, and single-use articles. This paragraph does not apply to equipment and utensil cleaners and sanitizers that are stored in warewashing areas for availability and convenience if the materials are stored to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles. On 03/24/2026 at 12:18pm observed a tub of hamburger buns with cheese sitting on the prep table and the cheese was temped at 54 degrees F using a thermometer probe. On 03/24/2026 at 12:45pm interviewed CDM H on whether the facility had a policy on hot and cold holding, and she stated there wasn't a policy. According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 degrees C (41 degrees F) or less. According to the 2022 FDA Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control . time/temperature control for safety food shall be maintained .at 57 degrees C (135 degrees F) or above. R17 According to a review of R17's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses including debility, heart failure, depression and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14/15 that indicated the resident had intact cognition. On 03/23/2026 at 10:15 AM, during an interview with R17 about food at the facility she stated The food is so-so; The temperature is usually off; Dinner is always cold when asked to clarify dinner was always cold R17 said it did not matter if she went to the dining room or ate in her room that her dinner was always cold. According to a record review of R17's care plan: Focus: I am at risk for an alteration in nutritional status r/t GERD, hypothyroidism, major depressive disorder, COPD, CHF and weight gain/edema with intervention: Honor my food preferences when possible. According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control. for safety food shall be maintained . at 57 degrees C (135 degrees F) or above. Timely distribution is essential to ensure food and beverages are served at the proper temperature.

Based on observation, interview, and record review the facility 1) Failed to practice best infection control methods in soiled utility areas resulting in the potential to spread pathogens through the laundry process, affecting all residents and 2) Failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP).Findings include:On 03/24/2026 at 10:44am observed a hopper in the soiled utility room on the first floor. There are gloves and a face shield, but there were not any gowns in the soiled utility room. During this observation, Housekeeping Manager J was interviewed on what the hopper was used for and she stated it's used to rinse out bedpans and soiled linen. On 03/24/2026 at 10:47am observed a hopper in the soiled utility room on the second floor. There were gloves stored in the soiled utility room, but there weren't any gowns or face shields. On 03/24/2026 at 10:51am during the housekeeping tour, Housekeeping Manager J stated there are several bathtubs that are not being used in the facility and the tubs cause an odor, but they are flushed once a month. On 03/25/2026 at 11:33am reviewed the facility's water management plan for legionella and the water management plan is missing the following elements: a description of the water system using flow and text diagrams, where Legionella and other opportunistic waterborne pathogens can grow, and adequate control measures to prevent the growth and spread of legionella. The legionella folder given at the time of survey had multiple legionella test results dating from 2023, but there weren't any recent preventative measures taken in the past year. In addition, a legionella environmental assessment form was completed, but it is dated 2019 and there hasn't been a reassessment. On 03/24/2026 at approximately 1:20pm interviewed Maintenance Director K on whether the unused tubs were flushed, and he stated no. On 03/25/2026 at approximately 9:45am observed unused tubs located on the second floor in both bathrooms adjacent to the stairs and in bathroom in room [ROOM NUMBER]. The tub in room [ROOM NUMBER] did not turn on. On 03/25/2026 at 9:59am interviewed DON and Maintenance Director K on whether the facility had a water system flow or text diagram, a list of high-risk areas for legionella growth, or any other water management plan information that was not included in the folder given at the time of survey, and they stated no, and were unaware of the missing elements to the water management plan requirements. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.

Based on observation, interview, and record review, the facility failed to mitigate the presence of pests, maintain safe hot water temperatures, and ensure that appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents. Findings include: On 03/24/2026 at 8:45am while entering the facility, observed an outside spigot with an attached hose and a spray nozzle downstream of a hose bib vacuum breaker. On 03/24/2026 at 9:25am observed a spigot with an attached hose and a spray nozzle downstream of a hose bib vacuum breaker in the basement. According to the State of Michigan 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve). On 03/24/2026 at 10:34am observed used paper towels and a cloth towel on the floor behind the whirlpool in the shower room on the first floor. During this observation, Housekeeping Manager J was asked how often the floors are cleaned and she stated they're cleaned every night. On 03/24/2026 at 10:35am observed several gnats flying around in the shower room on the first floor. During this observation, Housekeeping Manager J stated they don't know where the gnats are coming from and they've been having this issue during the winter season. On 03/24/2026 at 10:38am observed multiple used razors overflowing on top of the sharp's container dated 2/25/26 in the shower room. During this observation, Housekeeping Manager J stated the sharps container should be changed out every 30 days or whenever it's full, and that the date on the container was the last time it was changed out. On 03/24/2026 at approximately 1:00pm during the environmental tour with Maintenance Director K, he stated the boiler is set to 160 degrees and it's 140 degrees going out to the floor. On 03/24/2026 at 1:05pm reviewed hot water temp logs and on January 7th, 2026, hot water was temped at 153 degrees at the hand sink in the restorative. On January 17th, 2026, hot water was temped at 156 degrees at the hand sink in restorative. And on February 7th, 2026, hot water was temped at 157 degrees at the hand sink in restorative. During this observation, Maintenance Director K was asked what the range should be for hot water temperatures, and initially he stated he didn't know, but then he answered probably around 125-130 degrees. On 03/24/2026 at 1:10pm hot water was temped at 129 degrees F at the bathroom sink located in restorative. On 03/24/2026 at approximately 1:12pm hot water was temped at 136 degrees F at the hand sink in restorative. On 03/24/2026 at approximately 1:16pm interviewed Maintenance Director K on what is the corrective action when the hot water temperatures get too high, and he stated the next step should be to turn down the hot water by adjusting the mixing valves. Then he was asked whether anything was done in response to the high hot water temperatures listed on the hot water temperature log, and he stated that not all of them were turned down and he wasn't sure which ones were corrected. On 03/25/2026 at 9:41am interviewed Maintenance Director K on the range of hot water temperatures and he stated hot water temperatures should be 115 degrees F or below. Pests in Resident Room On 3/25/26 at 12:21 PM, an observation was made in Resident 41's room. The Resident was not present in the room at the time. The observations were made with Nurse Consultant L of a kidney basin on the Residents overbed table that had candy inside partially covered with a soiled washcloth. There were fruit flies/gnats flying around the area of the dish and landing on the items in the kidney basin, on the wall, and the privacy curtain. Five flies were counted. The Nurse Consultant reported that staff would be made aware and taken care of the issue.

Based on observation, interview, and record review, the facility failed to ensure that residents were treated with dignity during incontinence care and that medications were administered in accordance with resident preferences affecting Resident #25 (R25) one of one resident reviewed for incontinence care, and Residents #25 (R25) and #39 (R39) two of two residents reviewed for medication administration preferences.Findings include: R25According to a review of R25's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses including below the knee (BKA) of the left lower extremity (LLE), Diabetes Mellitus type 2 and Polyneuropathy (nerve damage).The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated the resident had intact cognition; Section H. Bowel and bladder indicated R25 was occasionally incontinent.On 03/23/206 at 09:41 AM, During an interview with R25 he said that he did not feel that the night staff did not care, especially when they were agency staff. R25's said that he was incontinent mostly at night and that he wore briefs then and used a mattress pad to protect his bedding. R25 reported that he requested assistance because his brief and mattress pad were both soiled and he was told by the staff 'we can't be changing these pads all the time , we will run out' and that they placed a brief on him and he said it was very uncomfortable for him and it felt like a thong, when he asked for a different larger size he was told 'we ran out of bigger briefs'. It made him feel embarrassed. R25 said that night shift agency nurses were often late with his medications even when he asked to receive them on time.On 03/24/2026 at 02:10 PM during an interview with CNA B she was asked if she ever ran out of incontinence supplies or had complaints from residents, she said if we run out of items on the floor we usually have them in the big supply room in the basement, she said that she had heard of 'night shift not stocking the floor closet or going to the basement for supplies' but she did not have and issue with residents preferences on brief style or size.On 03/24/2026 at 02:12 PM during an interview with CNA C she escorted SA to the basement supply closet, there was ample supply of briefs in sizes from XS - 5XL available. CNAC said that some staff will be lazy and do not go to the basement or restock the supply closet, but they have the overflow of linens and supplies available if they wanted to.On 03/26/26 at 08:15 AM, during an interview with DON she was asked about any complaints from residents about staff, especially at night or agency staff, and she said she had to use agency more than she liked and that it usually was on the night shift. She said she has had complaints and that she had addressed them, she had the scheduler not allow some agency staff back at the facility to work due to complaints on night care. The DON did not specify when asked what the complaints were. The DON was asked about low supply of linens and/or briefs, and she said she has not had any complaints.On 03/26/26 at 09:37 AM, during an interview with Nurse A she was asked about medication pass process, she said after the resident is verified, the meds are pulled and marked as prepped in the system, the medications are given to the resident. Nurse A said that after the resident takes the medication it is then marked as complete. Nurse A said that if the resident is not available, refused etc. there was a drop down to mark why it was not given, she said you should put an additional comment in if you are late as to why. On 03/26/26 at 11:20 AM, during an interview with laundry staff F she was asked about stock of linens, she said they watch the supplies and order something new every month as needed, said last month they got more mattress pads and this month she would order more fitted sheets. She said that there was an overflow cart of clean linens available in the basement where the laundry room was and that staff had access to it even on off shifts and weekends. She said that the laundry staff checked and restocked the floor carts every 2-3 hours from 5 AM to 4 PM otherwise.A record review of R25's medication administration review's (MAR) for Jan revealed 8 PM medications charted over 2 hours late on 1st, 5th, 13th and 14th. February revealed 8 PM medications charted over 1.5 to 2 hours late on 1st,3rd, 9th, 13th, 15th, 16th, 17th, 24th and 25th. March revealed 8 PM medications charted over 1.5 to 3 hours late on 1st,2nd, 3rd, 9th, 15th and 16th. R39According to a review of R39's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses including cellulitis of the left lower limb, dementia, need for assistance with personal care, colostomy, anxiety and depression. The Minimum Data Set (MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 07/15 indicated the resident had severely impaired cognition.On 03/24/2026 at 10:48 AM, during an interview with R39 family member G she said that she felt the night shift was short staffed, and that on more than one occasion R39 had received her medications late on night shift and she preferred that R39 received medications timely due to her health concerns, she said that also made her wonder if other night care was lacking.A record review of R39's medication administration review (MAR) for Jan revealed 8 PM medications charted over 2 hours late on 5th, 13th,14th, 19th, 20th, 21st, 26th, 27th, 28th. February revealed 8 PM medications charted over 1 to 2 hours late on 2nd,3rd, 4th, 9th, 15th 16th, 17th, 24th and 25th. and March revealed 8 PM medications charted over 1 to 3 hours late on 1st,2nd, 3rd, 9th, 15th, 16th, 22nd, 23rd, and 25th.According to a Record review of the facilities policy titled Promoting/Maintain Resident Dignity indicated: policy; It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances residence quality of life by recognizing each resident's individuality. with Guidelines: 1. Staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents rights. 4. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the residents' needs and preferences. 5. When interacting with a resident, pay attention to the resident as an individual. 6. Respond to requested for assistance in a timely manner. 9. Groom and dress residents according to their preferences. 10. Speak respectfully to residents.According to a record review of the facilities medication administration policy: Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. with Policy explanation . 3. identify resident by photo in the MAR; 10. Ensure that the six rights of med administration are followed: a. right resident; b. right drug; s. right dosage; d. right route; e. right time; f. right documentation.; 12. Compare medication . b. Administer within 60 minutes prior to or after the scheduled time unless otherwise ordered by physician .; 18. Observe the resident consumption of medication.; 20. Sign the MAR after administration .

Based on observation, interview and record review, the facility failed to document an assessment and monitor open areas on the foot and ensure medical records were accessible in the electronic medical record per professional standards of care for one Resident (41) of one reviewed for skin conditions non-pressure related.Findings include:Resident #41: On 3/24/26 at 10:03 AM, an interview was conducted with Resident 41 (R41) who answered questions and engaged in conversation. The Resident was lying in bed with the head of the bed elevated with a sheet covering her with feet and lower legs not covered by the cover. An observation was made of multiple blackened, scabbed area on her toes with feet and ankles swollen. The areas on the left foot were asked about, and the Resident reported the areas were turning black and did not know why. A review of Resident 41's medical record revealed an admission into the facility on 2/28/18 with readmission on [DATE] with diagnoses that included heart failure, obesity, Cellulitis of lower limb, anxiety and chronic obstructive pulmonary disease. A review of R41's care plan revealed a focus: Problem Start Date: 04/17/2020 I have hx (history) of open area on right shin and recurring cellulitis. I continue to pick the area. I also pick at my hands/arms. I can have fungal dermatitis/ulcers to toes on my BL (bilat) feet/ankles. I sometimes get Bollous Pemphigoids. A review of the electronic medical record revealed a lack of documentation of the wounds on the toes of R41. There were no orders for treatments to the wounds on the feet. On 3/25/26 at 1:22 PM, an interview was conducted with the Director of Nursing (DON) regarding blackened and scabbed areas on the Resident toes. The DON reported that the Resident will pick at their skin and that it was care planned that she does that. The DON was asked if the Resident was making wounds on her feet, where would the Nurses document assessments. Even though she was care planned, once wounds are present, should they be assessed, monitored and treated? The DON reported that there might be skin assessments but looking at the medical record on the computer, there were no recent skin assessments uploaded in the EMR. Last month's skin assessments were requested and the DON reported she would have someone look for them and indicated Medical Records might have them. On 3/25/26 at 1:24 PM, an interview was conducted with Medical Records/Business Office Staff (MR) E regarding the head to toe skin assessments/shower sheets for R41. MR E reported multiple areas where the documentation might be located. An observation was made with the staff of an area by the door, she indicated when the DON was done with them, they go in that area. The Staff reported that they had to be scanned in and uploaded into the medical record. Office Staff N was also in the room and reported she would get them scanned in and the papers requested may not be uploaded yet in the medical record. The Staff started to review scanned in documents and indicated it might take a while to find them, or they could be in a pile of papers to the right of the Staff. MR E reported also having papers that she would look through that were in another area of the office. One document titled Weekly Head to Toe Skin Checks dated 3/6/26 was located for R41. The Medical Records/Office staff indicated getting records into the EMR was an issue and they would continue to look for other Weekly Head to Toe Skin Checks for R41. On 3/25/26 at 1:53 PM, the DON was interviewed regarding R41's wounds to the toes and the lack of documentation in the medical record. The DON reported that they were in the process of setting up to document wounds in the electronic medical record (EMR), but it had not been started, and paper documents were made for wound assessments. The DON was asked for recent wound assessments for the feet. The Resident was not available for an observation of their feet. Documentation of the Weekly Head to Toe Skin Checks that were found included dated documents for 2/24, 3/3, 3/6, 3/13, and 3/17. The dated 3/13/26 revealed, Skin Intact area that was not marked as yes or no, but had a description that revealed, open area on coccyx/between thighs and right foot. The diagram had the left foot circled. At 2:55 PM, the DON was asked about the assessment for the open area on the foot and which foot was it, a review of the medical record revealed no documentation of the assessment or treatment of the open area on the foot. The DON reported not doing an assessment herself and indicated that the Nurse Practitioner (NP) might have addressed the wounds of the foot, and the NP comes on Tuesdays and sees the Resident about every other week. The EMR was reviewed and had NP notes of being seen/date of service, dated 10/21/2025 that had been attached on 3/24/26. Two other notes were dated for service provided on 10/7/25 and 9/30/25 which both of those NP notes were attached into the EMR on 3/25/26. The DON was asked if the From Date was the date of service and the Attached Date was when the documents were uploaded, the DON indicated that was correct. When asked if the NP had seen the toes, had an assessment or plan for treatment, the DON reported she would have to find the notes and stated, They would still need to be uploaded into the computer system. When asked if they were readily available, the DON stated, I would have to look for them. It was reviewed with the DON of the concern of not having practitioner notes readily available to review, and with notes from 9/30/25 not uploaded until 3/25/26. The DON stated, I know, it's an issue, and discussed a backload of documents that needed to be scanned into the electronic medical record. On 3/26/26 at 12:30 PM, a review of the paper documents of Wound Evaluation revealed a lack of documentation of the open areas of the foot that had been identified on the Weekly Skin assessment dated [DATE]. A review of the NP M paper notes for a visit on 3/24/26 revealed, Nursing Home Visit: .She has a history of picking at her scabs and toes when bored, leading to bleeding. This occurs both when she is in bed and on the floorboard, and she sometimes kicks her feet, exacerbating the issue. The Assessment & Plan did not document further assessment of the wounds on the feet or a plan for treatment. An observation was made with the DON of Resident 41 with scabbed areas on the toes of her left foot. The DON reported they were keeping them open to air and there was not a treatment for the toes. A review of the facility policy titled, Wound Care revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the wound care was given. 3. Any change in the resident's condition. 4. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 5. Any problems or complaints made by the resident related to the procedure. A review of the facility policy titled, Documentation in Medical Record, revealed, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: .8. Paper documentation shall be scanned into the medical record and uploaded in a timely manner.

Based on observation, interview and record review the facility failed to store nebulizer equipment in a sanitary manner for one resident (Resident 41) of two residents reviewed for respiratory care.Findings include:Resident #41:On 3/24/26 at 10:00 AM, an interview was conducted with Resident 41 (R41) regarding the care received at the facility. The Resident answered questions and engaged in conversation. An observation was made of nebulizer equipment (medical equipment used to administer medication into the respiratory system by turning liquid medication into a mist) stored in a clear plastic bag hanging on the bedside table. The nebulizer was assembled and the medication chamber was moist with droplets. When asked when they had the last breathing treatment, the Resident reported having a treatment yesterday and explained not using it very often. On 3/25/26 at 12:21 PM, an observation was made with Nurse Consultant L of R41's room. The nebulizer equipment was stored inside a bag that hung from the bedside table. The nebulizer apparatus was assembled together, and moisture could be seen within the medication chamber of the nebulizer equipment. On 3/26/25 an interview was conducted with the Director of Nursing (DON) regarding facility policy on the storage of the nebulizer equipment. The DON reported that the nebulizer should be rinsed out after use and set out to air dry prior to storage in the bag. The DON reported that the Resident rarely had breathing treatments administered. A review of the facility policy titled, Nebulizer Therapy, revealed, .Care of the Equipment: 1. Clean after each use. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.

This citation pertains to Intake Number MI00152642 Based on the observation, interview and record review, the facility failed to supervise a group activity of five residents and prevent a resident-to-resident for two residents (Res.#502 and Res. #503) of five residents reviewed for abuse, resulting in a hospital transfer for evaluation and treatment. Findings include: A review of the Facility Incident Report was reviewed on 6/3/25 at 10:30 AM. The facility indicated a resident-to-resident altercation between R502 and R503 occurred on 4/18/25 at 7:32 PM. It happened in the dayroom while playing a game with two other residents. The incident started with an argument between R502 and R503, where they threw beverages at each other and escalated to physical contact. R502 started punching R503, then R503 struck back, hitting R502 in the face. The brawl ended when R503 decided to leave the day room after hitting R502 back. Although the incident was unwitnessed by staff, the event was captured on video and was reviewed by the Administrator the following day. As a result of the resident-to-resident physical altercation, R502 sustained some bruising and laceration on the bridge of her nose, and R503 complained of pain on her eye and left jaw. Both residents were separated after the incident. R502 resides on the main floor (first floor), and R503 resides on the second floor. Both R502 and R503 were transferred to the hospital where they were evaluation and received treatment. A review of records on 5/29/25 at 3:00 PM, revealed that after the physical altercation, R503 received a CT Scan of maxillofacial /brain/ head while at the hospital emergency room due to complaints of jaw and eye pain. R503 also had a scratch on her right arm. The Facility's Incident Report dated 4/18/25, concluded that, after completing the investigation by the Social Services and the Director of Nursing, the facility substantiated a resident-to-resident physical altercation. However, the facility's failure to supervise residents' activity after dinner at around 7:30 PM involving a group of five (5) residents with various levels of cognition in the day room and provide a safe environment free from physical harm was not mentioned as the root cause of the resident-to-resident altercation. According to the Administrator, on 5/29/30 at 3:30 PM, she revealed that staff had not witnessed the incident. The activity was unsupervised. The Administrator indicated she reviewed the video the following morning. She did not find any staff in the day room during the altercation. The incident ended when R503 was seen in the video exiting the dining room. After R503 left the dayroom, both were separated and assessed. R502 sustained a bruise under her right eye and a laceration on the bridge of her nose from her glasses. R503 complained of left eye and jaw pain. Both residents were sent to the hospital for evaluation. R502: Resident #502 (R502), [AGE] years old, was assessed with a Brief Interview of Mental Status (BIMS) Score of 15/15 assessed on (DATE). A score of 15 indicated that R502 was cognitively intact. R502 was admitted to the facility on [DATE] with the diagnosis of Atherosclerotic Heart Disease, Bipolar, and Anxiety Disorder in addition to other diagnoses. R504 is care planned for independent ADLs (Activities of Daily Living) with transfers. Although she ambulates independently all around the first floor, R502 is care planned as a fall risk related to new admission and medication use. The surveyor reviewed R502's hospital discharge documents dated 4/19/25 and residents' statements at the time of the physical altercation on 4/18/2025 on 6/3/25 at 12:00 PM. A brief interview with R502 was conducted on 6/3/25 at 3:45 PM. R503 recalled getting in trouble so many times but did not specify the resident-to-resident altercation. She explained how she got the laceration on her forehead when she fell sometime in May unrelated to the resident -to resident altercation R503: Resident #503 (R503),[AGE] years old, was assessed on 3/1/25, with a BIMS Score of 9/15 on 3/1/2025. A score of 9 means moderately impaired cognition. She was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Type 2 Diabetes Mellitus, and Dementia, in addition to other diagnoses. R503, like R502, was deemed safe to ambulate independently around the facility. R503's hospital discharge documents dated 4/19/25 and the resident's statements at the time of the physical altercation between residents on 4/18/2025 were reviewed. R503 was interviewed briefly on 6/3//25 at 1:30 PM at the dining room. She did not mention anything about the incident related to the resident-to-resident altercation. She did not apear to have bruising or discoloration. She denied any pain at the time of the interview. On 6/3/25 at 11:45 AM, Nurse B was interviewed on the phone. Nurse B revealed that she recalled a resident-to-resident incident in April. Nurse B indicated that she was passing medications after dinner the night it happened. She was the nurse on the first floor, and Nurse H (Nurse's name was mentioned) was on the second floor. There was no other staff in the day room when it happened because the staff was busy with patient care and putting residents to bed. Nurse B stated that R502 hit R503 first and R503 hit R502 hard that R502 ended up with a laceration on the bridge of her nose and bruising on one eye. There was blood coming from R502's nose after R503 punched her in the face. I evaluated R502 immediately because she was my resident on the first floor. R502 was immediately sent to the hospital for further evaluation. R503 lived on the 2nd floor. They were separated, and another nurse, Nurse P, evaluated R503 on the second floor. They were both sent to separate emergency rooms and were sent back the following day after treatment. Nurse B was asked if activities are monitored or supervised, Nurse B stated there are no activities staff after dinner. They all go home. No group activities are scheduled after 5 PM. Residents should not be left unsupervised, and someone should be checking on them. Nurse B recalled that at least four residents were present during the incident on 4/18/25; some had dementia diagnoses, and some had behaviors. The aides were in and out of the residents' rooms. The video camera in the dayroom was reviewed and showed no staff present during the altercation. Nurse H was interviewed on 6/3/25 at 11:22 AM by phone. Nurse H indicated that she worked the afternoon shift and was assigned to the second floor, where R503 stayed that day. Most of the time, R503 goes downstairs to the dayroom to play cards or other activities offered, and R503 enjoys spending time with other residents on the first floor. Nurse H described R503 to be impulsive at times because of her dementia and occasionally gets agitated. Although Nurse H did not see her physically act out, she corrected herself by saying, At least not with me. Nurse H further revealed that R503 was a little snippy verbally sometimes. Nurse H commented, Activities should have been monitoring residents in case there are residents with impulsive behaviors or dementia. Nurse H described evaluating R503 after the physical altercation and recalled that R503 complained of jaw and eye pain when R502 hit her but did not see any obvious bleeding or bruising. R503 was sent to the nearby emergency room to be evaluated appropriately that night. The Administrator indicated on 6/3/25 at 11:30 AM that staff did not witness the incident. The Administrator also revealed that the facility does not have an Activities Director and has now posted the position. When asked what the current plan is, the Administrator stated, There are no activities at night after dinner specified after 5:30 PM. The main dining is closed after dinner so our staff can get residents in bed. We do not have staff to conduct activities after dinner. An interview with the Social Services Director SSD was conducted on 6/3/25 at 3:45 PM. SSD revealed that both residents were receiving behavior care services. R503 has dementia and is taking some antipsychotic medications. Although R502 did not have dementia and her BIMS is 15, she does have some anxiety behaviors. R503 threw liquid on R502, and R502 hit R503 on the face. The SSD had indicated that 4/18/25 She received a call from the facility on 4/18 /25 after the physical altercation occurred because she had to call their families to inform them about the incident and that both residents were sent to the hospital for further evaluation. The SSD stated that the residents should have been supervised during the activities to start with because of mixed dementia and behaviors of residents participating in a group activity. R503's son emphasized that R503 should not have been left unsupervised. Regarding R502, even if her BIMS score is 15, she still needs supervision because of some behaviors. After dinner at 4:30 PM, residents who stay in the day room area for independent activities should be supervised to prevent this. They have not been supervised enough in activities, especially after dinner. After dinner, they are supposed to close the dining room, but some residents prefer to stay and watch television or play games with other residents. However, the staff is busy with other residents and schedules no activities after dinner. When activities staff leave at 5:30, they close the dining room. Sometimes, residents stay out in the hallway to talk to each other, but no activities are scheduled because there are no activities staff to hold and get residents to participate. The facility has been trying to figure it out up to now. It's been over a month. On 6/3/25 at 3:30 PM, the facility's Abuse Policy dated 4/8/23 was reviewed. It indicated that the facility (name of facility specified) will not tolerated Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident's Property. Definitions: .Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .

This citation pertains to Intake Number MI00153237 Based on observation, interview, and record review, the facility failed to follow the standards of practice and physician's order to reduce the methadone dosage administered to one resident (Resident #502) of four residents reviewed for medication errors. Resident 502 received the wrong dosage five times (5/17/25, 5/18/25, 5/19/25, 5/23/25, and 5/24/25), and potentially a second dosage was administered on 5/24/25. Findings include: Resident #502 (R502): R502's Electronic Medical Record (EMR) was reviewed on 6/3/25 at 11:00 AM. R502 was [AGE] years old and admitted to the facility on [DATE], with the diagnosis of Atherosclerotic Heart Disease, Gastro-esophageal Reflux Disease, Altered Mental Status, Major Depressive and Bipolar Disorder in addition to other diagnoses. R502's Brief Interview for Mental Status (BIMS) Score is 15/15, assessed on 4/23/2025. A score of 15 means R502 is cognitively intact. The Minimum Data Set (MDS) revealed that R502 is independent of ambulation, transfers, and mobility. R502 receives trazodone and Xanax for the diagnosis of Anxiety and Depression. R502 also receives Methadone 100 mg (1 tablet) daily for chronic pain as care planned. During a record review of R502's Physician's orders on 6/3/25 at 11:00 AM, it was noted that on 5/16/25, the physician changed the Methadone order to reduce the dosage due to a recent fall sustaining a laceration to her forehead. The change of order form was filled out and was noted as follows: Methadone-Scheduled II Concentrate: 10 mg/ml: amt: 70 mg: oral Frequency: Once A Morning at 6:00 AM Special Instructions: Give 70 mg (7 mL) by mouth every morning A verbal order by R502's primary physician received by the DON on 5/16/25 at 2:02 PM. The Director of Nursing (DON) was interviewed on June 3, 2025, at 1:30 PM. She recalled the change of R502's Methadone dosage order. She admitted that she received a report from staff of a medication error was reported on 5/25/25. The DON provided the surveyor with an Incident Report dated 5/29/25. When asked why it took so long to do the Incident Investigation? Why did the Med Error investigation start on 5/29/25 when the surveyor was already at the facility? The DON stated that the incident was reported to her on 5/25/25, but she couldn't get to it until 5/29/25. The day the surveyor was at the facility. The DON revealed that the nurse who administered the wrong dosage, Nurse C, received an in-service with other nurses and one-on-one counseling on medication errors on 5/29/25. When asked if another nurse made the same error, The DON was unaware of a second nurse who had given the wrong dosage of Methadone to R502 or multiple episodes of an incorrect dosage administered on 5/17, 5/18, and 5/19. She only knew about the 5/23/25. A review of the R502's narcotic log entitled: Controlled drug receipt/Record/Disposition Form was conducted with the DON on 6/3/25 at 1:35 PM. It revealed that despite a written and verbal physician's order to reduce the methadone from 7.5 mL to 7.0 ml daily at 6:00 AM. Two Nurses continued to administer a 7.5 dosage and were not following the most current order given by the physician. The following data was noted: R502 received incorrect dosages on: 5/17/25 R502 received 7.5 mL at 6:00 AM, given by Nurse B 5/18/25 R502 received 7.5 ml at 6:00 AM by Nurse C 5/19/25 R502 received 7.5 ml at 6:00 AM by Nurse C Error continued on 5/23/25 R502 received 7.5 ml at 6:00 AM by Nurse C 5/24/25 R502 received 7.5 ml at 6:00 AM by Nurse C and another entry was noted: 5/24/25 %502 received 7.0 (correct dosage) given by Nurse B A review of R502's Progress Notes dated May 2025 on 6/3/25 at 11>05 AM indicated No physician's progress notes were noted related to the medication errors on 5/17, 5/18, 5/19, 5/23/ & 5/24/2025. Upon further review of R502's Narcotic Log on 6/3/25 at 1:30 PM, the DON further explained that the error on 5/24/25 was that the second entry was on the date. Nurse B made a mistake in putting the correct date, 5/25/25, instead of 5/24/25. The DON was not sure if R502 received two doses on 5/24/25. The DON indicated that Nurse C had signed the Med Error Incident report and received education about the error on 5/29/25. On the other hand, Nurse B, the second nurse who made an error, did not receive in-service educational counseling. The Medication Error Incident report addressed the dates 5/23 and 5/24/25. The medication error filed did not address the dates 5/17, 5/18, and 5/19, which also had a dosage error. The DON revealed she did not know about another set of errors until now. The DON only knew of the 5/24/25 and was unaware that there were six episodes of medication errors, as evidenced by R502's narcotic log. The DON assured the surveyor that Nurse B would receive the appropriate education and counseling for medication administration errors (Med Errors) this week. Nurse B was interviewed by telephone on 6/3/25 at 11:25. She reported the medication errors made for R502 by Nurse C. She denied receiving an in-service education related to medication errors herself. Nurse B denied any mistakes made by her. Nurse D was observed on 6/3/25 at 12:30 PM. When Nurse D was asked to do a narcotic count for R502's controlled medications, Nurse D warned the surveyor that the narcotic count for R502's Xanax would be wrong because she had marked the sheet as given today but was not administered. The Xanax count sheet says 21 tablets left, but found 22 tablets in the blister pack. Nurse D apologized and stated she had not given the medication to R502 but had marked it earlier as given. Nurse D apologized for making the error. In an interview on 6/3/25 at 4:30 PM, the Administrator stated she was unaware of the Med Error and was not informed of any discrepancy with R502's medication. Otherwise, we would have immediately investigated it and brought it to the QA (Quality Assurance) committee. The facility's Policy on Medication Errors, Revised on February 2023, was reviewed on 6/3/25 at 4:00 PM. It indicated: 1. A medication error is defined as the preparation or administration of drugs or biological's that are not in accordance with a physician's order, manufacturer specifications, or accepted professional standards and principles of the professional (s) providing services. 2. Examples of Medication errors include: a. Omission- a drug ordered but not administered. b. Unauthorized drug- a drug is administered without a physician's order. c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given) . 3. A significant medication-related error is defined as: a. Requiring modification, discontinuation, or dose modification. b. Requiring hospitalization or extending a hospitalization. c. Resulting in disability. d. Requiring treatment with a prescription medication. e. Resulting in cognitive deterioration or impairment. f. Life threatening. g. Resulting in death The facility provided a 2-paged medication error policy only for the surveyor to review, but on the bottom of page 2, it noted: continues on next page. The surveyor was not provided with the following pages of the policy. The first two pages did not emphasize the importance of notifying the physician when the Medication error occurred or was discovered. The medication error was not indicated in the progress notes nor when the physician was notified. The facility's Medication Administration Policy was reviewed on 6/3/25 at 4:15 PM. Policy Statement: Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation specified: .4. Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and the right method (route) of administration before giving the medication .

Based on observation, interview and record review, the facility failed to provide two diabetic medications (Jardiance and Januvia (sitagliptin)) timely for one resident (Resident #151) of six residents reviewed for medications. Findings include: Resident #151: On 2/25/25, at 12:42 PM, Resident #151 was in their room. They complained about their sugar levels seemed to be a bit higher than normal. Resident #151 complained they thought they weren't getting enough protein or maybe too much starches since their admission. On 2/25/25, at 2:30 PM, a record review of Resident #151's electronic medical record revealed an admission on 2/21/2025 at 11:43 AM with diagnoses that included Diabetes, Stroke and Transient Ischemic Attack (TIA). Resident #151 was noted to be alert and orientated. A review of the Physician orders revealed the following: Received Date: 02/21/2025 Order Description sitagliptin tablet; 100 mg; amt: 1 tablet; oral . Once A Day 08:00 AM . Give one tablet by mouth once daily for diabetes . Received Date: 02/21/2025 . Jardiance (empagliflozin) tablet; 25 mg; amt: 1 tablet; oral . Once A Day 08:00 AM . Give one tablet by mouth once daily for diabetes . Pharmacy Directive: Substitution Permitted . A review of the Medications Administration History: 02/01/2025 - 02/27/2025 revealed the following: Order Jardiance (empagliflozin) tablet; 25 mg; Amount to Administer: 1 tablet; oral . Start/End Date 02/21/2025 - Open Ended . For the days Sat 22 Sun 23 Mon 24 Tue 25 Wed 26 Thu 27 the nurse initials were surrounded by parenthesis which revealed . Reasons/Comments Not Administered: Drug/Item unavailable . This was documented for 02/22/2025 thru 02/27/2025 which revealed Resident #151 did not receive Jardiance one time from the facility. Order sitagliptin tablet; 100 mg; Amount to Administer: 1 tablet; oral . Start/End Date 02/21/2025 - Open Ended . For the days Sun 23 Mon 24 the nurse initials were surrounded by parenthesis which revealed . Reasons/Comments Not Administered: Drug/Item unavailable . A review of the progress notes revealed 02/22/2025 10:58 AM Spoke with Pharmacy. Will send Jardiance and sitagliptin tonight. signed by Nurse A. On 2/26/25, at 9:00 AM, A review of Resident #151's blood sugar results revealed Search Vitals Results . Blood Sugar revealed since admission of the 10 results 7 were over 200 mg/dL. On 2/26/25, at 10:15 AM, an observation of medication cart along with Nurse A was conducted of the upstairs medication cart. There was bottle of home-brought (Sitagliptin/Januvia) medication for Resident #151 that had a VA label on it. Nurse A offered that his daughter brought that in from home. Nurse A was asked if Resident #151 had Jardiance in their medication supply and Nurse A offered, were still waiting on that one and that they had called the pharmacy over the weekend. Nurse A was asked if they knew why the pharmacy didn't supply the Jardiance and Nurse A offered, maybe they are waiting on an authorization. On 2/26/25, at 2:00 PM, the Director of Nurses (DON) was asked regarding Resident #151's diabetic medications. The DON offered, the pharmacy wanted to send another medication in the place of the one but that because the resident was going to be in the facility short term the DON decided that wouldn't work. The DON explained that they did authorize the medication so now it will be sent. On 2/27/25, at 12:12 PM, a follow up interview with Resident #151, who was in their room, was conducted. Resident #151 complained they were still worried about their sugar levels and thought it might be the food they were offered. Resident #151 was asked if they knew what their sugar levels normally run, and Resident #151 went on to complain that their sugar levels had been a bit higher with some over 200. Resident #151 was asked if they knew the names of their diabetic medications and Resident #151 knew they took 2 tablets of Metformin a day but was unsure of the other ones. Resident #151 offered that they had the pills at home but couldn't remember them all because the stroke they had makes me forgetful and that their daughter helps them out. On 2/27/25, at 12:21 PM, Nurse A was asked if Resident #151's Jardiance had been supplied from the pharmacy and Nurse A offered, they sent the Januvia last night but not the Jardiance. An observation of the pharmacy supplied Januvia revealed a pharmacy supplied cartridge of Januvia. There was no Jardiance housed in the medication cart for Resident #151. A further review of Recent Progress Notes through 02/27/2025 01:14 AM revealed no further progress notes regarding the medications Jardiance nor the sitagliptin. A review of the facility provided Pharmacy Agreement revealed . Pharmacy shall supply the Facility and its residents with FDA approved pharmaceuticals . Deliver of Services . In the event an ordered medication is for any reason unavailable, the Pharmacy shall notify the Facility .

Based on observation, interview and record review, the facility failed to ensure safe narcotic storage and reconciliation for one medication room backup supply. Findings include: On 2/26/25, at 10:00 AM, an observation of the medication room on the first floor was conducted along with Nurse B. The outside door required a key to open which was on the Nurse B key ring. There was a small black refrigerator that was unlocked. Inside the refrigerator was a clear plastic locked box that housed 2 vials of Ativan. Nurse B was asked where on the narcotic reconciliation form do they reconcile the vials of Ativan and Nurse B stated, I don't think we count these. Nurse B pulled out the plastic box which was approximately 10 inches long by 5 inches high and wide. The box was not affixed inside the refrigerator. Nurse B tried their keys on their key ring which did not open the box. Nurse B was asked how many Ativan vials were in the box and Nurse B offered, I think maybe 2 but could be 3 as they were housed inside blue plastic bags and not visible. On 2/26/25, at 9:55 AM, a record review of the narcotic reconciliation booklet housed on medication cart on the first floor revealed no reconciliation form for the Ativan housed in the medication room refrigerator. On 2/26/25, at 10:30 AM, the DON was interviewed regarding the Ativan vials in the refrigerator in the medication room and asked how the facility ensures reconciliation. The DON offered, (pharmacy consultant D) comes in every other week and reconciled the backup medications including the Ativan vials. The DON was asked to provide the pharmacy documentation of the Ativan reconciliation. The DON was asked how the nurses would get the Ativan from the refrigerator and the DON offered, the nurses key should open the box. On 2/26/25, at 10:35 AM, an observation of the medication room refrigerator along with Nurse B and the DON was conducted. The DON opened the unlocked refrigerator and pulled out the plastic box. Nurse B's key ring did not house a key to open the box. Nurse B stated, the key is in the nexys system (pharmacy backup storage machine). The DON offered they would call the pharmacy consultant and inquire on the Ativan reconciliation. On 2/26/25, at 10:50 AM, while on the phone with pharmacy consultant D, the DON entered the medication room, logged into the nexys (backup machine) and was able to obtain the key for the lock box of Ativan vials. The DON opened the box and counted 2 vials of Ativan, locked the box and replaced it back into the refrigerator. The DON was asked again for any documentation the pharmacy consultant could provide that ensures the Ativan had been reconciled and to provide the narcotic reconciliation procedure. On 2/27/25, at 10:00 AM, the DON offered that the pharmacy consultant could not run a reconciliation report for just the one facility. On 2/27/25, at 2:05 PM, an observation of the medication room refrigerator along with Nurse C was conducted. Nurse C removed the box from the refrigerator and offered, we used to count it on our sheets but now the key is locked in the nexys. Prior to exit, the facility did not provide any reconciliation documentation that ensured the Ativan vials had been reconciled. A review of the facility provided Controlled Substances Revised February 2023 revealed The facility complied with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up . Storing Controlled Substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected . 12. Some controlled substances may be stored in the emergency medication supply. Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services .

Based on observation, interview, and record review, the facility failed to assess and monitor weights and ensure that interventions to promote nutrition and prevent weight loss were in place for two residents (R#19 and R#37) of four sampled residents reviewed for food and nutrition. Findings include: Resident #19 (R19): Nutrition According to a review of the Electronic Medical Records on 2/27/25 at 2:18 PM, R19 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease, Adult Failure to Thrive and Malignant Neoplasm of Prostate in addition to other diagnoses. R19 Brief Interview for Mental Status (BIMS) score was zero (0/15) assessed on 12/04/2024. A score of zero means severe cognitive impairment. R19's GG section revealed that R19 required substantial/maximum assistance with eating, which means the helper assistant does half the effort to complete the task. R19's GG (Functional assessment) indicated that he depended on staff to perform most activities of daily living (ADL's), such as personal hygiene, toileting, showers, and upper and lower body dressing, and was always incontinent with bowel and bladder elimination patterns. R19's weight record and calculations were reviewed on 02/27/25 at 02:38 PM, and R19's weight was recorded at 124.4 pounds on 2/26/25. According to weight calculations: > On 11/09/2024, the resident weighed 133.4 lbs. On 02/26/2025, the resident weighed 124.4 pounds, which is a -6.75 % Loss in 3 months. >On 09/04/2024, the resident weighed 147.2 lbs. On 02/26/2025, the resident weighed 124.4 pounds, which is a -15.49 % Loss in 6 months. The following were recorded weights taken by the facility: 9/4/2024 147.2 pounds (lbs.) BMI:24.49 10/11/2024 138.6 lbs. BMI 22.2 11/9/2024 133.4 lbs. BMI 22.2 12/4/2024 129.2 lbs. BMI 21.5 01/07/2025 129 lbs. BMI 21.5 02/11/2025 121.8 lbs. BMI 2027 The Dietary Progress notes reviewed on 2/27/25 at 2:00 PM confirmed that R19 had a significant weight loss on December 20, 2024, and February 27, 2025 (during the survey). The RD, on 12/20/24, recommended increasing house shake supplements to four times(4 X) daily instead of TID (3 X a day), adding a shake at HS, and continuing to monitor R19. R19, according to the supplemental record, did not receive supplements 4 times a day. The recommendation of increasing the house shakes to 4 times on December 20, 2024, was not followed. R19's Intake/Supplement Record in February 2025 revealed: February 2025 Supplemental Intake Monitoring Log showed NO ENTRIES (BLANK) on: 2/10/25 at 12:00 PM Blank 2/24/25 at 12:00 PM Blank 2/27/25 at 12:00 PM Blank The Food Acceptance Record for R19 was reviewed on 2/27/25 at 2:15 PM. R19's daily food acceptance was not monitored or recorded daily. The surveyor asked the DON on 2/27/25 at 2:30 PM what it meant when the box was blank. The DON stated that it meant either the supplement was not given or recorded. The DON indicated that not all residents' food acceptance is monitored or recorded automatically. She further explained, It is only if it triggers it! such as significant weight loss or, if indicated, a dietician recommendation or MD orders. The DON confirmed that the facility did not have a consistent documented record to monitor R19's food intake and supplements. A physician's order was noted on 2/26/25 at 2:00 PM, and it was specified that the House Shakes TID with meals record the amount consumed. There was no accurate and consistent monitoring of food intake and supplements recorded/documented for R19. The Registered Dietician's recommendation for R19 dated 12/20/24, for an increase in the supplement (house shakes) to 4 times as recommended in December 2024, was not implemented, and meanwhile, R19's weights continued to decline. R19's Alteration in Nutrition Care Plan was reviewed on 2/27/25 at 2:30 PM. Goal: I will be free from signs and symptoms of malnutrition and dehydration through the next review date. Approach Start Date: 6/26/25 Specified: 1. Encourage and record intake of food and fluids. Monitor and record output. 2. Monitor for signs and symptoms of malnutrition. 3. Monitor/record weight 4. Report and document if I leave 25% or more food uneaten. 5. R19 Short-Term Target Date was 12/17/2024. No updated follow-up of the care plan and revision was found. Resident # 37 (R37): Nutrition During Dining Observation conducted on 2/27/25 from 11:45 AM to 12:30 PM, The Lunch meal trays were delivered late, between 12:00 PM to 12:30 PM instead of 11:30-11:45 AM per the posted Lunch delivery schedule. as confirmed by the Director of Nursing and residents did not receive their trays timely. The facility meal times policy revealed that lunch is served between 11:30 and 11:45 AM. There were 13 residents in the dining area, with staff waiting for the resident's cart to arrive in the dining area. The cart arrived at 12:00 PM from the kitchen. Staff distributed the trays to other residents while R#37 kept wandering around the dining room ambulating in her wheelchair and was redirected by staff to return to her spot twice. A few minutes later, R37's tray arrived. The DON explained on 2/27/25 at 12:30 PM that there was a misunderstanding in the kitchen, and they delivered it to his room instead of sending it to the cart for dining room residents. The surveyor observed R#47's tray delivered to him at 12:31 PM. The posted meal times per facility were 11:30 AM to 11:45 AM, and the three trays were delivered late at 12:22 PM (R#5), 12:24 PM (R#37), and R#47 arrived at 12:31 PM. Weight: R37 had a BIMS Score of 15/15 assessment done on 1/23/25. A perfect score of 15 indicates that the person is cognitively intact. R 37 was admitted to the facility on [DATE], with a diagnosis of Dementia, GERD (Gastro Esophageal Reflux Disease), Difficulty Walking, and a History of NSTEMI (Non-ST-Elevation Myocardial Infarction), in addition to other Diagnoses. R37's Functional Assessment (Section GG of the Minimum Data Set) dated 1/23/25 revealed no assistance needed for eating but partial assistance from staff during ADL's (Activities of Daily Living) such as grooming, personal hygiene, and dressing. R37 did not have a weight found in the admission record. No records of R37's food acceptance record and supplements were found in her clinical record during the review. The Director of Nursing DON later confirmed that they failed to measure R37's weight when she was admitted in January 2025. During an interview with R#37 on 02/27/25 at 02:45 PM. R#37 revealed that she was not happy with her weight. She expressed that she only weighs 135 typically and did not get weighed at the facility. During dining room observation conducted on 02/27/2025 at 11:45 AM, R37's tray was delivered late for almost an hour. An interview with the Director of Nursing (DON) was conducted on 02/27/25 at 02:56 PM. The DON confirmed that R#37 did not have a record of initial/baseline weight taken upon admission on 1/16/25. They did not have any weight taken at the first of the month. She stated, It was apparently missed. The Director of Nursing reported that neither Food nor Fluid Acceptance Records were found in the R37 clinical record. According to the DON, There should be an admission weight for every newly admitted resident and a follow-up weight every first of the month unless weekly weights are triggered. Although we did not require a food acceptance record for everyone, it is just for those who trigger it. One of the triggers is significant weight loss or suspected weight loss. R37's Nutrition Care Plan was reviewed on 2/27/25 at 2:15 PM. No nutrition, weight, or eating problem was in her care plan. Nutritional Assessment Policy Revised in 2/2023 was reviewed on 2/27/25 at 2:30 PM. Policy: Resident weights are recorded and monitored at least monthly . PROCEDURES: 1. Admission height and weight are to be obtained by nursing staff within 24 hours of admission and recorded on the nursing admission assessment. 2. Nursing staff weighs and records residents' weights each month by the 7th of the month. Weekly weights are obtained on those residents within the first 4 weeks of admission and those residents deemed appropriate per the assessment of the dietician, dietary manager, physician or as an outcome of the NAR meeting .

Based on observation, interview and record review, the facility failed to ensure a timely meal pass for three residents (R#5, R#37 and R#47) of 13 residents at the main dining area observed during lunch. FACILITY A dining observation was conducted on 02/27/25 at 11:45 AM to 12:30 PM. The facility meal times policy revealed: Lunch are served between 11:30 and 11:45 AM. There were 12 residents in the dining area with staff waiting for resident's cart to arrive in the dining area. The cart arrived at 12:00 PM from the kitchen. Staff distributed the trays to residents and started setting up and assisting other residents that required feeding. There were three residents R#5, R#37 and R#47 observed without a meal tray while others started eating. At 12:20 PM, The three residents trays have not arrived. R#47 was restless and become loud stating that his tray came late last night and often comes late. While R#37 kept wandering around the dining room ambulating in her wheelchair and was redirected by staff to return back to her spot twice. R#5 remained calm and quiet but looked bored. The Director of Nursing (DON) entered the dining room at 12:22 PM carrying R#37 lunch tray. A few minutes later R#37's tray arrived. At 12:26 PM, R#47 tray did not arrive yet. R47 continued to verbalized where his tray at, that he was starving and that his tray was late last night for dinner. As the surveyor went out of the dining room, at 12:30 PM, the DON was approaching the dining room carrying the last tray and explained that it is R#47 lunch tray. The DON further indicated that there was a misunderstanding in the kitchen that they delivered it to his room instead of sending them to the cart for dining room residents. The surveyor observed R#47's tray delivered to him at 12:31 PM. The posted meal times per facility was 11:30- 11:45 AM and the three trays were delivered late at 12:22 PM (R#5), 12:24 PM (R#37), and R#47 arrived at 12:31 PM. Interview with the Director of Nursing (DON) was conducted on 02/27/25 at 02:53 PM. The DON confirmed that three residents' trays were delivered late for R#5, R#37, and R#47. The Meal Distribution Policy revised on 2/2023, was reviewed on 2/27/25 at 3:00 PM. Policy Statement: Meals are transported to the dining locations in the manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Procedures .4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 5. For point-of-serving dining, the Dining Services Department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident /patient. 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining .

Based on observation, interview and record review, the facility failed to serve, store, and prepare food under sanitary conditions in the facility kitchen, resulting in the increased potential for foodborne illness. This deficient practice had the potential to affect all residents who ate meals prepared by the facility out of a census of 43 residents residing in the facility. Findings include: An initial tour observation of the kitchen was conducted with the Dietary Cook (Staff B) on 1/4/2024 at 09:30 AM. The following items were observed: -The Cook's Refrigerator #1 had a temperature log filled out on 1/4/24 current date. The inside thermometer reading was 34 degrees Fahrenheit. The following items were found inside Refrigerator#1: -A container of cooked scrambled eggs, uncovered and not labeled. Staff B identified the container as scrambled eggs leftovers from breakfast meal but was not labeled. Staff B indicated that the label should include the name of the product, the date prepared and the use by date. -A container identified as containing (ground) turkey unlabeled, undated and no use by (UB) date. -A container of (pureed) turkey-unlabeled and undated. -A whole can of Marinara sauce 6 lbs. and 8 ounces opened with a spoon ladle placed inside the can without an open and no UB date. Staff B revealed that they used the sauce to prepare the pizza for lunch and did not have time to put it in the proper container and labeled. -A labeled container of chocolate pudding with a UB date: 1/1/24. -A container labeled cooked rice with a UB date: 1/3 -A container was identified by Staff B as cherry pie filling -not labeled with no open date and no UB date. -Two cups containing unlabeled soup, each covered with a small dish plate (saucer). Staff B confirmed it was unlabeled chicken noodle soup saved for the two residents, specifically requesting it for lunch. -A labeled container identified by Staff B as cranberry sauce with a written UB date: 1/3. Other foods found in the refrigerator#1 were: -A block of Swiss cheese with a UB date of 12/31. -A bag #1 of sausage patties (cooked) with a UB date: 12/29. -A bag #2 of sausage patties (cooked) with a UB date: 1/1. -A bag identified by Staff B as cooked diced chicken with a UB date: 1/1. -A container identified by Staff B as grilled cheese sandwiches with a UB date of 1/3. -A container of cooked pork with a UB date of 12/29. -A container of cooked brisket identified by Staff B was unlabeled with no UB date. -A bag of cooked sausage patties was unlabeled with no UB date. -A container labeled as Shredded ham with a UB date: 1/3/24. All these foods were found inside Cook's Refrigerator #1 and were validated by Staff B by removing the items from the refrigerator to be discarded. The kitchen observation continued on 1/04/24 at 9:50 AM with Staff B. The Drink Cooler (Refrigerator #2) is the facility's designated beverage refrigerator. The thermometer found inside Refrigerator #2 was 40 degrees Fahrenheit. It contained V-8 beverages, gallon milk jugs, individually packed protein shakes, and fruit juices. The following were observed: -Fruit juice in a pitcher was found inside Refrigerator #2 with a label UB 12/31/23. -A gallon bag of sausage links unlabeled with no UB date. -A gallon bag of Fruits in syrup unlabeled with no UB date. - A half-consumed 20 fluid-ounce bottle of Sprite (soda). When queried, Staff B explained that the Drink Cooler (Refrigerator #2) should only store the drinks and refreshments for residents. Someone must have put their personal food and drink in here. A half-consumed sprite should not be placed in the resident's beverage refrigerator. There should be no food items (for staff) in the Drink Cooler. On 1/4/24 at 10:00 AM, the kitchen observation tour continued to the basement where the pantry stored dry goods, nine (9) refrigerators and freezers, and one (1) employees only refrigerator: Inside freezer #3, it was observed that there were: -One box of bacon unwrapped (not sealed) without a non-permeable/non-absorbable protective covering that was found inside a box covered with dried blood spatters. -Ground beef in a plastic sealed packaging was frozen but noted to have frozen dried blood that came out from one side of the packaging seal. The box of bacon and the ground beef were removed from Freezer #3 by Staff B who stated, This will be tossed (discarded) due to potential for contamination. The tour observation with StaffB ended 01/04/24 at 10:28 AM. A review of the facility policy was conducted on 1/9/2024 at 3:00 PM. According to the facility policy entitled: Food: Cold Storage (Revised date 2/2023), revealed, Policy Statement: All/Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures . 5.) All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . According to USDA Food Safety and Inspection Service (fsis.usda.gov), their publication last updated July 31, 2020, recommended: Wrap Leftovers Well. Cover leftovers, wrap them in airtight packaging, or seal them in storage containers. These practices help keep bacteria out, retain moisture, and prevent leftovers from picking up odors from other food in the refrigerator .Store Leftovers safely. Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months .

This Citation pertains, in part, to Intake Number MI00141874. Based on observation, interview and record review, the facility failed to: (1.) Identify 'purple bag syndrome' for Resident #8, (2.) Keep catheter & tubing on the floor, (3.) Practice hand hygiene with medication pass, (4.) Initiate surveillance of facility monitoring of laundry hot water temperatures, (5.) Prevent overflow of trash receptacles in Transmission Based Precaution rooms, and (6.) Follow up on employee health call-ins, resulting in the likelihood for cross contamination with fingers in the med bottles, overflow of trash receptacles with no lids, low water temperature in laundry services, and cross contamination of urinary catheter, and the spread of illness from employees to residents with likelihood for prolonged illness and/or hospitalization . Findings include: Record review of the facility 'Policies and Practices-Infection Control' policy revision date 10/2018, pages 24-25, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Record review of the facility 'Surveillance for Infections' Infection Control Policy and Procedure Manual revision date 9/2017 revealed that the infection preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAI) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. (1.) Purple Bag Syndrome: Resident #8: Observation and interview on 01/04/24 at 02:12 PM with Resident #8 revealed a urinary catheter size 16 French, tubing and catheter collection bag are purple/blue in color. Resident #8 stated that he has had the catheter for 6 months and it has not been changed. There was no leg strap noted to hold the catheter in place. Observation on 01/05/24 throughout the day revealed that Resident #8 had the urinary catheter with tubing and collection bag of the purple/blue color. Observation of the bag revealed that the staff had emptied the collection bag. Observation and interview on 01/08/24 at 09:18 AM the state surveyor requested that the Registered Nurse (RN) K infection control nurse to tour Resident #8's room. While standing at the bedside of Resident #8 with the state surveyor, RN K observed the resident urinary catheter bag and tubing on the floor of the resident's room. RN K acknowledged that cross contamination from the floor was a concern. The state surveyor inquired how long had Resident #8 had purple bag/catheter syndrome. RN K stated that she was not aware that the resident had purple bag/catheter syndrome and was not familiar with that. RN K stated that no not normal to be color purple. The state surveyor wanted to know how long the urinary catheter bag has had been purple, and when was the last catheter changed. There was no catheter strap last or this week. RN K stated that she would have to do some digging to get the answers. In an interview on 01/08/24 at 11:21 AM with Registered Nurse (RN) K infection control nurse stated that she had called the doctor, and he has never heard of purple bag syndrome, he wants to come in tomorrow morning and look at the bag himself. Lab will come in the morning to draw labs for Urinary Tract Infection. Resident #8's last labs were in November 2023 that were blood samples not urinary. record review of Resident #8's electronic medical record for a six month look back revealed change of urinary catheter was July 2023 and there were no mention/notes of the Purple Bag/catheter syndrome. Record review of physician notes revealed that there was no mention of the urinary catheter of abnormal color/purple and there was no follow-up or concern related to urinary catheter noted. In an interview on 01/09/24 at 09:45 AM with Registered Nurse (RN) K infection control nurse stated that Resident #8's urinary catheter was replaced on July 20th, 2023, and that the catheter was replaced twice on that day because the resident kept pulling the catheter out. RN K acknowledged that Resident #8's urinary catheter had not been replaced until yesterday (1/8/2024). RN K stated that there were PRN orders for the catheter to be changed, but when it turned purple, she was not notified until the state survey identified the purple bag syndrome. (2.) Urinary catheter on floor: Record review of Resident #8's Care plans pages 1-22 revealed that the resident had an indwelling urinary catheter care plan with up dated 10/2022 with interventions of: make sure the bag is hanging and kept off the floor at the level below my bladder. I will sometimes place it on the floor so check periodically to make sure it is off the floor. Observe for signs/symptoms of urinary tract infection, such as bladder spasms, pain, blood in urine, odor, cloudy urine, and notify physician. Observation and interview on 01/08/24 at 09:18 AM the state surveyor requested that the Registered Nurse (RN) K infection control nurse to tour Resident #8's room. While standing at the bedside of Resident #8 with the state surveyor, RN K observed the resident urinary catheter bag and tubing on the floor of the resident's room. RN K acknowledged that cross contamination from the floor was a concern. The state surveyor inquired how long had Resident #8 had purple bag/catheter syndrome. RN K stated that she was not aware that the resident had purple bag/catheter syndrome and was not familiar with that. RN K stated that no not normal to be color purple. The state surveyor wanted to know how long the urinary catheter bag has had been purple, and when was the last catheter changed. There was no catheter strap last or this week. RN K stated that she would have to do some digging to get the answers. (3.) Hand Hygiene with medication administration: Record review of the facility 'Hand hygiene' policy dated 9/21/2023 revealed all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene table indicated hand hygiene between resident contacts, before and after removing personal protective equipment, including gloves, before preparing or handling medications, before and after performing care to residents in isolation. Observation on 01/05/24 at 07:02 AM of the off going Registered Nurse Q and the oncoming Registered Nurse (RN) M were at the first-floor medication cart and performed narcotic count with RN M noted to touch each punch card to count shift to shift narcotic count performed in front of surveyor. RN M locked the drawer and put the keys into her sweater pocket over her uniform. RN M then started her medication administrations. Observation of medication administration on 01/05/24 at 07:22 AM with RN M of both residents in room [ROOM NUMBER] who both were in Transmission Based Precautions (TBP), the nurse prepared both residents medications at the same time and wrote bed numbers on the clear medication cups, walked to the room and applied gown and gloves. Resident #8 bed 109-1 received his medications from the nurse, the nurse picked up the water glass and assisted the resident to a sitting position. Nurse M then turned to the roommate and used same glove between resident administrations, did not perform hand hygiene after administering medications, returned to the medication cart went on to the next resident. Observation of medication administration on 01/05/24 at 08:47 AM with Licensed Practical Nurse (LPN) N of Resident #27's medication prep/set-up revealed that the LPN N placed her right index finger into the senna multi-dose bottle to get one tablet out of the bottle with no gloves on. In an interview on 01/08/24 at 02:55 PM with the Director of Nursing the state surveyor explained that during medication pass the downstairs nurse M put her left-hand index finger into the senna bottle and flicked a tablet out of the bottle into the cup, no gloves were used. Surveyor explained that the upstairs nurse N also placed her right index finger into the senna bottle for Resident #27 to get a single tablet out of the bottle with no gloves on. (4.) Laundry service water temperature monitoring: Record review of the facility provided 'Laundry and Bedding, soiled' Nursing Services Policy and Procedure Manual for Long Term-Care revision date 9/2022 revealed soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Onsite Laundry Processing: (#10.) Laundry processing in hot water temperatures is 160-degree Fahrenheit (71 degree Celsius) for 25 minutes. Observation of the on-site laundry department on 01/08/24 at 01:27 PM with Registered Nurse/Infection Control Preventionist K and the laundry tech U revealed that the laundry process is the dirty laundry comes down in bags or a barrel, goes to the dirty side. Once sorted comes across the hall to the clean side to the washers. Observation of the Dryer vents observed and clean of lint. Washing process was reviewed: Laundry tech U when asked about water temperature for sanitation/infection control revealed that the facility only had the two (2) washers and the temp reading on the machine #1 has no temperature reading it been broken for 6 months. The repairman came 6 months ago and that's what he stated it has not been working. Observation of the Machine #1 temp reading was blank, no reading. Observation of Machine #2 temp is 95 degrees. Laundry tech U stated that the machine usually temp at 130 degrees. Observation of the chemicals used with hoses directly to the washers included: de-stainer, suds laundry detergent, laundry breaker, and a softener agent. In an interview on 01/08/24 at 01:35 PM with Registered Nurse K Infection Control nurse revealed that she tours the area but, looks at items on the floor, but I do not push any buttons. she did not know that the water temperatures were not over 130 degrees. Observation and interview on 01/08/24 at 01:43 PM with Maintenance Director C revealed that the facility checked the water lines to the washing machines with a handheld Dual [NAME] 30 laser thermometer. There were no washing machine water temperature logs when requested by the state surveyor. There was no facility rounding documents found from January through October 2023 when requested by the surveyor during the survey. In November 2023 Registered Nurse K initiated rounding by departments from the manager's not by actually performing a physical round. The RN K presented a 15-minute check sheet that each manager takes 15 minutes and walks through the facility to ensure that staff are performing their duties. On 01/08/24 around 3:00 PM the Maintenance Director C presented the state surveyor with a photo of the wash machine screen that he temped on the hot water cycle at 127 degrees Fahrenheit. Record review on 01/08/24 at 03:20 PM with Registered Nurse K Infection Control Nurse reviewed the facility laundry processing policy with the state surveyor that revealed washing water temperature is to be 160 degrees in hot water. In an interview and record review on 01/08/24 at 03:23 PM with the Director of Nursing was notified that the surveyor took the Infection Control nurse to the laundry service area and checked the water temperatures with the maintenance director and laundry tech of the washing machine #1 with a broken water temperature reader and of washing machine #2 with water temperature of less than 130 degrees Fahrenheit. Maintenance Director C took a photo of the washer temp in hot cycle of 127 degrees Fahrenheit. The DON reviewed the laundry policy which stated 160 degrees Fahrenheit. In an interview on 01/09/24 at 08:21 AM with the Maintenance director revealed the facility was having (Company name) Laundry service, we have de-Stainer, suds laundry detergent, laundry breaker, and a softener. There is No Ozone used here at this facility. The chemicals, we don't know about, we are looking at the different types and have call out to [NAME] laundry chemicals and reach out ask what to use. (5.) Overflow Trash receptacles: Record review of the facility 'Surveillance for Infections' Infection Control Policy and Procedure Manual revision date 9/2017 revealed that the infection preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAI's) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. Observation on 01/04/24 at 10:15 AM of both first floor and second floor Transmission Based Precaution (TBP) resident rooms with positive COVID noted that there were no large trash receptacles noted in resident rooms with lids. Observed at resident's bedside were small 2-gallon black trash cans with clear plastic bag liners noted in resident rooms. There were no larger trash cans noted in the rooms for TBP gowns, gloves, mask, etc. noted in the rooms. Observations on 01/05/24 at 7:18 AM during the medication pass task on first floor revealed rooms that there were in Transmission Based Precaution with noted signage on doors revealed larger estimated 13-gallon size open topped trash cans with red biohazard bag liners, there were no lids, and some were noted to be overflowing with gowns, gloves, etc . Registered Nurse (RN) M stated that those will be collected by housekeeping when they clean the rooms later in the day. Observation and interview on 01/05/24 at 9:45 AM with the Director of Nursing (DON) went on tour of the first floor COVID positive room and observed with the surveyor that there was larger trash estimated 13-gallon size receptacle with red biohazard bag liner's that had no top on the trash receptacles next to the door with gowns and gloves noted in the trash receptacles. The DON agreed with the surveyor that there should be a lid on the trash cans to contain the organisms to stop cross contamination from spreading. Observation and interview on 01/05/24 at 10:32 AM with housekeeping staff O and P were observed with a rolling cart full of trash can lids stacked up in the first-floor hallway entering rooms with the lids. Housekeeping staff O and P stated that they were placing the lids on the trash cans in resident rooms because they were told to do so by management. (6.) Employee Health: Request for Employee health/illness follow-up policy was done on 1/5/2024 and again on 1/8/2024 with no policy received. In an interview on 01/08/24 at 02:18 PM with Registered Nurse K Infection Control nurse the state surveyor requested employee illness call-in sheets to review. RN K stated she not getting the call-in sheets until mid-December 2023, they were going to human resource person for attendance recording and not getting passed on to the infection control nurse. RN K started to get the call-in sheets in December 2023. Record review of the November employee call-in log identified staff with nausea/vomiting, diagnosis. RN K was not aware until the QA meeting in December for the November data. RN K revealed that she had recently started to call back/follow-up with employees on the positive COVID results with staff on day 5 of the outbreak. RN K stated that the COVID-19 outbreak started 12/28/23 was first day staff and residents started to test positive. It was after the holidays/Christmas. We had family/visitor/community members and school kids/ church people/ dancing senior ladies, Elivs impersonator had all been in the building prior to the outbreak. Residents had a lot of exposure to the public. The facility had a total of 22 positive residents and 22 positive staff. RN K stated that the NIHN weekly reporting is still done by the former Infection Control nurse, that was the only infection control task that she performed. RN K started the weekly reporting during outbreak status. Communicable disease is also reported.

Based on observation, interview, and record review, the facility failed to label opened, used, multi-dose medications with opened dates for four residents (Resident #12, Resident #21, Resident #30, Resident #50), resulting in the likelihood for residents to receive medications with altered efficiency and potency. Findings include: Record review of the facility 'Administering Medication' policy dated 4/2019, pages 5 through 7, revealed medications are administered in a safe and timely manner, and as prescribed. (#12.) The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. (#25.) Staff follows established facility infection control procedures (e.g., handwashing) for the administration of medications. Record review of the facility 'Medication Labeling and Storage' policy dated 2/2023, pages 28-29, revealed that the facility stores all medications and biological's in locked compartments under proper temperature, humidity, and light control. (#5.) Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. In an observation and interview on 01/04/24 at 10:04 AM, Licensed Practical Nurse R stated that she was done administering medication. Observation of the first-floor medication cart revealed that the laptop screen was open. An observation and interview on 01/04/24 at 01:05 PM with Registered Nurse S of the 100-hall cart noted undated opened medications: -Resident #12 had an Advair discus 250/50 one puff/inhalation twice daily 8:00 AM and 8:00 PM used with no open date found on container and a multi-pack of Albuterol Neb 0.63 mg 3 ml ampoules packet of 5 with 2 left in foil packet open with no open date noted on the foil packet. -Resident #13 had Flonase 50 mcg nasal spray multi-dose container was used and there was no open date noted on the container. -Resident #21 had Flonase nasal spray multi-dose 50 mcg nasal spray was used and there was no open date noted on the container. -Resident #30 had a Ventolin Inhaler aerosol, two puffs three times daily, the Ventolin multi-dose inhaler was used with no open date noted on the container. -Resident #50 had a Breztri 160 mcg/9 mcg/4.8 mcg aerosphere inhaler, two puffs twice daily. The multi-dose inhaler was used with no open date noted on the container. Registered Nurse S stated that she had checked the medication cart before she had time off for vacation. On 01/04/24 at 01:31 PM the state surveyor requested the medication policy for dating open multi-dose medications.

Based on interview and record review, the facility failed to maintain documentation per facility policy requiring a current cardiopulmonary resuscitation or CPR Certification for one (1) of five (5) nurses reviewed for Licensure and Credentialing resulting in a potential delay involving monitoring residents and the performance of timely emergency response to basic cardiopulmonary resuscitation protocols. This deficient practice affects residents residing in the facility that may require CPR. Findings include: A list of employees was given to the facility Human Resource Staff D on [DATE] at 10:30 AM to review the staff annual training, credentialing, licensure and certification. On [DATE] at 3:45 PM, five licensed nurses were reviewed for credentialing and verification of licensure. One (RN Q) of five (5) nurses reviewed had an expired CPR certification issued on [DATE] and renew by date of ,d+[DATE]. Human Resources Staff D on [DATE] at 12:00 PM stated that all nurses are required to have a current BLS certificate in their file. It is part of employment requirement and we have held classes on site to provide recertification. When asked about RN Q's proof of current CPR certification, HR D stated, we don't have her current CPR Certificate. The Director of Nursing (DON) on [DATE] at 2:30 PM, indicated that they had a class in June last year (2023) and RN Q was in the class. When the DON was requested to provide proof of training such as CPR Class attendance sheet, proof of training completion or testing result scores, the DON was unable to provide the document upon time survey was completed and exited. The Administrator on [DATE] at 2:16 PM revealed that they have reached out to the CPR training agency and to American Heart Association via phone, text and email. The Administrator reported the CPR training agency used was no longer in business. There was no CPR certificate for RN Q received upon exit of the survey. On [DATE] at 12:30 PM, the surveyor reviewed the policy entitled, License Nurse Credentialing and License Verification. It revealed, It is the policy of this facility that all licensed nurses (RN/LPN) have their credentials and license verified upon initial employment and annually thereafter during the term of employment .7.) The following documentation (as applicable) is required for the credentialing and licensing process: a. Evidence of a current, unencumbered RN/LPN license to practice in this State. b. Malpractice insurance. c. Curriculum vitae. d. Current CPR Certification e. Other as may be requested by the facility to verify credentialing and licensing status .

Based on observation, interview and record review, the facility failed to justify the administration of antibiotic therapy for two residents (Resident #9, Resident #27) resulting in Resident #9 and Resident #27 receiving antibiotic therapy without appropriate clinical rationale and the possibility of antibiotic resistance due to inappropriate usage. Findings include: Record review of the facility provided 'Antibiotic Stewardship' Infection Control Policy and Procedure Manual revision date 12/2016, pages 1-2, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the Antibiotic Stewardship Program was to monitor the use of antibiotics in the residents. (#4.) If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following: (a.) Drug name. (b.) dose. (c.) Frequency of administration. (d.) Duration of treatment: (1) start and stop date or (2) number of days of therapy. (e.) Route of administration. (f.) Indications for use. (#11.) When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Record review of facility 'Antibiotic Stewardship-Orders for Antibiotics' Infection Control Policy and Procedure Manual revision date 12/2016, pages 3-4, revealed that appropriate indications for use of antibiotics include: (a.) Criteria met for clinical definition of active infection or suspected sepsis; and (b.) Pathogen susceptibility, based on culture and sensitivity, to antimicrobial. Resident #9: Observation and interview was conducted on 01/04/24 at 10:36 AM during the initial tour of the resident living area and revealed Resident #9 to be lying in bed. Resident #9 stated that she has been to the hospital numerous times and does not remember any of it. She did have a catheter for urine, but it was removed. Resident #9 was noted to be wearing briefs for incontinence. An interview and record review on 01/08/24 at 11:33 AM with Registered Nurse (RN) K (infection control nurse) of Resident #9's Infection control logs revealed: facility acquired Urinary Tract infections (UTI's) in the months of May, September, October and November 2023 and Resident #9 received antibiotic therapy each of the months. May 2023 UTI: Record review of Resident #9's physician order dated 5/19/2023 revealed Resident #9 was placed on Keflex/cephalexin 500 mg capsule three times daily till 5/26/2023. there was no indication for the antibiotic use noted on the physician order. Record review of the May 2023 infection control line listing revealed that there were no culture/organisms identified with the treatment of facility acquired urinary tract infection. Record review of Resident #9's 5/24/2023 urine dip lab identified abnormal results: leukocytes, protein, white blood cells, red blood cells and bacteria. There was no culture or sensitivity for an organism found at the time of the survey. September 2023 UTI: Record review of Resident #9's progress notes dated 9/23/2023 revealed that Resident #9 was a Hoyer lift for transfers and two (person) assist with extensive assist with bed mobility and dependent with toileting. On 9/27/23 at 11:10 AM progress notes revealed that Resident #9 had a change in condition with confusion and vomiting was tested for COVID-19 which was negative. On 9/28/2023 at 9:27 AM Resident #9 was noted to have an altered mental status and was sent to hospital. Record review of Resident #9's hospital discharge record dated 9/28/23 revealed the resident was diagnosed with urinary tract infection and received Rocephin IV (antibiotic), came back to facility, but no organism was found with in the facility medical records. Record review of the September 2023 infection control line listing revealed Resident #9 received Keflex 500 mg oral twice daily for seven (7) days antibiotic therapy and that there were no culture/organisms identified with the treatment of facility acquired urinary tract infection. October 2023 UTI: Record review of Resident #9's progress note dated 10/16/23 at 9:04 AM noted the resident to be confused and would open her eyes but not responding, physician was notified, and resident was sent to the hospital. Progress note dated 10/21/23 at 2:57 PM noted Resident #9 came back to facility on antibiotic for urinary tract infection and was treated with Augmentin 875/125 mg oral twice daily for ten (10) days of antibiotic. Record review of the October 2023 infection control line listing revealed Resident #9 received antibiotic therapy and that there were no culture/organisms identified with the treatment of facility acquired urinary tract infection. Under the other actions column on the 'Line Listing of Resident Infections' form noted obtain C&S (culture & sensitivity) ensure susceptible. November 2023 UTI: Record review of Resident #9's progress note dated 11/2/23 at 8:52 AM noted the resident to be lethargic and unable to answer questions. Resident #9 was sent to the local hospital and returned. Progress notes on 11/3/23 at 3:1 noted Resident #9 was sent to a different hospital with no use of her right arm and difficulty swallowing. Progress not on 11/11/23 at 6:47 PM revealed the resident returned from the hospital with a Foley (urinary) catheter. On 11/1223 the Foley (urinary) catheter was discontinued. Progress note dated 11/25/23 at 1:17 AM noted Resident was confused with a low-grade temperature of 100.0 (degrees), COVID-19 test was negative. Order to obtain urine analysis (UA). Progress note dated 11/25/23 at 7:43 AM revealed urine sample collected with dark amber urine noted. Resident was very lethargic and difficult to arouse, physician notified. Progress noted to keep resident at facility a treat with Rocephin (antibiotic) Intramuscular twice a day for 5 days and to send urine for analysis. Record review of the 'Line Listing of Resident Infections' November 2023 revealed that the urine sample was collected on 11/25/2023 sent for urinalysis and culture & sensitivity. Rocephin 1 gram intramuscular twice daily for 5 days was started. on 11/27/2023 noted culture pending. Record review of Resident #9's physician orders from 12/1/2023 through 12/31/2023 revealed that the resident received Amoxicillin (antibiotic) tablet 500 mg one table oral three times daily from 12/1/23 through 12/8/23. There was no diagnosis noted. Record review of the 'Line Listing of Resident Infections' December 2023 revealed there was no line listing for the antibiotic of amoxicillin antibiotic for Resident #9. Resident #27: Record review of Resident #27's Minimum Data Set (MDS), dated [DATE], revealed an individual with intellectual disabilities (ID) with moderately impaired cognitive skills decisions poor, cues/supervision required. medical diagnosis included medically complex conditions and seizures. Section H: Bowel and Bladder revealed indwelling urinary catheter. Record review of Resident #27's medical record reveal the that the resident was admitted on [DATE], on antibiotics for wounds from a hospital. The medical record revealed urinary tract infections treated with antibiotic therapies. An interview and record review on 1/5/2024 at 11:33 AM, during the Infection Control Task portion of the survey, with Registered Nurse (RN) K (Infection Control nurse) revealed that Resident #27 had multiple urinary tract infections while residing at the facility. Resident #27 was noted to receive antibiotic therapy in the months of: May, July, August, September, November, and December 2023. May UTI 2023: Record review of Resident #27's Observation detail list report dated 5/14/2023 at 3:15 PM revealed that the resident was screened for urinary tract infection with indwelling catheter with purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. Urinary catheter specimen culture with at least 100,00 cfu/ml of any organism. Record review of the facility' Infection Control antibiotic 'Line Listing of Resident Infections' May 2023, noted on 5/13/23 noted urinary tract infection and Resident #27 was sent to the emergency room . The line listing noted culture at hospital, but none was found within the resident's facility medical record. Ceftriaxone 1 gram intramuscular for 3 days, Facility-Acquired Infection (HAI) was identified. Record review of Resident #27's prescription order dated 5/16/23 through 5/27/23 ordered antibiotic piperacillin-tazobactam 4.5 grams intravenous every six hours was ordered for urinary tract infection. July UTI 2023: Record review of the facility's Infection Control antibiotic 'Line Listing of Resident Infections' July 2023, noted Resident #27 to have urinary tract infection with indwelling catheter, symptoms/date only listed 'urosepsis', culture 'yes plus urine' no culture/organism identified on the line listing form, Bactrim DS twice daily for 14 days, identified as Facility-Acquired Infection (HAI). Record review of Resident #27's urine culture results dated 7/4/2023 revealed proteus mirabilis. A handwritten order of Ciprofloxacin 500 mg twice daily for 14 days signed by the DON on 7/10/2023. Record review of prescription order dated 7/10/2023 Cipro 500 mg oral twice daily 8:00 AM and 8:00 PM with diagnosis left blank. August UTI 2023: Record review of the facility's Infection Control antibiotic 'Line Listing of Resident Infections' August 2023, noted Resident #27 to have urinary tract infection with indwelling catheter, no symptoms identified dated 8/8/ (23), culture positive urine (no organism identified, ertapenem 1 gram intravenously at bedtime for 10 days, identified as Facility-Acquired Infection (HAI). Record review of Resident #27's prescription order dated 8/8/23 through 8/18/23 ordered antibiotic metronidazole (Flagyl) 500 mg oral three times daily was noted with no diagnosis for antibiotic. Record review of Resident #27's 'Observation detail list report' form dated 8/8/23 at 2:04 PM revealed chronic indwelling catheter with urinary tract infection that met the minimum criteria to initiate antibiotics for urinary tract infection. Record review of Resident #27's urine culture results dated 8/8/2023 revealed proteus mirabilis and Extended Spectrum Beta-Lactamase (ESBL). These organisms are uniformly resistant to all penicillin's, cephalosporins and aztreonam. September UTI 2023: Record review of the facility's Infection Control antibiotic 'Line Listing of Resident Infections' September 2023, noted Resident #27 to have urinary tract infection with indwelling catheter, with change in condition suprapubic pain, no date listed, culture: urine sent, no organism identified, Bactrim DS antibiotic twice daily for ten days, identified as Facility-Acquired Infection (HAI). Record review of the continued pages of the 'Line Listing of Resident Infections' August 2023, noted Resident #27 on 9/26/2023 to have urinary tract infection with change in condition with increased pain, positive culture, the line listing had a handwritten note: continued treatment from 9/12/2023. Peripheral Inserted Central catheter (PICC) line ordered, meropenem 1 gram intravenous three times daily for 10 days and Flagyl 500 mg oral twice daily for 10 days, identified as Facility-Acquired Infection (HAI). Record review of Resident #27's urine culture results dated 8/8/2023 revealed proteus mirabilis and Extended Spectrum Beta-Lactamase (ESBL). These organisms are uniformly resistant to all penicillin's, cephalosporins and aztreonam. Record review of Resident #27's prescription order dated 9/26/23 through 10/6/23 ordered antibiotic metronidazole (flagyl) 500 mg oral three times daily was noted with no diagnosis for antibiotic, and meropenem 1 gram intravenous three times daily, no diagnosis was noted on the order. Record review of Resident #27's progress note dated 9/26/23 at 6:04 AM revealed that the PICC line was placed, and the antibiotic was given with urine very cloudy. November/December UTI 2023: Record review of Resident #27's urine culture dated 11/29/2023 revealed proteus mirabilia, pseudomonas aeruginosa, and extended-spectrum beta lactamase (ELBS). No treatment was found within the medical record for the infection. Record review of the facility's Infection Control antibiotic 'Line Listing of Resident Infections' December 2023, noted Resident #27 to have urinary tract infection with indwelling catheter, on 12/19/2023 with the culture on 11/29/2023, tobramycin sulfate 80 mg/2 ml injection once daily for seven (7) days for urinary tract infection. In an interview on 01/05/24 at 02:45 PM with Registered Nurse (RN) K infection control nurse revealed that Resident #27's November 2023 urinary culture was Positive for proteus mirabilia, pseudomonas, Extended-Suspectable Beta Lactamases (ESBL) has a urinary catheter in place. The 11/29/23 urine culture was received, and the attending physician was for Resident #27's wound care physician and did not want to start any antibiotics he felt urine was colonized. The Medical director physician decided to start the Tobramycin on 12/19/2023. That is a delay in treatment of antibiotic therapy for the resident #27.

This Citation pertains to Intake Numbers MI00136477, MI00141844, and MI00141874. Based on observation, interview and record review, the facility failed to ensure that residents' rights were met when the facility failed to 1.) Ensure call lights were answered timely for six Residents (Resident #14 and 5 Residents in the Confidential Group of Residents (E, F, G, H, and I)); 2.) Ensure food was served warm at a palatable temperature for two residents from the Confidential Group of Residents (G and I); and 3.) Ensure that showers/bed baths were provided to five residents from the Confidential Group of Residents (E, F, G, H, and I), of a sample of 12 residents reviewed for residents' rights and accommodation of needs and a group of five residents from the Confidential Group, resulting in unmet care needs, incontinent episodes, feelings of shame and humiliation; dissatisfaction of cold, unpalatable food with the potential for weight loss; and a lack of showers for more than seven days, embarrassment and the potential for body odor and infection. Findings include: On 1/05/2024 at 1:15 PM, a group of five confidential residents were interviewed during the survey task for the Resident Council. Meeting minutes from past Resident Council meetings were reviewed before the group meeting. The group was asked about individual issues and concerns not brought to the Resident Council meetings. Five of five confidential residents expressed that there was a pattern of delayed call light responses from staff and frustration with the outcome of the delay. During the Resident Council meeting, three confidential residents described that they required using a mechanical transfer lift for transfers to and from the toilet and needed extra time to perform the activities of daily living compared to other residents and when call lights were not answered timely, caused a delay in making it to the toilet timely. One resident, Resident G, stated, staff would come in to turn off the call light and say that they will be back but don't return. Resident G further revealed waking up in the middle of the night soaked in urine because the staff did not return after turning off my call light. Resident G stated, It seems worse on the night shift than during the day. At least the day shift returns after a couple of hours. The night shift doesn't seem to do their job. Resident H revealed that the day shift staff turned off the call light and did not return. Resident H expressed that at times, they were unsure if the staff intentionally ignored the request or forgot because they were too busy and short of staff. On 1/9/2024 at 10:27 AM, Resident #14 (R14) was interviewed, answered questions and engaged in conversation. R14 indicated that she had brought up the issue with the Director of Nursing (DON) of the call light being turned off by staff from the nursing station. The Resident reported the staff turned their call light off without coming to the room to check on us. During the interview, although non-verbal, R14's roommate, Resident #6 (R6), was making signals and noise, indicating that she agreed with the call lights being shut off from the nurses' station. R14 stated, It happened again last night during the night shift. R14 further stated, I don't know why they would shut it off when you need something .they would not even come to the room to ask what you need. CNA BB was interviewed on 1/9/24 at 10:30 AM regarding call light response from staff. The CNA stated, we turn off the call lights in the resident's room. We are not supposed to shut it off from the phone. Nurse CC was interviewed on 1/9/24 at 10:37 AM regarding call lights shut off at the nurses' station. Nurse CC demonstrated how the call lights can be turned off or shut off from the nursing station desk phone. The Nurse indicated staff were to answer the call light in the room and not shut it off at the Nurses Station. The DON was interviewed on 1/9/24 at 10:47 AM regarding call light response. The DON indicated she was unaware of the incident from last night when the call light was not answered for Resident #14 but had received a previous complaint from R14 regarding call lights being turned off without CAN's going in the room. The DON stated, It was around October of 2023. The DON revealed that she instructed R14 to report directly to the DON when it happens again but had not heard from R14 since then. The DON was asked about facility policy and indicated staff were to go into the room to answer call light. The DON was queried if interventions had been implemented to prevent the staff from shutting off the call lights at the nurses' station. The DON said that she had not done anything because no one had reported anything since. The DON indicated that she would follow up with R14 and R6 regarding staff shutting off the call light from the nurse's station. A review of the Resident Council Suggestions/Concern Form dated 10/9/2023. R14 initiated the concern. The DON wrote, States they turn her call light off from nursing station never checks what she needs. Resolution/response: Resident to report to manager immediately when this happens. Nurses to be notified if on night shift. Signed by the DON, dated on 10/10/23. Resident Response to resolution: (was left blank) Administrator Signature: (was left blank) Date: (was left blank). Maintenance C was interviewed on 1/9/2024 at 10:50 AM, regarding the call light system. Maintenance C demonstrated how the staff could turn off or cancel the call light alarm by pressing a button from the telephone at the nurse's station. During the Resident Council meeting on 1/5/24 at 1:45 PM, the confidential residents emphasized their concern about hot food being served cold and cold food being served warm. The Residents expressed that sometimes, the food is not thoroughly cooked, they had complained about it, but they didn't come back to heat it or cook it properly. The Residents reported that sometimes one side of the food was frozen, and the other was half-cooked. Resident G described a particular experience of being served a quarter of a sausage, and stated, like someone had taken a bite of it. During the resident's dining observation conducted with the dietary Cook (Staff B) on 1/08/24 at 12:30 PM, Resident G's dish, a chicken pot pie, was temped at 137 degrees Fahrenheit. Resident I's Pot pie dish was at 113 degrees Fahrenheit. During the dining observation, an observation was made of Staff B hearing the comments from the residents, especially regarding dissatisfaction with their meal experience and the food temperature. On 1/5/24 at 1:45 PM during the Resident Council group meeting, Resident H expressed concerns about not getting showers for over a week. Resident H recalled not getting a shower since returning from the hospital from Thursday until the following Friday. Resident H expressed they preferred to have a shower than a bed bath. An updated Shower Schedule (dated 11/8/2023) was reviewed on 1/05/24 at 4:25 PM. It revealed that Resident H is scheduled to receive showers three (3) times a week on Monday, Wednesday, and Friday. Resident G was scheduled twice weekly on Monday and Wednesday. Resident I was scheduled twice a week on Tuesday and Thursday. Resident E was scheduled twice weekly on Wednesday and Friday. Resident F was scheduled every Friday. The shower schedule entitled Downstairs Shower noted each of the resident's shower schedules on the first floor and noted: Friendly Reminder: If the shower aid is pulled to work the floor, each individual CAN's (Certified Nurse's Aide) is responsible for their own shower that day. During the Resident Council meeting, the group of confidential residents was asked to raise their hands if they had not received their planned showers or baths for over a week. Five of the five confidential residents raised their hands. The confidential residents revealed that they were told that showers were not done because the shower aide had COVID and told them to stay in their room until further notice. The shower aide, CAN's V, was interviewed on 1/5/2024 at 3:16 PM. CAN's V admitted she was off last week and was unsure how the showers were given. The Shower CAN's mentioned the facility policy, that if the shower aide could not do showers, it would be the responsibility of every resident's assigned aide to do baths. CAN's V indicated the aides have to fill out the skin sheet for every shower and stated, That's when we know that the bath/showers were done. CAN's V revealed being sick and was absent last week. CAN's V had just returned to work from illness, reported she was unsure if the CAN's were giving residents their scheduled showers/baths and stated, They should have filled out the skin sheet to see if they have done them. The Administrator was queried on 1/5/24 at 3:07 PM regarding the Residents' missed showers/bathing and stated we have not been doing showers because of the COVID outbreak, but residents should receive bed baths. The quarantine started on December 28, 2023. The residents were instructed to stay in their rooms. They were to use commodes instead of using shared bathrooms, and staff were to give bed baths. Some residents prefer showers. An interview with the Director of Nursing DON was conducted on 01/05/24 at 11:00 AM. The DON explained that each bath/shower should have a skin assessment sheet. That's when staff identify any skin discrepancies. The surveyor requested the residents' shower skin assessments. The DON could not provide the skin assessments for the group of confidential residents for the dates requested for the past two (2) weeks (December 20th, 2023- January 5th, 2024). When queried, she could not tell if the showers/baths were done for the residents because no skin sheets or documentation indicated showers were given to the requested residents. A review of facility policies was conducted on 1/8/24 at 4:00 PM. The Bath, Shower/Tub Policy (revised Date February 2018) revealed, Purpose: .the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation: 1.) The Date and time the shower/tub bath was performed. 2.) The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3.) All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath . Reporting: 1.) Notify the supervisor if the resident refuses the shower/tub bath. 2.) Notify the physician of any skin areas that may need to be treated. 3.) Report other information in accordance with facility policy and professional standards of practice. The facility policy was reviewed on 1/9/24 at 3:00 PM entitled: Answering Call Light Policy (revised Date September 2022). It revealed, Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Steps in the Procedure: 1.) Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?). a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. If the resident's request requires another staff member, notify the individual. c. If the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance . The facility's policy on Food Quality and Palatability Policy (undated) was reviewed on 1/9/24 at 3:15 PM. It revealed, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form and texture to meet resident's needs .Procedures: .2.) The Cook (s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code . According to the US Department of Agriculture USDA (December 12, 2023), https://ask.usda.gov/s/article, Once the food is cooked or reheated, it should be held hot, at or above 140 degrees Fahrenheit (60 degrees Celsius). Food may be held in the oven or on the serving line in heated chafing dishes, or on preheated steam tables, warming trays and/or slow cookers.

Based on observation, interview, and record review, the facility failed to ensure that proper Pre-Admission Screening and Resident Review (PASARR) or DCH-3877 Form documentation was completed annually for one resident (Resident #39), of three residents reviewed for PASARR documentation, resulting in the potential for inappropriate admission, and absence of available services for mental disorders or unmet specialized needs. Findings include: Resident #39 (R39): On 1/4/24, at 11:39 AM, R39 was observed in his room and complained about being unable to get out of the room to use the bathroom on the second floor. R39 had a roommate (Bed #2) and was asleep during the observation. R39 had expressed, I don't like it here but don't want to complain. My roommate has dementia and needs a lot of attention. I don't like being here. A record review of R39's Electronic Medical Record (EMR) dated 11/08/23 revealed R39 was [AGE] years old, admitted to the facility on [DATE], with diagnoses that included Anxiety Disorder, Depression, Schizophrenia and Post Traumatic Syndrome Disorder (PTSD). The Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15/15. A BIMS Score of 13 to 15 indicated that a person was cognitively intact. According to the MDS assessment dated [DATE], R39 did not receive any antipsychotic prescription or did not receive any mental health services despite the list of diagnoses for Mental disorders mentioned above. A review of R39's PASARR indicated that the last assessment was done in 2022. There was no PASARR found after 2022 in R39's EMR. On 1/9/24 at 11:30 AM, R39 current PASARR was requested. The Social Worker SW A presented a PASARR (Form 3877) for R39 dated 1/9/24. The PASARR submitted by SW A revealed: The screening purpose was for (X) Change in Condition. Section II. Screening Criteria: (All six items must be completed.) 1. (X) NO ( ) Yes The person has a person current diagnosis of ( )Mental illness or ( ) Dementia 2. (X) NO ( ) Yes The person has received treatment for ( ) Mental Illness or ( ) Dementia 3. (X) NO ( ) Yes The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. 4. ( ) NO (X) Yes There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. Presenting evidence may include, but is not limited to, suicidal ideation's, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. 5. (X) NO ( ) Yes The person has a diagnosis of an intellectual disability or a related condition including, but not limited to, epilepsy, autism, or cerebral palsy, and this diagnosis manifested before the age of 22. 6. (X) NO ( ) Yes There is presenting evidence of deficits in intellectual functioning or adaptive behavior, which suggests that the person may have an intellectual disability or a related condition. These deficits appear to have manifested before the age of 22. Note: If you check Yes to items 1 and or 2, circle the word Mental Illness or Dementia Explain any Yes: Resident displays indicators of mood Section III. Clinician Statement: I certify to the best of my knowledge that the above information is accurate. Electronically signed by SW A dated 01/09/2024 . When queried, the SW A indicated that the last PASARR 3877 for R39 was performed when he was admitted in 2022. SW A confirmed that the submitted PASARR was done today (dated 1/9/2024). When SW A was queried where the PASARR evaluation was in 2023 and why the submitted PASARR was dated 1/9/24, SWA further revealed: I just did it today after realizing it was not done. I honestly did not get to it. SW A further verified, referring to the PASARR dated 1/9/24, that R39 did not have any Mental Disorder as a diagnosis and was not receiving medications and treatments for mental disorders. The facility's policy: Resident Assessment-Coordination with PASARR Program, was reviewed with the Administrator on 1/9/24. It was noted that The facility coordinates assessment with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: . 2.) The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission .6.) The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 7.) Recommendations, such as any specialized services, from a PASARR Level II determination and or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transition of care. 8.) Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review .

Based on observation, interview and record review, the facility failed to review and revise care plans with resident changes, to ensure that interventions necessary for care and appropriate care and services were provided for two residents (Resident #8, Resident #35), resulting in the likelihood for unmet care needs. Findings include: Record review of facility provided 'Change in a Residents Condition or Status' policy revision date 2/2021, revealed the facility promptly notifies the resident, his or her physician, and the resident representative of changes in the residents medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) #2. (c.) requires review interdisciplinary review and/or revision to the care plan Record review of the facility provided 'Attachment D-Residents Rights & Facility Responsibilities' undated, pages 1-24, revealed that the planning and implementing care the resident/representative has the right to participate in developing and implementation of person-centered plan of care. The resident has the right to be informed, of and participate in treatment. Resident #8: Record review of Resident #8's Care plans, pages 1-22, revealed that the resident had an indwelling urinary catheter care plan up dated 10/2022 with interventions of: make sure the bag is hanging and kept off the floor at the level below my bladder. (Resident) will sometimes place it on the floor so check periodically to make sure it is off the floor. Observe for signs/symptoms of urinary tract infection, such as bladder spasms, pain, blood in urine, odor, cloudy urine, and notify physician. Record review of the urinary catheter care plan did not identify if a catheter strap is used or refused by the resident. In an observation and interview on 01/08/24 at 09:18 AM the state surveyor requested that the Registered Nurse (RN) K (infection control nurse) tour Resident #8's room. While standing at the bedside of Resident #8 with the state surveyor, RN K observed the resident's urinary catheter bag and tubing on the floor of the resident's room. RN K acknowledged that cross contamination from the floor was a concern. The state surveyor inquired how long had Resident #8 had purple bag/catheter syndrome. RN K stated that she was not aware that the resident had purple bag/catheter syndrome and was not familiar with purple bag syndrome. RN K stated that no it's not normal for the catheter and catheter bag to be the color of purple. The state surveyor wanted to know how long the urinary catheter bag has had been purple, and when was the last catheter changed. There was no catheter strap last noted. RN K stated that she would have to do some digging to get the answers. Resident #35: Record review on 01/08/24 10:49 AM of Resident #35's Care plans, pages 1-19, revealed there was no care plan for the use of Ativan to monitor the resident for side effects or the purpose of the medication. There was a care plan for the use of Seroquel antipsychotic medication noted. Record review of Resident #35's pharmacy 'Note to Attending Physician/Prescriber' form, dated 9/9/23, revealed recommend discontinuing PRN use of Ativan 0.5 mg BID (twice daily) for this resident, or reorder for specific number of days, per following federal guidelines. The physician left the number of days blank and circled the benefit outweighs the risk, and wrote recently started, continue current dose/order and monitor. There was no indication/diagnosis for the use of the medication noted by the attending physician. There were no development or revision of interventions added to the care plan when the lorazepam/Ativan anxiolytic/benzodiazepines medication was ordered for treatment.

This Citation pertains to Intake Number MI 480. Based on interview and record review, the facility failed to ensure proper supervision while offering assistance with Activities of Daily Living for one resident (Resident #1) of three residents reviewed for supervision, resulting in an unwitnessed fall off a beside commode, hospitalization and a fracture of the C 3 vertebrate. Findings include: Resident #1: On 10/20/21, at 9:30 AM, a record review of Resident #1's Electronic Medical Record (EMR) revealed an admission on 9/29/21 with diagnoses that included recurrent falls, stroke and Dementia. Resident required extensive assistance with Activities of Daily Living including toileting. Resident had severely impaired cognition. A review of the Physician Visit progress note, 09/30/2021 6:30 AM, revealed This patient is seen in the hospital for recurrent falls return to the ECF for further short-term rehab. She lives with daughter and she is declining with Alzheimer's dementia. She is baseline confused with generalized weakness . Plan: . Issue: Falls medication list is reviewed to rule out possible cause for the falls, evaluated and updated the measures to treat the pain following the fall . Issue: Recurrent falls Obtain further PT OT consult. Continue closely monitor unable to prevent the falls due to her cognitive impairment with dementia . A review of the fall report 10/1/21 930 revealed the following: Reason(s) for transfer: Fall c/o (complaint of) neck pain . Condition prior to incident . the box was checked for Alert and Confused/Disorientated . Was incident witnessed? the box No was checked. Brief Description I was summoned to resident room she had fallen was laying flat on her back next to bed she stated she was going to the BR she also said her neck hurts she was confused unable to answer most of my questions when I asked her to squeeze my hand she either could not or didn't understand she would not move her legs when asked she just kept says please hurry my neck hurts we did not move her I immediately called 911 they were here by 945 A.M. They gently loaded her onto stretcher & left to take her to hospital ER. There was additional writing on the report that revealed Resident was observed on the floor on her back in her room with pants around knees. Resident was on toilet in room and stood up by herself lost balance and went down to the floor. Able to squeeze hand left on command weak squeeze with right hand. c/o pain in knee, ( R ) arm/shoulder, lower back, mid back neck, head foot. Due to c/o pain with back and neck resident was not moved until EMS arrived to place collar and back board for transport to ER for eval and treat. Signed by Director of Nursing. A review of the Problem Start Date: 09/29/2021 Category: ADL Functional / Rehabilitation Potential CNA Care Guide care plan revealed the following: Goal . I will be well groomed free from skin breakdown and falls. Approach . Ambulation - THERAPY TO EVALUATE FOR WALKING ABILITY/SAFETY. (#) (Device used) (Distance/to where) Walk in room/Corridor. How resident walks in his/her room/corridor. Flowsheet: ADL . The lines clarifying device used and distance was left blank. Approach Start Date: 09/29/2021 Toilet Use - Extensive Assist of (1) - How resident uses the toilet room, commode, bedpan, or urinal; transfer on/off toilet . Approach Start Date: 09/29/2021 Transfer Extensive Assist of (2) to wheelchair - How resident moves between surfaces including to or from; bed, chair, wheelchair, standing position (excludes to/from bath/toilet . A review of the Fall Risk Completed Date: 09/30/2021 01:52 AM revealed EVALUATION Fall Risk Score - Score of 10 or higher represents a high risk for falls. Total Fall Risk Score: 21 . A review of the progress notes revealed Description Daily Skilled Completed Date: 09/30/2021 02:59 AM . COGNITIVE . The following boxes were check marked: Memory problems Short -term (unable to recall after 5 minutes) Long - term Yes . . Memory/Recall Problems (If yes, check those that apply) . Current season Location of Own room Yes Staff Names and Faces That he/she is in Nursing Home . Impaired Decision Making On 10/20/21, at 12:10 PM, Aide D was interviewed via phone regarding Resident #1's fall on 10/1/21. Aide D explained that they assisted the resident to the bedside commode which was at the end of the bed in the room. Aide D explained to the resident that she would be right back and stay on the commode. Aide D was asked why she left the resident alone and Aide D stated that the other aide that was working needed help getting someone up for therapy. Aide D was asked if they reviewed the care guide for Resident #1 and Aide D stated that they didn't that morning because Resident #1 was up ambulating in their room without the walker and they needed to keep reminding the resident to use it. Aide D further stated that the resident should have been a one on one supervision because they kept wandering in the room and wouldn't follow directions. Aide D further offered that they were feeling rushed that day because they had 15 residents and the other aide needed their help. On 11/09/21, at 7:15 AM, a record review was conducted of Resident #1's hospital documents that revealed Exam: SPINE CERVICAL WO CONTRAST History: Fall with pain . There appears to be a fracture which is minimally displaced through the lateral lamina of the vertebral of C 3 . Patient is . presenting to the ED after falling at her ECF. She is altered . EMS states she has BL (bilateral) hand numbness, neck pain from C 2 down, and R (right) shoulder and arm pain. She has a c-collar on. She is on [MEDICATION(S)] and has a goose egg on her L parietal bone .

This Citation Pertains to Intake Number MI 730 Based on observation, interview and record review the facility 1) Failed to prevent a fall with injury for one resident (Resident #26), 2) Failed to ensure that Resident #26's Minimum Data Set (MDS) assessment and care plan were accurate, and 3) Failed to complete post-fall neurological checks for one resident (Resident #35). These deficient practices resulted in Resident #26 being rolled away from the aide during a change of briefs and suffering a fractured clavicle, lacerations to the head and the bridge of the nose, skin tears, and a hematoma to the forehead. In addition, Resident #26's care plans and the MDS assessment were inaccurate and post-fall neurological checks were not completed for Resident #35. Findings include: Resident #26: On 8/10/21 at 1:27 PM, Resident #26 was observed resting in her Geri Chair. She appeared to be in good spirits. Resident #26 was queried regarding when she fell some months prior. She reported CNA (Certified Nursing Assistant) S was cleaning her up and he turned her toward the wall, while his hand was on her back (not on her side) and she rolled off the bed onto the floor. Resident #26 stated as she fell , she hit the vent that runs along the side of that wall and suffered a cut on her head, black eye, and a fracture. On 8/10/21 at approximately 3:00 PM, a review was completed of Resident #26's medical records and it revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included Acute [CONDITION(S)], [CONDITION(S)], Dysphagia, Major Depressive Disorder, Anxiety Disorder and Congestive Heart Failure. Resident #26 is alert and able to make her needs. On 8/12/21 at 10:13 AM, CNA S was interviewed regarding Resident #26's fall while he was changing her. CNA S reported as he was preparing to change Resident #26, he gathered his needed supplies and raised the bed to his midline height. He reported at the time of the fall Resident #26 was a one-person assist. CNA S explained the resident's bed was not flush against the wall and there was a gap between the wall and bed. CNA S explained he began to take off the resident's brief and started to clean the resident's private area. He stated he then tucked the brief some to make it easier for him to pull out once he turned her. CNA S stated he placed one hand on Resident #26's thigh and the other on her shoulder/back area and rolled her toward the wall (away from him). He then began to clean her coccyx area and taken off the soiled brief and threw it in the trash can. CNA S further explained he believed he was either reaching for a new brief and this is when she rolled out of the bed. CNA S reported he could not recall where his hand was on Resident #26's body. He stated once she fell he immediately went over to her to make sure she was conscious and then he alerted the nurse. CNA S stated the DON (Director of Nursing) was in the building and she also came to the room to assist in assessing the resident. CNA S stated the resident suffered a broken clavicle and facial bruising. CNA S was queried on how he was trained to roll residents that are one-person assist and he explained during initial training and skills' check off, this was not reviewed on which way to turn a resident. He reported after this incident he did receive a 1:1 training and is now aware he should have turned Resident #26 toward him. On 8/12/21 at 10:40 AM, an interview was conducted with ADON (Assistant Director of Nursing) regarding training of new CNA's. The ADON explained the aides are assigned a preceptor who will acclimate them to the floor and assist them in their transition to working independently. The ADON stated the nurses will watch the new CNA's complete skills and check them off. The ADON added she follows up with new hires prior to them completing their time with their preceptors. The ADON reported she was not involved in CNA S training. ADON was queried on how they train their staff to turn residents in bed when they are changing their briefs. The ADON reported if the resident is a one-person assist as Resident #26 was, they would instruct staff to turn the resident toward them. On 8/12/21 at approximately 3:00 PM, a review was completed of Resident #26's MDS assessment prior to her fall in January. The MDS was dated 12/16/20 and it indicated Resident #26 was a two- person assist for bed mobility (how resident moves to from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and two-person assist for toileting. Review was then completed of the resident's care plan for the same time frame, and it indicated Resident #26 was one-person assist for bed mobility and toileting. Further review was completed of Resident #26's medical records and it revealed in July and August facility staff documentation was inconsistent based on Resident #26's current assist level. There were more than 20 times within this time frame when staff documented they provided care to the resident with only one person. On 8/12/21 at approximately 3:30 PM, a review was completed of the facility FRI (Facility Reported Incident) dated 1/22/21 for Resident #26, the investigation stated the following: - (Resident #26) was being changed by staff member (CNA) .resident is a one person assist for bed mobility and incontinent care. Staff member had residents bed in high position for check and change and when he rolled resident away from him to fasten her brief she rolled off the side of the bed. Resident hit left side of head, midline forehead and nose .Resident sustained left clavicular fracture from fall, contusions to the face and skin tears to left extremity . CNA was provided with One-to-one Education on 1/22/21: - When changing residents that are one person assist, turn resident towards you, not away from you. On 8/13/21 at 9:25 AM, an interview was conducted the DON (Director of Nursing) regarding Resident #26's fall with fracture on January 22, 2021. The DON reported she was paged down to Resident #26's room and observed her on the floor. She kneeled next to the resident, and she reported she rolled out of bed. The DON asked CNA S what happened, and he explained when he rolled her over, she kept rolling and went off the side of the bed. The DON stated she then asked CNA S if he rolled Resident #26 toward him or away from him. CNA S admitted he rolled the resident away from him. The DON instructed the CNA he should have rolled her toward him. The DON reported at the time of the fall Resident #26 was a 1 person assist for toileting and bed repositioning. The DON reported she instructs staff to review the residents POC (plan of care) for their specific needs. The DON was queried if she was aware Resident #26's MDS (Minimum Data Set) Assessment indicated she was a 2 person assist for toileting and bed mobility at the time of the fall. The DON stated she was not aware of this. Record review of facility 'Neurological Assessment' policy dated 10/2010, revealed that the purpose of the procedure is to provide guidelines for a neurological assessment: 1) Upon physician orders; 2) when following and unwitnessed fall; 3) subsequent to a fall with a suspected head injury . Resident #35: Accidents: On 08/10/21 at 10:10 AM Resident #35 was observed to ambulate with a quad cane on the upper level of the facility. Resident #35 was noted to self ambulate and chose to sit in the hallway in chairs and watch people. On 08/12/21 at 9:30 AM Resident #35 was observed to be seated in the hallway and picking at the 4 rubber stoppers on her quad cane. Record review on 08/12/21 at 02:09 PM of Resident #35's accident incidents revealed: the resident had three (3) falls within the last 6 months. Two (2) of the falls involved head injuries. An interview and record review was conducted on 08/13/21 at 10:49 AM with the Assistant Director of Nursing (ADON) of Resident #35's incident reports. Record review was made of the resident's fall dated 2/12/2021. The ADON reviewed the indent report. The DON oversees falls and investigations. She signs off this incident. Injury facial bruising and skin tear to forehead. Reviewed 4 different head injury areas assessed, skin tear, etc No neuro checks, I believe that she just got lost, are nurses are usually good about it. It would have been with the report and the DON did sign off on the report. Upon exit of the annual survey the facility was not able to provide neuro checks for the February 12, 2021, fall.

This Citation pertains to Intake Number MI 675 Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to their failure to institute and operationalize appropriate Infection Control practices in accordance with the Centers for Disease Control and Prevention's (CDC's) recommended measures of co-horting and Isolation of residents with similar signs and symptoms of infection to prevent exposure and transmission of the Covid-19 virus to residents and staff. This included implementation of appropriate interventions, such as Transmission Based Precautions, timely creation of a Covid unit and designated staff for the Covid and Transitional monitoring units to prevent the spread of respiratory illness from the Covid-19 virus. The failure to maintain infection control practices resulted in the likelihood for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Immediate Jeopardy: On arrival to the facility on [DATE] at 2:30 PM, during an interview with the Administrator, she said the facility had sent 33 Covid-19 positive residents to hospitals or HUBs (facilities that cared for Covid-19 positive nursing home residents) beginning on [DATE]. The facility had 8 residents who were currently Covid positive, with a resident census of 16: 8 Covid positive and 8 Covid negative residents. The facility had 1 nurse attempting to find placement at a HUB or hospital for the Covid positive residents. In addition, she said 37 staff had tested positive for Covid-19 between [DATE] and [DATE]. During the interview, the Administrator was asked if the facility had a designated unit or area for Covid positive residents and stated, No, we initially had a resident on the 2nd floor test positive on [DATE] and then one on the first floor. Eventually, we moved the 2nd floor residents to the first floor, because many of the staff were sick also. The Administrator also said on [DATE], the facility began having groups of residents gather for Activities, such as Bingo, crafts, games etc., but that was discontinued upon the first positive Covid-19 resident. While entering the facility on [DATE] at 10:30 AM, the back door Main entrance was locked, and no one answered the bell. Upon proceeding to the entrance in the back of the building near the nurse's desk, the door was unlocked and open to walk in. A screening table was set up near the entrance. Nurses L and V were sitting talking at the nurse's desk about 10 feet away. After waiting several minutes, this surveyor asked the nurses for assistance. Nurse L was asked if anyone was assisting with screening staff and visitors and stated, I thought there was someone, but I don't know where they are today. Nurse L called for the IC Nurse and Administrator. During a tour of the facility on [DATE] at 10:35 AM with Infection Control (IC) Nurse A, she identified the 1st floor Hall (rooms 101 - 114) as the area designated for all residents: Residents that tested negative for Covid-19 and were asymptomatic, for those residents with signs and symptoms of Covid-19 and for the residents who tested positive for Covid-19; she said there was no area specific to Covid-19 positive residents or a monitoring unit for those with signs and symptoms of infection or potential exposure. The hallway was not partitioned off and was open on both ends. All of the resident's doors were open. The residents were intermingled with each other. There were no signs to identify Transmission-Based Precautions or which residents were placed in Transmission-Based Precautions to aid in preventing the spread of infection. The IC Nurse A said there were still Covid-19 positive residents awaiting transfer to a Hospital or HUB on the Hall. IC Nurse A was asked about the resident pictures and names on the room doors, as they were not matching which residents were in the rooms and stated, We've had people coming and going. Some of the previously Covid positive residents are being readmitted and I'm not sure who is in what room. The IC Nurse said Covid positive residents were sharing rooms with Covid negative/asymptomatic residents, We are waiting for some to transfer out. There were empty rooms observed on the hall. The IC Nurse indicated the resident in room [ROOM NUMBER] frequently left the facility for offsite [MEDICAL TREATMENT] services and was recently positive for Covid-19. The resident's room was located across from the nurses desk in the same hall with the other residents. During the tour with the IC Nurse and Administrator the IC Nurse said the 2nd floor unit was closed. All prior residents and the 16 current residents were placed in rooms on the first floor. The Administrator said the facility initially had a census of approximately 51 residents prior to residents testing positive for Covid-19 on [DATE]. The same day several staff members tested positive. While touring the facility, a resident (#5) was observed being transferred into another resident's room (Resident #4 in room [ROOM NUMBER]). Several staff were in the room wearing a Mask, but no additional PPE. The IC Nurse was asked if the residents were negative or positive for Covid and she said she didn't know, but on further discussion she said (Resident #4) had been refusing testing and was not symptomatic for Covid. The IC Nurse later said (Resident #5) was positive for Covid and they were waiting to send her to a HUB. She said she wasn't sure why Resident #5 was placed with Resident #4 when there were empty rooms. While walking down the hallway, it was noted that many of the resident's rooms shared a bathroom with the room next door. The resident in room [ROOM NUMBER] (a male) shared a bathroom with room [ROOM NUMBER] (A female #3 who was transferred to a HUB on [DATE]). Resident rooms that shared a bathroom on the first floor included: 114 and 112, 110 and 108, 107 and 106, 111 and 109. One resident in room [ROOM NUMBER] and one in 106 each tested positive for Covid-19 while sharing a bathroom. Resident #9/Covid positive shared a room (111) with Resident #10/Covid negative. Resident #9 was transferred to the hospital 5 days after testing positive and then Resident #10 transferred to room [ROOM NUMBER]. Resident #10's 2 roommates in 105 tested positive for Covid-19 and during the tour the IC Nurse said he was the only Covid-negative resident in room [ROOM NUMBER]; they were awaiting transfer of his roommates. Rooms ,[DATE] were 3 bed wards. On the 2nd floor unit there were 13 semi-private rooms. Only 1 room had a bathroom. The remainder of the rooms had to share 3 bathrooms in the hallway. All of the 2nd floor residents were transported to the 1st floor for a shower. In addition, the 1st floor resident bathrooms did not have a shower. There was 1 shower in the building located on the first floor, across the hall from rooms [ROOM NUMBERS], both with Covid positive residents and next to room [ROOM NUMBER]. All residents on both floors, regardless of exposure status were transported to this potentially infectious area for a shower, per the IC Nurse, until the facility stopped providing showers and residents were given bed baths in their rooms. During the tour on [DATE] at 11:40, staff were observed walking from one resident's room to another on the first floor. When questioned, Certified Nursing Assistants (CNA's) P, Q and T were entering room [ROOM NUMBER]. They said the 3 residents in the room were Covid positive. The CNA's were asked if they only cared for Covid positive residents and said their assignments were in various sections of the hall with some residents Covid positive and some negative. The IC Nurse was asked if the facility had dedicated staff for the Covid-19 positive residents and said they did not. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), last update: [DATE] . Any infectious agents transmitted in healthcare settings may, under defined conditions, become targeted for control because they are epidemiologically important .In determining what constitutes an epidemiologically important organism, the following characteristics apply: A propensity for transmission within healthcare facilities based on published reports and the occurrence of temporal or geographic clusters of >2 patients . A single case of healthcare-associated invasive disease . is generally considered a trigger for investigation and enhanced control measures because of the risk of additional cases and severity of illness associated with these infections . Common and uncommon microorganisms with unusual patterns of resistance within a facility . A newly discovered or reemerging pathogen . Numerous factors influence differences in transmission risks among the various healthcare settings . LTCF's (Long Term Care Facilities) are different from other healthcare settings in that elderly patients at increased risk for infection are brought together . Documented LTCF outbreaks have been caused by various viruses . and bacteria . prompt detection and implementation of effective control measures are required . Fundamental Elements Needed to Prevent Transmission of Infectious Agents in Healthcare Settings . Adherence to recommended infection control practices decreases transmission of infectious agents . Surveillance is an essential tool for case-finding of single patients or clusters of patients who are infected or colonized with epidemiologically important organisms . Surveillance of both process measures and the infection rates to which they are linked are important for evaluating the effectiveness of infection prevention efforts and identifying indications for change . Cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology and mode of transmission . Assigning or Cohorting healthcare personnel to care only for patients infected or colonized with a single target pathogen limits further transmission of the target pathogen to uninfected patients . A review of the facility Respiratory Infection Surveillance Line Listings for [DATE] - [DATE] revealed 43 of 51 residents (84.3%) tested positive for Covid-19 and 10 residents testing positive died . [DATE]: 1 resident tested positive for Covid-19 and was transferred to a Hospital. [DATE]: 4 residents tested positive for Covid-19 and were transferred to a Hospital. [DATE]: 2 residents tested positive for Covid-19 and were transferred to a Hospital [DATE]: 7 residents tested positive for Covid-19 and were transferred- 1 to a Hospital and 6 to a HUB. [DATE]: 1 resident tested positive for Covid-19 and was transferred to a HUB. [DATE]: 15 residents tested positive for Covid-19 and were transferred- 1 to a Hospital, 13 to a HUB and 1 to Home. [DATE]: 1 resident tested positive for Covid-19 and was transferred to a Hospital. [DATE]: 11 residents tested positive for Covid-19 and were transferred to a Hospital or a HUB. [DATE]: 1 additional resident tested positive and was transferred to a HUB. As of [DATE], 41 of 77 (53.2%) staff had tested positive for Covid-19: 16 of 24 Nurse Aides (66.7%) and 11 of 17 Nurses (64.7%). The facility did not have consistent dedicated and separate staff for Covid-19 positive residents, residents with potential exposure to Covid-19 and Covid-19 negative residents. On [DATE] the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) issued the following recommendations: . new recommendations to State and local governments and long-term care facilities (known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (Covid-19) . To provide critical, needed leadership for the Nation's long-term care facilities to prevent further spread of Covid-19, CMS and CDC are now recommending the following immediate actions to keep patients and residents safe: . To avoid transmission within long-term care facilities, facilities should use separate staffing teams for Covid-19 positive residents . and work with State and local leaders to designate separate facilities or units within a facility to separate Covid-19 negative residents from Covid-19 positive residents and individuals with unknown Covid-19 status . The goal is to decrease the number of different staff interacting with each patient and resident as well as the number of times those staff interact with the patient and resident. Also, staff as much as possible should not work across units or floors . Long-term care facilities should separate patients and residents who have Covid-19 from patients and residents who do not, or have an unknown status . Covid-19 positive units and facilities must be capable of maintaining strict infection control practices and testing protocols, as required by regulation . As of [DATE] the facility was still housing residents suspected of exposure to Covid-19 next to asymptomatic residents. Residents continued to share bathrooms. The facility did not designate a separate Covid-19 positive resident unit/area or observation/monitoring area for those residents potentially exposed to Covid-19 until [DATE]. This was 6 months after the CMS and CDC guidance was issued and almost 3 weeks after the facility began to identify positive cases of Covid-19. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated [DATE], . 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic . Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19. Limit and monitor points of entry to the facility. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection and that they are [MEDICATION NAME] source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a [DIAGNOSES REDACTED].??rm they have not been exposed to others with [DIAGNOSES REDACTED]-CoV-2 infection during the prior 14 days . . Re-evaluate admitted patients for signs and symptoms of COVID-19, Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate). . HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers .HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection . They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Wear an N95 or equivalent or higher-level respirator . . 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection . For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization . place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom . As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts . only patients with the same respiratory pathogen may be housed in the same room . Findings Include: On [DATE] at 2:35 PM, several staff members were observed sitting together in their cars in the parking lot without wearing Facemasks. An interview with IC Nurse A on [DATE] at 7:51 AM, revealed the facility previously had no identified residents with Covid-19 until the outbreak began [DATE]. However, there had been 3 Covid-19 positive staff: 1 on [DATE], 1 on [DATE] and 1 on [DATE]. The IC Nurse said the facilities residents were tested weekly after the [DATE] positive staff member and the staff began wearing masks, gowns, and gloves in the resident's rooms for approximately 14 days. She said the facility received a memo suggesting they could begin providing small resident group activities if social distancing measures were in place. On [DATE] through [DATE]th, 2020 the resident group Activities continued in the dayroom and upstairs areas until a staff member and resident tested positive for Covid-19 on [DATE]. She said all of the residents who attended the first group activity in the day room became positive for Covid-19, then multiple staff and residents began testing positive over the next 2 weeks. During the interview, the IC Nurse said she contacted the Local Health Department after the Covid-19 outbreak began and was advised to close the employee break room to limit staff contact and exposure and all staff were to go to their cars individually on break and not congregate. On [DATE] at 12:45 PM, Certified Nursing Assistant Y was observed standing in-between 2 parked cars, approximately ,[DATE] feet away from the open window of a truck, talking to another staff member. Certified Nursing Assistant Y did not have a mask on. The Nursing Assistant was asked about standing so close to the other staff member without a mask and said she didn't have to wear a mask in the parking lot. The Nursing Assistant was asked if she was following Social Distancing recommendations by standing and talking that close to someone else without wearing a mask and she said she didn't know. On [DATE] at 1:30 PM, during an interview with Certified Nursing Assistant AA, she was asked if residents who were positive for Covid-19 were placed in the same room with residents who were negative and said Yes, not now, but previously they were. On [DATE] at 2:37 PM, Nurse BB was interviewed about preventing the spread of Covid-19 infection and stated, Our assignments were with residents both negative and positive. I didn't know a Covid positive resident was supposed to have their doors shut. We didn't have signs telling us who was in precautions. CDC, Coronavirus Disease 2019 (Covid-19), Preparing for Covid-19 in Nursing Homes, updated [DATE], . Given their congregate nature and resident population served (e.g. Older adults often with underlying chronic medical conditions), nursing home population are at high risk of being affected by respiratory pathogens like Covid-19 and other pathogens . Core Practices . Educate Residents, Healthcare Personnel, and Visitors about Covid-19; current precautions being taken in the facility and actions they should take to protect themselves; Provide information about Covid-19 (including information about signs and symptoms) . Regularly review CDC's Infection Control Guidance for Healthcare Professionals about Covid-19 for current information and ensure staff and residents are updated when this guidance changes . Educate and train HCP (Healthcare Providers) . Reinforce adherence to standard IPC (Infection Prevention and Control) measures . On [DATE] at 1:20 PM, during an Interview with the Administrator, she was asked about staff education and said the facility provided the staff with education but did not always have proof that they received it. Sign in sheets for staff education related to Infection Prevention practices and Covid-19 were previously requested on [DATE] and not yet received during this interview. During an interview with the IC Nurse on [DATE] at 1:42 PM, related to staff education for Infection Prevention and Covid-19, she stated, Periodically I had hand-outs for the staff. She said education was provided in [DATE] and [DATE]. Copies of the staff sign in sheets was requested during the interview. A review of the Staff Education Meeting Sign- in Sheet topic Infection Control- Coronavirus dated [DATE] indicated 53 facility staff members signed that they received the training, including 16 of 23 Certified Nursing Assistants and 7 of 17 nurses. A review of the Staff Education Meeting Sign-in Sheet topic Annual Abuse and Safety Training, Covid/Infection Control, dated [DATE] indicated 18 of 23 Certified Nursing Assistants and 5 of 17 Nurses signed that they received the training. The facility lacked sufficient training for Covid-19 and Infection Control Practices to ensure all staff were prepared to provide necessary care to the facilities residents to prevent the spread of infection. During an interview with the Activities Director on [DATE] at 2:05 PM, she provided, The week before the outbreak, our restrictions were a little loosened. We could have activities with small groups; less than 10 residents. We had bingo downstairs, some crafts, games upstairs. There were about 15 group activities between [DATE]th and [DATE]th. There were stipulations. Employees and Residents had to wear full masks. We set it up so they could sit 6 feet apart. The first employee and resident that tested positive, at that point everything hit the fan. It felt like we were experiencing the second wave first-hand. CDC, Nursing Homes and Long-Term Care Facilities, Applying Covid-19 Infection Control Strategies in Nursing Homes, Closely Monitor Residents for Covid-19, [DATE], . You can identify changes early . The earlier you identify sick residents, the faster you can prevent Covid-19 from spreading . monitor for symptoms: New or different cough, sore throat, shortness of breath, muscle aches, new or worsening discomfort or tiredness, change in sense of smell or taste, diarrhea, chills, headache, new dizziness, confusion . older adults may not show typical symptoms . Sick Residents can Develop Severe Illness Quickly. Monitor Sick residents at least 3 times daily; Check vitals each shift; check oxygen saturation using pulse ox each shift; Look for new or worsening symptoms: Cough, Shortness of Breath, Worsening discomfort or tiredness, Confusion, dizziness; Report any concerning change in resident appearance or behavior . An Interview with the Director of Nursing DON, on [DATE] at 1:47 PM, related to assessment of the Residents for signs and symptoms of Covid-19 revealed, We take the resident's temperature twice each shift/ 4 times a day. There are sheets on each floor to record them. The nurse assessed for shortness of breath, loss of taste and smell, problems with eating and drinking. The DON was asked if an assessment with blood pressure, pulse, respirations, and oxygen saturation levels and lung sounds were completed routinely for the residents and said, No, it's not needed, unless they have shortness of breath or signs and symptoms for Covid. The DON was asked if a thorough nursing assessment may have identified residents with Covid-19 sooner and stated, No, I don't believe so. While interviewing Nurse I on [DATE] at 1:00 PM, she was asked what assessment was performed on the residents to aid in identifying signs and symptoms of Covid-19 and said, I would do whole body assessment: Respiratory, oxygen saturation, lung sounds, Blood pressure, heart rate, temperature and skin turgor/full body systems. On [DATE] at 4:28 PM, during an interview with Physician B on nursing assessment for Covid-19 provided, I believe they should do basic vital signs: Blood pressure, pulse, respiratory rate, temperature and lung sounds. These are basic. They do need to assess for loss of taste and smell, nausea and vomiting, diarrhea, respiratory signs and symptoms, cough, oxygen saturation, muscle aches. Reviewed with the Physician during the Resident's chart audits, there was documentation of ,[DATE] times daily Temperature, but not additional vital signs. The nurses were not documenting assessment of lung sounds or additional signs and symptoms of Covid-19. I can work on that. During the same interview, Physician B was also asked about Infection Control Practices for residents with signs and symptoms of Covi-19 or for those that tested positive and stated, Isolation means they have to put the residents in a single room, if they can. They should put them in one wing; keep them in their room in strict precautions- droplet and contact. N95 masks, gowns, gloves and all the PPE. If they are positive, they should be in strict precautions. Physician B discussed the process for new admissions and residents returning from the hospital and appointments and stated, They have to take precautions for 14 days. We don't know if they might have been exposed. On [DATE] at 4:23 PM, IC Nurse A who is also the Staff Educator, was interviewed related to nursing assessments to aid in identifying signs and symptoms of Covid-19, because upon chart review, it was identified that nurses were only completing routine temperatures on the residents without any other vital signs or body system assessments to aid in early identification of Covid-19 signs and symptoms; the IC Nurse said the nurses should have documented vital signs and assessments for signs and symptoms of Covid-19. On [DATE] at 11:55 AM, during an interview with Nurse E, the nurse said there were not enough nurses to perform resident assessments including a full set of vital signs, lung sounds and signs and symptoms of Covid-19. [DATE] at 1:54 PM, an interview with Nurse U, she said the nurses had been documenting resident temperatures only but were now completing a Covid assessment each shift for every resident. On [DATE] at 2:15 PM, an interview with the DON revealed, We were doing oxygen saturation and temps twice a shift. We do it at least 3 times a day. If they are not having low oxygen saturation or other issues, we are not necessarily assessing lung sounds. A record review of the Face sheet, vital signs, progress notes, physician orders, assessments, Minimum Data Set (MDS) assessments and Care Plans was completed for several of the following facility residents who were symptomatic or tested positive for Covid-19: Resident #1: Resident #1 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE] indicated the resident had full cognitive abilities with a BIMS (Brief Interview for Mental Status) score of ,[DATE] and needed some assistance with all care. The resident tested positive for Covid-19 on [DATE]. A review of the Weights and Vitals, indicated weekly blood pressure, pulse and respirations and a temperature three times a day. There were no oxygen saturation rates. There were no routine nursing assessments to identify signs and symptoms of Covid-19. The resident was transferred to the hospital on [DATE]. A progress note dated [DATE] at 4:07 PM revealed, Resident had two positive Covid tests today using the rapid [MEDICATION NAME] test. She is afebrile and asymptomatic . Resident #1's Care Plan dated [DATE] Potential for infection related to Covid-19 Pandemic, provided an intervention Monitor temperature BID (twice a day.) Report any fever Report any signs of pneumonia . Follow principles of infection control . Resident #2: Resident #2 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated he had moderate cognitive loss/BIMS ,[DATE] and needed extensive to total assistance with all care. A review of the resident's vital signs indicated temperatures were taken 3 times a day and a weekly blood pressure, but a full set of vital signs was not performed. There were no oxygen saturation rates to aid in identifying signs and symptoms of Covid-19 illness. On [DATE] he had a fever of 100.3 and 100.4 on [DATE]. There were no consistent assessments to aid in identifying signs and symptoms of Covid-19 illness. The resident was tested for Covid-19 on [DATE] during routine weekly testing and the results were received positive for Covid-19 6 days later on [DATE]. He was transferred to the Hospital on [DATE]. Resident #2's Care Plan dated [DATE] Potential for infection related to Covid-19 Pandemic, provided an intervention Monitor temperature BID (twice a day.) Report any fever Report any signs of pneumonia . Follow principles of infection control . Minimal 14-day quarantine for anyone suspected of exposure, has signs and symptoms of or active coronavirus and newly or readmitted residents. There was no clarification or description for quarantine. The Care Plan did not mention Transmission Based Precautions or what they would include. A review of the physician orders did not identify any order for assessment or Isolation precautions. Residdent #3: Resident #3 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed severe cognitive decline/BIMS ,[DATE] and assistance with all care. The resident was tested for Covid-19 on [DATE] with positive results received on [DATE]- 6 days later, with transfer to a HUB (for Covid-19 care) on [DATE]. A review of the vital signs indicated temperatures were taken three times a day and on [DATE] blood pressure, pulse and respiration and oxygen saturation were also documented. On [DATE] the resident had a temperature of 98.9 which was higher than her normal range of 96's to 97's. A review of the progress notes revealed the resident had vomited on [DATE] and had a temperature of 98.4. There was no increased monitoring documented. Resident #3's Care Plan dated [DATE] was the same as the other residents with the same interventions. Resident #4: Resident #4 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss with a BIMS score of ,[DATE] and needed some assistance with all care. During a tour of the facility with the IC Nurse on [DATE] at 10:40 AM, the resident was observed lying in bed near the window. The IC Nurse indicated the resident refused Covid-19 testing at times but did not have signs or symptoms of illness. On the same day at 11:15 AM, 2 staff members were observed transporting a resident into the room with Resident #4. The IC Nurse was asked if the resident was Covid negative and she said she did not know. She said it was a new admission. She was not placed in a separate monitoring area to determine if she may have been exposed to Covid-19 or was symptomatic. <br (TRUNCATED)

This Citation pertains to Intake Number MI 675. Based on interview, and record review, the facility failed to 1): consistently assess/monitor resident's respiratory status for signs and symptoms of COVID-19 including, but not limited to, cough, shortness of breath, sore throat, body aches, loss of taste, smell, diarrhea, nausea/vomiting, respiratory rate, lung sounds, chills; 2): failed to assess and monitor 20 of 20 residents reviewed for assessments (Residents #1 - #20) resulting in 10 residents, who were diagnosed with [REDACTED].#'s 5, 8, 9, 12, 13, 14, 15, 16, 19, 20) who expired without consistently documented respiratory assessments and complete vitals signs, in a facility census of 51 residents, resulting in 43 residents diagnosed with [REDACTED].#7, #16 and #17), resulting in the potential of serious complications related to head injuries to go undetected and untreated; and identify and implement interventions for those three residents with changes in condition, and appropriately assess and monitor a suspected Urinary Tract Infection for Resident #6. Findings include: Resident #6: According to Resident #6's medical record documented an admitted [DATE], into the facility with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) [DATE], reflected a Cognition Assessment Score of 5 out of 15 indicating severe cognition impairment. MDS reflected that Resident #6 required limited assistance with Activities of Daily (ADL) care. According to Facility investigative report dated [DATE], reflected an allegation of Abuse was made against the Director of Nursing, indicating he hurt Resident #6's hands. The Administrator suspended the DON and completed an investigation; reported to local Law Enforcement and State Agency. The report documented that Resident #6 was suspected of having a Urinary Tract Infection. In the investigation, it was documented that Resident #6's recollection of the events changed from time to time, and could not recall the event. An X-ray of left hand revealed no osseous abnormalities (no bones broke), Biofreeze was ordered to manage left knuckle pain. A Urinalysis Culture and Sensitivity (UA C&S) was ordered. The investigation reflected that Resident #6 was treated with Antibiotics, Keflex three times a day for 7 days. The facility was asked to provide the UA C&S that was collected to reflect appropriate use of Antibiotics to treat suspected urinary infection. The facility provided results of collected urinary specimen. Review of Urinalysis report dated [DATE], documented Results--UA C&S rejected. Sample expired. Collected date [DATE]. Arrived to lab [DATE]. Please recollect and return to lab with a new requisition date, ensuring specimen is within shelve life. The report was signed by the Medical Director as reviewed on [DATE]. Review of medical record reflected no additional urinary sample collected and sent until [DATE], to indicated appropriate use and treatment for [REDACTED]. Review of Progress notes dated [DATE], documented at 08:21 AM, Nurse received report from night- shift nurse that UA w/ C+S was obtained, and that her urine was positive for [MEDICATION NAME]. UA w/ C+S is pending pick up from lab. (There were no vital signs or temperature documented as obtained, or any documented signs and symptoms assessed for Urinary Infection such as frequency, urgency, burning and or flank pain). Review of Resident #6's vital signs section in the medical record, documented in 'Vital Signs' incomplete and sporadic vital signs entered in the record from time frame of [DATE] through [DATE], to include ( Blood Pressure, Pulse, Respiratory Rate, Oxygen Saturation, and Temperature). Resident #8: According to admission face sheet, Resident #8 was [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's MDS dated [DATE], documented a Cognition Assessment score of 9 out of 15 indicating moderate cognition impairment. MDS also reflected that Resident #8 required limited assist with 2 person for Activities of Daily Living Care. Resident #8 expired in the facility on [DATE]. Review of Progress notes dated [DATE] at 02:31 AM, documented Resident alert able to make needs known. CNA reports resident complained of SOB (shortness of breath). Nurse in to see. Resident stated she was hyperventilating, O 2 sat at 87 %. Concentrator obtained and resident on O2 (oxygen) on 2L (2 Liters), SVN (single volume nebulizrer) initiated for SOB and wheezes. Post treatment sat 92 %. (There was no documented assessment in the notes for Blood Pressure, Pulse, Respiratory Rate, Lung Sounds, or Temp. This was a noted change in condition from the previous note related resident up to activities sitting in her wheelchair in no distress.) Review of the next Progress note on [DATE] at 08:27 AM, documented Resident in bed, presents with acute dyspnea (Shortness of breath) with accessory muscle usage. Is alert but has difficulty speaking due to dyspnea. Oxygen placed previously. B/P ,[DATE], P ,[DATE], R ,[DATE], PO2 (oxygen saturation) 93 %, O2 on at 2L, spoke w PCP (primary care provider) send resident to hospital. ( There were vital signs documented with this assessment, but no documentation of a Temp, or lung sounds.) Review of vital signs in 'Vitals Sign' section' documented time frame of [DATE] - [DATE], three times complete set of vital were documented as obtained. Review of Progress notes dated [DATE] at 07:28 PM, Resident arrived from hospital, Alert and oriented, denies pain, VS-,[DATE], 80, 16, 95.8. There was no assessment for lung sounds, oxygen saturation or complete Respiratory Assessment documented. (Also no assessment made related to possible COVID-19 symptoms, which was beginning to appear in other Long Term Care facilities and hospitals at this point, along with recommendations from the CDC for preparation, assessment and monitoring.) Review of Progress notes dated [DATE] at 02:37 AM, documented Resident stated she was having a hard time breathing, PO,[DATE]%, resp 18, oxygen applied at 2L/NC after 15 minutes 95%, no use of accessory muscles noted, no neck vein distension, noted lungs diminished, some slight congestion noted. (There was no Blood Pressure, Pulse, Temperature documented, or any other assessment documented to include loss of taste/smell, body aches, chills, or potential COVID-19 symptoms documented as assessed.) Review Progress notes [DATE] at 02:59 PM, Rechecked resident and she said her breathing was much easier spo,[DATE]. (There was no documentation of lung sounds or vital signs or Respiratory assessment as performed). Review Progress notes dated [DATE] at 01:54 AM, documented At 11:30 Resident states I can't catch my breath. Her BP was ,[DATE], temp 98.8, pulse was 68, respirations were 20. Her spo2 was 93 on 2 liters. I was able to calm her down by sitting with her and getting her to do pursed lip slow breathing. But in no time she was high anxiety again. After several attempts of not being able to calm her down, I called the Doctor and he ordered [MEDICATION NAME] 0.5 mg for her. I gave her this at 1:20 AM, and at 2 PM, still high anxiety. Respirations were 28 and labored and not able to calm down. Spo2 was 92 on 2/liters. Doctor called and gave order to send resident to hospital. Resident still alert and responding well agrees to go. Son was called and informed. At 215 911 called. At245 911 (SIC) here evaluating her. At 3:15 left for hospital. (SIC). (There was no documented assessment for lung sounds, or any other documented assessment for COVID-19 symptoms.) Review Progress notes on [DATE] at 05:55 PM, Resident arrived to facility via EMS from hospital. In isolation for 14 days. Skin assessment completed with numerous bruising to right arm/hand .BP ,[DATE], res 20, pulse 64, PO2 98 % on 2 liters oxygen, temporal temp 96.3 ax. (SIC) Spoke with son and requested resident not be put back on [MEDICATION NAME], and [MEDICATION NAME], and [MEDICATION NAME]. Doctor notified of residents arrival. Meds approved and d/c of [MEDICATION NAME] and [MEDICATION NAME] at this time per family wishes. Diet cardiac with 2000 ml fluid restriction. HOB with 2 Liters o2 per n/c. (No assessment for lung sounds, body aches, loss of taste/smell or any COVID-19 signs and symptoms.) Review of progress notes dated [DATE] at 07:01 AM, documented Doctor called regarding resident restless sleep at night. Mumbles all night. Order received for [MEDICATION NAME] at bedtime. Order noted and carried out. (There was no vital signs documented or Respiratory assessment documented). Review of progress notes dated [DATE] at 02:22 PM, Resident resting in room, up in w/c. Denies pain. BP ,[DATE], pulse 90, res 18, P02 96%, Afebrile (no temp documented). On 2 liters per n/c. Resident able to express needs and concerns .LCTA (lungs clear to auscultation) yet with lobes diminished Review of progress notes dated [DATE] at 06:30 AM, documented Resident pronounced at this time. Resident son notified of his mother's passing. Doctor and on-call aware. Review of progress notes dated [DATE] at 07:00 AM, (30 minutes after resident expired), documented Resident was observed with her oxygen off and respirations at 24 - 26 per minute around 515am. The o2 was reapplied and HOB elevated to 90 degree's, spo2 at that time was 94%. An SVN (breathing treatment) was given at that time with some relief (no lung sounds assessed or respiratory rate documented post breathing treatment and pulse, or any other vital signs documented). Resident was asked if she wanted to go to the hospital and said 'No'. Resident with increased respiration's ,[DATE] per minute. The CNA assigned to her was asked to sit with her awhile, while a call was placed to the Doctor. The CNA came to the nurse station to report resident was unresponsive. The resident was unresponsive with no respirations. CPR was started and EMT was called. (There was no documentation's of Blood Pressure, Pulse, Temp, lung sounds, or any documentation made related to vitals signs before or during the code, or any assessments completed during resuscitation efforts, and/or any documented assistance from other staff in the facility, or any additional assessment completed. Resident #8 was a Full Code) Review of vital signs in 'Vitals Sign' section' documented in a time frame of [DATE] - [DATE], three times complete set of vital were documented as obtained. Resident #11: According to admission face sheet, Resident #11 was [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #11 Also had a peg tube in place for enteral feeding. Resident #11's MDS dated [DATE], documented a Cognition Assessment score of 15 out of 15 indicating no cognition impairment. MDS also reflected that Resident #11 required staff assist for Activities of Daily Living Care. Resident #11 expired in the facility on [DATE], and was a Full Code. Review of progress notes dated [DATE], documented Resident out of facility for eye exam. Review of progress notes dated [DATE], documented a dietary order for Nectar thick liquids only, by spoon, no straws, no sips, per Speech. Give resident small portions of food and small cup of liquids. Pt (patient) difficulty if given too much liquid orally. (resident previously not consuming oral intake and received feeding thru peg tube that was d/c in February.) Review of progress notes dated [DATE], resident out to doctor for new glasses's. Review of progress note dated [DATE], resident having difficulty with nectar thick liquids, increased episodes of coughing, or liquids running down mouth as spoon fed by staff. Staff also expressed concerns about nectar thick liquid safety. Resident did well with pudding thick liquids. Order changed back to previous of puree with pudding thick liquids. (There was no assessment made of lung sounds or any additional assessment with change in condition,) Review of progress notes dated [DATE] at 01:38 PM, After breakfast, temp 100.4. Tylenol given before lunch 98.9 and mid afternoon temp 97.7, Doctor called and given update message left on answering machine. At 01:49 PM, lung sounds diminished through out, no complaints of chest pain or back pain, heart rate 74 and regular, denies burning, and denies pain with voids, temp at this time 97.8, spo,[DATE]% and respiratory rate is 18. Review of progress notes dated [DATE] at 11:37 PM, documented that Resident is resting comfortably at this time, no s/s (signs and symptoms) of respiratory distress noted, T-97.5. (No set of vital signs or Respiratory Assessment completed and there were no other entries made in the progress notes by nursing related to Respiratory assessment, or any assessment from [DATE] until [DATE]. There were no entries made to indicate resident vomiting.) Review of progress notes dated [DATE], made by the Director of Nursing, documented Case discussed with IDT (Interdisciplinary Team) r/t resident's constant and consistent need to consume fluids to the point of gross excess. Resident consumes large glasses's of thickened liquid on a daily basis and continues to complain that she is not getting enough fluids. Staff is constantly offering and giving her fluids. This is not so much a matter of physical need to drink v (versus) a mental need for constant attention from staff. Resident on numerous occasions consumed enough fluids to the point of vomiting because her stomach cannot contain the fluid. ( There were no documented entries made by nursing indicating vomiting or demanding excess fluids prior to this entry.) Review of progress notes dated [DATE], reflected an entry upgraded to honey thick liquids again. Review of progress notes dated [DATE], reflected an entry liquids changed to pudding thick only. Resident coughing and choking, kitchen aware. (There were no previous entries made by nursing of Resident #11 not tolerating her liquids, vomiting, choking, and there was no documented Respiratory Assessment completed to include vital signs and lung sounds or Oxygen saturation.) Review of Progress notes dated [DATE] at 10:50 AM, Resident running a low grade fever on midnights, then 99.0, 97.8, 97.9. Infection control Nurse aware and B/P ,[DATE], spo-2 96%, pulse 74, resp 20. In bed with HOB elevated, also appears flushed in the face.(There was no entry made by previous shift of an increase in temp or any assessment documented. No Assessment of lung sound or any symptoms of COVID-19 documented.) Review of progress notes dated [DATE] at 11:12 AM, Resident presents with a cough, coughing up phlegm at times, had temp 100. Temp 99.0 (There was not a documented Respiratory Assessment). Review of progress notes dated [DATE], UA +, many bacteria, awaiting C&S, c/o pain, Tylenol given. ( There were no vital signs documented or signs and symptoms for Urinary Tract Infection such as frequency, burning, or flank pain.) Review of progress notes [DATE], UA with > 100,000 E Coli (bacteria found in stool), Start [MEDICATION NAME]. (There was not an assessment documented for Urinary Tract Infection or vital signs.) Review of progress notes dated [DATE] at 06:14 AM, Resident alert, slow to respond. No other symptoms so far .at 5 AM, resident had a temp of 101.7. Tylenol given. Spo2 95%. (There was no Respiratory Assessment completed for lung sounds, Respiratory Rate, Pulse, and there was no Blood Pressure documented as obtained.) Review of progress notes dated [DATE] at 07:15 AM, Resident with cough and congestion. Temp 101.2. Tylenol from 2nd shift given. Po2 93% RA (room air). (There was not a Respiratory Assessment documented as completed.) Review of progress notes dated [DATE] at 10:00 AM, Temp 100.6, fluids given. (No Respiratory Assessment documented as completed.) Review of progress notes dated [DATE] at 05:25 AM, Resident was complaining of pain all over. I gave her Tylenol at 4 AM. At 5:30 AM, her Temp 99.9. (No Respiratory Assessment documented or vitals signs.) Review of progress notes dated [DATE] at 04:12 AM, Resident displayed DIB (difficulty in breathing). O2 at 4 liters given via nasal cannula and breathing tx (treatment) given. HR 150, BP ,[DATE], T 98.9, O2 90 % and falling to 86%. LS (lung sounds) with rales (abnormal lung sounds) thru out. expiatory (SIC) grunting began by resident. DON and Doctor notified. EMT's called and they arrived in room. At 3 17 (SIC) resident coded and code was called at 3:49 am. DON Doctor and family notified. Doctor at hospital called residents demise . (There was no additional notes related to resuscitation efforts and related to staff assist.) Resident #12: According to admission face sheet, Resident #12 was [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #12's MDS dated [DATE], documented a Cognition Assessment as not scored, indicating cognition impairment. MDS also reflected that Resident #12 required staff assist for Activities of Daily Living Care and receiving Hospice Services. Resident #12 expired in the facility on [DATE]. Review of progress notes dated [DATE], Resident admitted to the facility from (another LTC facility) to room ,[DATE]. Alert with confusion displayed. No verbal response. Up in wheel chair. No signs and symptoms of pain . Review of progress notes dated [DATE], [DATE], and [DATE], documented by nursing, reflected several self transfer attempts. There was not another entry in progress notes made by nursing until [DATE], which did not reflect any Respiratory Assessment for COVID-19 symptoms or any documented assessment or monitoring being done. There was no Respiratory Assessment documented as being conducted to monitor for COVID. On [DATE], a note was made by Nurse Practitioner, (entered as late entry on [DATE]). Review of progress notes dated [DATE] at 02:32 PM, documented Resident tested positive for COVID-19 and will be sent to hospital. Family and PCP (Primary Care Physician) notified. STAT EMS notified for transfer. (There was no Respiratory Assessment documented, or any vital signs to reflect symptomatic or symptomatic for COVID-19 infection. Review of progress notes dated [DATE] at 11:01 PM, documented Resident returned from hospital tonite via ambulance she is alert. Does not seem to be in any distress. Doctor aware of her return. Orders are to resume previous orders. Temp 97.7 pulse 84 resp 18 bp ,[DATE] Spo2 is 92 on room air (This was the only assessment and vital signs documented in progress notes made by nursing.) Review of progress noted dated [DATE] at 06:09 AM, Resident at 330 (SIC) has increased chest congestion. Temp now is 99.2 Tylenol given. spo2 is 92 on room air. (There was no Respiratory Assessment to include Lung sounds, Blood Pressure, Pulse, Shortness of Breath, Respiratory Rate. The only assessment was for temperature and oxygen saturation.) Review of progress notes dated [DATE] at 02:16 PM, Resident continues to be lethargic with [MEDICATION NAME] congestion. Poor oral intake today. Hospice RN here and orders noted for 2 view chest X-ray and O2 2L/min as needed for dyspnea. (No vitals documented or Respiratory Assessment.) Review of progress notes dated [DATE] at 10:07 PM, Nurse in room start of PM shift. O2 sat in low 80%. O2 turned up to 3.5 liters and sat up to 90 %. In room after med pass and legs and arms mottled (changes color with lack of blood perfusion to extremities). DON notified, Dr notified and Hospice called. (There was no Respiratory Assessment or vital signs documented to reflect Resident #12's declining status.) The next entry in progress notes was made by nursing on [DATE] at 04:00 AM, Resident is non responding She opens her eyes but non verbal, unable to accept food or fluids. Her spo2 on 3.5 liters is 90. She has increased chest congestion. At 4am I gave her [MEDICATION NAME] and [MEDICATION NAME] for shortness of breath and restlessness as well as [MEDICATION NAME] increased congestion and terminal restlessness. At 430 seems to be helping (SIC). Resident was given bed bath and good oral care. (There were no vital signs documented or completed Respiratory Assessment documented as performed.) Review of progress notes dated [DATE] at 10:35 AM, Resident resting in bed and did appear to have slight increase in respirations (no rate documented) and restlessness. Given PRN [MEDICATION NAME] and [MEDICATION NAME] for comfort measures with good results. Family updated on condition. (No vitals documented or Respiratory Assessment.) Review of progress notes dated [DATE] at 08:16 PM, CNA (nursing assistant) at cart to report resident not breathing. Nurse in room for vitals. NO pulse or blood pressure obtained. DON notified of event. Hospice called and will call back. (There were no documented assessments from previous shifts with vital signs or and assessment made by nursing prior to Resident #12 expiring. There were no assessments completed related to COVID-19 during COVID crisis. COVID was in the facility around mid October with positive residents and staff.) Review of Resident #12's Vital Signs section in the medical record reflected from a time frame of [DATE] - [DATE], there were no complete documented vitals signs in the record to reflect Blood Pressure, Pulse, Respiratory Rate, Temperature, and Oxygen sat's. The vitals signs were sporadic and at times only Temps were obtain. Other times Oxygen sat's were obtain . A phone interview was conducted with the Medical Director on [DATE] at 4:38 PM, related to what specific assessments nursing should be completing during COVID-19 crisis, and verbalized that Nursing should be assessing at a minimum at least Temperature, Respiratory Signs and Symptoms such as lung sounds, respiratory rate, shortness of breath, cough congestion . diarrhea, mental status changes, confusion, loss of taste and smell, and a variety of other things. For unwitnessed falls, or if a resident hits their head, a Neurological Assessment be completed to monitor changes in level of consciousness and other serious complication such as bleeding in the brain or increased pressure, for minimum 72 hours. For Urinary Tract Infections, assessment for burning during urination, flank pain, frequency, and Temps. The MD was asked about assessments for Hospice residents and if nursing should be performing them. The MD indicated that anyone on Hospice should have a basic assessment completed regularly, and that Hospice residents need alittle more of an assessment completed to ensure comfort care, and extra care and ensure good pain management. The MD also verbalized that anyone returning from the hospital, the nurses should be assessing for shortness of breath, fever, fluid or oral intake, overall vital signs, and assess for Pneumonia as a basic assessment. The MD also indicated that they should be assessing for COVID-19 and if there are no symptoms, than an assessment completed for change in condition, mental status changes. The MD was made aware that nursing was not consistently monitoring for COVID-19 signs and symptoms and are mainly taking Temperatures as an assessment and had not been assessing through out the COVID-19 Pandemic. He indicated there should be a completed basic assessment done at a minimum and that nursing should be documenting a basic assessment at least once a shift times 14 days continuously to include vitals signs and Respiratory Assessment upon return from hospital. The MD verbalized he was aware that documentation was lacking on the facility's part. He also verbalized he was aware of COVID out break that occurred in the facility and swept through sometime in October. Resident #13: According to admission face sheet, Resident #13 was [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #13's MDS dated [DATE], documented a Cognition Assessment was not scored indicating cognition impairment. MDS also reflected that Resident #13 required staff assist for Activities of Daily Living Care. Resident #13 expired in the facility on [DATE], and was receiving Hospice Services. Review of progress notes dated [DATE] at 04:12 PM, by Activities Resident is sitting up in bed during staff visit review of progress notes dated [DATE] at 09:12 AM, Congestion present, vitals ,[DATE], 16, 70, 98.1, spo2 94, Hospice called and waiting call back. Resident unable to cough up secretions. 2nd call to Hospice at 09:57 AM, to eval resident. At 10:17 AM, Hospice to evaluate Resident today. Review of progress notes dated [DATE] at 05:53 PM, Hospice nurse visited. Staff reported that resident was congested and having difficulty coughing up mucous. Resident has diminished lung sounds. Hospice ordered [MEDICATION NAME] (med to help dry up secretions) Q (every) 4 hours PRN (as needed) (There was no vital signs takes or complete Respiratory Assessment documented by nursing). Review of progress notes dated [DATE] at 03:50 PM, by the DON, Resident continues on Hospice, no changes to left heel diabetic heel ulcer, conservative measures in place. Continue with present interventions. Review of progress notes dated [DATE] at 10:38 AM, Resident appears to be resting comfortably in bed, however, her respiratory rate increased to 30 and shallow, and she has audible secretions. Given PRN [MEDICATION NAME] and [MEDICATION NAME] at that time with effective results. Will continue to monitor. (There were no vitals signs documents, or Respiratory Assessment documented.) Review of progress noted dated [DATE], documented that residents guardian was informed of a room change. Review of progress notes [DATE] at 09:45 AM, CNA at desk said resident had passed. Nurses in room with 0 vitals obtained. Doctor notified. Order received to release body. Hospice called and will return call. Review of Resident #13's Vital Signs section in the medical record reflected from a time frame of [DATE] - [DATE], there were not complete documented vitals signs in the record to reflect Blood Pressure, Pulse, Respiratory Rate, Temperature, and Oxygen sat's. The vitals signs were sporadic and at times only Temps were obtain. Other times, Oxygen sat's were obtain. Resident #17: According to admission face sheet, Resident #17 was [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #17's MDS dated ,[DATE]//20, documented a Cognition Assessment as 2 out of 15, indicating severe cognition impairment. MDS also reflected that Resident #17 required staff assist for Activities of Daily Living Care to include Bed Mobility and Transfers. Review of progress notes dated [DATE] at 02:27 PM, Resident has a non productive cough. PRN cough syrup given as ordered. No respiratory distress noted. (There was no vital signs documented, or basic assessment documented as completed or Respiratory Assessment documented.) Review of progress notes dated [DATE] at 01:52 PM, Observed on floor, feet by locked wheel chair and upper body near foot of bed facing door, at this time no complaints of pain, no injuries noted, Dr. notified and family contacted and DON notified Vitals 97.3, 68, 18, ,[DATE], 94spo2, (SIC) alert and oriented times 2. (There was no documentation about Range of Motion to extremities or any assessment for Neurological Status, such as Pupil response, hand grips, or changes in level of Consciousness.) Review of progress notes dated [DATE] at 12:59 PM, Approximately 1220 pm (SIC) resident was observed on floor on knees in front of w/c (wheelchair) and bedside table. Resident was eating lunch in room. Denies pain. Denise hitting head yet unwitnessed. No apparent injury noted. Resident was wearing non grip socks as well. BP ,[DATE] pulse 59 res 18 PO2 92% on room air temp 96. F tympanic ( behind ear). Assisted times 2 back to w/c. Neuro checks initiated. WNL at this time. Will initiate floor pad at bedside. Physician, DON, Family, notified. Review of progress notes dated [DATE] at 01:52 PM, At 1:10 pm, summoned to resident's room, observed resident laying on the floor on his stomach at bedside. He is alert and responsive, denies pain or discomfort, yelling to get him off the floor. With assist x 2, resident repositioned on his back, ROM (range of motion) performed x 4 extrems with no s/s of pain or injury, no scratches or abrasions noted. Vitals ,[DATE], 64, 18, 98.8. Hoyer lifted back to bed, neuro checks initiated. Physician and guardian aware. Review of progress notes dated [DATE] at 12:21 PM, Observed on floor, pillow under head laying on left side, resident want (SIC) to walk to bathroom unable to bear weight on legs and he is hoyer, wheelchair not in room, gripper socks in place, Dr. called and daughter and ADON (Assistant Director of Nursing) notified. Temp 98.5, 68, 18, ,[DATE], 96%, Alert and oriented times 2, unsafe safety awareness, denies pain at this time. The facility was asked to provide Incident and Accident reports for 4 unwitnessed falls and Neurological Assessments for all 4 falls. Review of Incident/Accident report dated [DATE], documented an unwitnessed fall on the report, that occurred in resident's room, due to self-transfer, and no documented injuries. The intervention documented on the Incident report was Not to leave resident alone in room. The facility did not provide Neurological Assessment after 3 requests by the end of survey. The DON verbalized he was not able to find a Neurological Assement for that fall. Review of Incident/Accident report dated [DATE], documented an unwitnessed fall that occurred in resident's room, alert with confusion at times. The Incident indicated Neurological Assessment was initiated at that time. Intervention documented was for floor mats to be initiated and care plan updated. A completed Neurological Assessment was provided. Review of Incident/Accident report dated [DATE], documented an unwitnessed fall in resident's room, of resident lying on stomach on the floor. No injuries were documented on the report. On the report, the DON documented that the Care Plan was not followed due to CNA left room briefly and came back to room and resident was on the floor. (previous intervention from [DATE], not to leave resident alone in room.) Neurological Assessment was provided that was initiated on [DATE] at 1:15 PM. Review of the Neurological Assessment reflected that on [DATE], 1st shift, no Neurological Assessment was performed for the whole shift. It was blank all the way down the form. Documentation for the Neurological Assessment resumed on [DATE] on 2nd shift. According to the Neurological Flow sheet, Neurological Assessment are to be completed at a suggested frequency of: every 15 minutes x 1 hr, every 30 minutes x 2 hrs, every 1 hr x 2 hrs, and every shift for 72 hrs. Review of Incident/Accident report dated [DATE], documented an unwitnessed fall in residents room, where he slid to the floor. No injuries were documented on the report. Resident #17's head was documented as being at the foot of the bed. The intervention documented for Resident to be up by the nurse station. The facility did not provide Neurological Assessment for the unwitnessed fall for [DATE], by the end of survey. The DON was not able to locate Neurological Assessment for that fall. Review of Facility Policy 'Neurological Assessment' documented under 'Purpose' as to provid (TRUNCATED)

This intake pertains to Intake Number MI 985 and MI 150 Past noncompliance was presented by the facility on 11/1/18 at the beginning of the investigation and was accepted by the survey team. Following discussion with the State Agency, past noncompliance was accepted and cited. Based on observation, interview and record review the facility failed to prevent continuous sexual acts and contact between Resident #501 and a facility staff member. The facility was placed in Immediate Jeopardy (IJ) as a result of the facility's failure to prevent a sexual relationship between CNA (Certified Nursing Assistant) C and Resident #501 and to ensure that facility staff are not utilizing their position of power to take advantage of facility residents. Resident #501 disclosed on (MONTH) 13, (YEAR) to her daughter that she engaged in two separate sexual acts with CNA C on two separate occasions. Michigan State Police administered a polygraph examination on CNA C on (MONTH) 29, (YEAR). CNA C failed the polygraph and subsequently admitted to receiving oral sex and masturbation from Resident #501, in addition to clutching the resident's breasts. CNA C was arrested and lodged at Genesee County Sheriff's Department on a felony charge of Criminal Sexual Conduct (CSC) in the 3rd Degree. This deficient practice placed all female residents under the care of CNA C at risk for sexual assault, harm and/or injury and caused Resident #501 mental and emotional anguish. Findings include: On 11/1/18 at 9:50 AM, an interview was conducted with the Administrator and DON (Director of Nursing) regarding the incident with Resident #501. The Administrator reported the resident's daughter contacted the facility on 10/13/18 and reported her mother disclosed that she had sexual contact with a male facility staff member. The Nurse ended the phone call with Resident #501's daughter and contacted the DON. The DON arrived at the facility on 10/14/18 around 9:00 AM with Argentine Township Police Department to begin the investigation. CNA C was interviewed by the Administrator and DON and denied the allegations. CNA C was interviewed a 2nd time by law enforcement and then submitted to a polygraph examination that was conducted by the Michigan State Police on 10/29/18. The CNA failed the examination, confessed and was lodged in the Genesee County Jail. The DON reported the resident reported the incident was about 2 weeks ago but added she is a poor historian as it relates to time. The DON reported they were unable to solidify an exact date that the interactions occurred. Resident #501 is cognitively intact and is her own decision maker. The DON stated the Resident explained CNA C and Resident #501 became friends in the summer and she would confide in the CNA as she was depressed and felt abandoned. In July, CNA C's brother passed away and he confided in Resident #501 about this. It was believed Resident #501 is in love with CNA C and feels scorned. On 11/1/18 at 10:46 AM, a search was completed on Vinelink (Michigan website that displays current county jail inmates). This search conducted for CNA C showed he was currently In custody at Genesee County Sheriff's Office. A review was completed of Resident #501's medical records on 11/1/18 at approximately 10:55 AM. It revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #501 was cognitively intact. On 11/1/18 at 11:05 AM, an interview was conducted with Nurse D, who received the phone call from Resident #501's daughter on 10/13/18. Nurse D reported she worked from 4 AM- 8 PM on this day and added Resident #501 was under her care for her entire shift. She reported this resident is the 1st resident that she visits in the morning due to her medication needs. She reported Resident #501 likes to hold conversations and throughout the shift the resident never mentioned anything to her about her sexual contact with CNA C. Nurse D explained around 4:15 PM Resident #501's daughter called the facility and was upset and stated her mother had called her and said she was sexually assaulted by a male CNA. The Nurse ended the phone call and took CNA E with her to Resident #501's room to complete a brief interview and assessment. The Resident was taken to a private area and asked about the sexual incident. Resident #501 stated what her daughter reported to the nurse was true and the male aide was CNA C. When the resident was questioned on what occurred she stated, He (CNA C) put his fingers inside of me and there was oral. Nurse D questioned Resident #501 if the sexual encounters were forced and the Resident replied, I preformed oral on him and then laughed and said, I'm fine. Resident #501 stated, It (CNA C's penis) was right there. She continued that the incident occurred 1.5 weeks ago. Nurse D reported the resident denied telling anyone until today as CNA C had stated, He knew how to hurt people if she told anyone. The DON completed a skin assessment on the resident and there were no unusual marks or bruises observed on Resident #501's body. Nurse D reported she called the DON who instructed her to contact CNA C and inform him that he is suspended pending the outcome of the investigation. On 11/1/18 at 11:30 AM, an interview was conducted with Resident #501 regarding her sexual contact with CNA C. The resident stated when CNA C was assigned to care for her, they established a friendship. She reported he would talk to her about his mother and the death of his brother over the summer. She reported she would talk out his issues with him and CNA C consistently said that he loved, wanted to take care of and protect her. She reported her daughter informed her that she would be leaving the facility and she told CNA C this and he stated, She (Resident #501's daughter) did not know that you (Resident #501) already have someone to take care of you. She continued that the CNA put his number in her phone and she called him a few times. She reported CNA C was frightened of losing his CNA license and did not want the resident to have her daughter come after him (Resident #501's daughter is employed in Law Enforcement). Resident #501 reported there were two separate incidents. The 1st time, she was laying down in her bed and had on her pajamas. CNA C was sitting in the resident's wheelchair that was near the resident's bed. Resident #501 reported CNA C shoved his hand down her pajama pants and then went underneath her brief (he entered her brief close to her inner thigh). CNA C then inserted his fingers into the Resident's vagina, he took his thumb and massaged Resident #501's clitoris causing her to have an orgasm. The resident reported she did not hit the call light button because CNA C would have saw her and could have easily just turned it off. She reported she said, OMG (oh my god) I just had a climax, that was my first, and CNA C responded I know. She reported after this incident they never spoke about it and he would come in during his shifts and give her a kiss on the cheek. Resident #501 explained she was gullible and thought that CNA C cared about her and wanted to take care of her once she was released from the facility. She reported she bought what he said, Hook, line and sinker. The 2nd incident: Resident #501 was again in her room and CNA C asked if she sucked? She reported she told the aide she had not performed oral sex in a long time. Resident #501 reported she preformed oral sex on CNA C and during the act he kept pushing the back of her head forward, to insert more of his penis into her mouth. She reported He was too big and I did not last long. Resident #501 denied she and CNA C ever had sexual intercourse with one another. Resident #501 reported throughout her conversations with CNA C he kept reiterating that he did not want to lose his CNA license and their sexual contact with one another would screw that up. The resident reported CNA C never physically harmed her, but he did emotionally and mentally abuse her. Resident #501 reported she disclosed what happened to her, because once she was discharged she did not want this to occur to anyone else. The resident reported she believes that both of her roommates were present during these incidents. An interview was conducted with Detective Sergeant F on 11/1/18 at 12:10 PM. He reported CNA C initially denied all of the allegations and once he was administered the polygraph and failed, was when he admitted to clutching Resident #501's breast and receiving oral sex and masturbation from the resident. Resident #501 wrote CNA C a list of demands for him and made multiple calls to his cell phone, but he never answered. Detective Sergeant F reported CNA C was subsequently charged with CSC (Criminal Sexual Conduct) in the 3rd Degree. Detective Sergeant F provided a copy of the polygraph examination with CNA C. At 1:06 PM on 11/1/18, a phone call was attempted with CNA E who accompanied Nurse D during the initial interview with Resident #501. There was no answer and voicemail was left requesting return phone call. A review was completed of the FRI (Facility Reported Incident) investigation file that the facility provided, on 11/1/18 at approximately 1:30 PM and the following documents were reviewed: Argentine Township Police Report Interview with Resident #501 on 10/14/18 at 9:30 AM. - .(Resident #501) explained she didn't remember the exact date, but about two weeks ago around approximately 8:00 PM she was in her bedroom .She stated in the first incident with (CNA C), he sat in a chair next to her bed. He inserted his finger in her vagina and moved her clit with his thumb .Resident #501 said that days before the first incident, CNA C told her that he knew how to hurt her, and she took it as a physical threat .A couple days after the first incident she was laying in her bed again sometimes between 9:00 PM-10:00 PM, when CNA C came to her room and asked her if she sucked and she replied not for a long time. She said then he put his penis in her mouth. He was next to her bed and grabbed her head and pushed the back of her head further on to his penis. (Resident #501) stated she must not have been that good since he didn't do it very long . Interview with CNA C on 10/15/18 at 12:45 PM - .(CNA C) said after a while (Resident #501) stated asking a lot of personal questions. (CNA C) said as time went on (Resident #501) wanted more than a friendship. (CNA C) said he brushed off the comments being made by (Resident #501). (CNA C) said he did make the mistake of giving (Resident #501) his phone number. (CNA C) said he gave (Resident #501) his phone number because she told him she was having issues with her husband and she feared her money was being spent. (CNA C) said he felt he could help her by giving his phone number in case she wanted to talk. (CNA C) said after he gave her the phone number, he felt that was probably a mistake. (CNA C) said she called him once and he did not answer and block her number . (CNA C) denied all of the allegations and stated never touched (Resident #501) in any sexual manner. (CNA C) said he only helped (Resident #501) off the toilet twice, that is the only time he touched her . Phone call history for CNA C from 8/29/18-9/25/18 revealed there were 11 calls made to CNA C's cellular device by Resident #501 from her personal cell phone. It can be noted CNA C did not answer any of the phone calls and the duration of all 11 phone calls were 0 minutes, 0 seconds: 8/29/18 at 6:28 PM 9/3/18 at 5:32 PM 9/4/18 at 9:26 AM 9/4/18 at 5:49 PM 9/15/18 at 10:28 AM 9/23/18 at 6:51 PM 9/27/18 at 3:26 PM 9/30/18 at 6:24 PM 10/1/18 at 10:48 AM 10/6/18 at 8:50 PM 10/15/18 at 1:34 PM On 11/1/18 at approximately 2:00 PM, a review was completed of CNA C's Human Resources File and it revealed the following: - Personal Electronic Device Policy signed by CNA C on 3/18/18. The facility policy stated, .Freedom from Abuse: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated by nursing home staff/contracted employees/volunteers taking or using photographs or recordings in any manner that could demean or humiliate a resident(s) - Per the Training Hours report ran on 10/30/18 for CNA C he received the following trainings as it relates to this incident: - The Elder Justice Act completed via online training on 3/8/18 - Protecting Resident Rights, Abuse & Neglect, Safety Lockdown Policy completed via online training on 7/11/18 - Preventing, Recognizing, and Reporting Abuse completed via online training on 8/2/18 - Abuse and Neglect completed via online training on 8/2/18 - On 3/8/18 CNA C signed off on the following items which acknowledged his understanding and willingness to abide by them: Bill of Right Acknowledgment I, as an employee of the (Nursing Home Facility) acknowledge receipt of the Patient Bill Rights and further understand that these rights have been explained and/or read to me in the language which I understand. Employee Certification I have read the definitions of abuse, neglect, endangerment, catastrophic reactions and exploitation, and understand the responsibility I have to not violate the rights of the residents and requirement to report any violations, which I suspect. I understand that any suspected violation will be reported to the Charge Nurse, Director of Nursing and Administrator. On 11/1/18 at 3:12 PM, an interview was conducted with Family Member K regarding the incident with Resident #501. Family Member K reported her mother was requesting an attorney for over a week but would never tell her the reason why she needed one. On 10/13/18 is when Resident #501 disclosed that for the last few weeks she was being touched in a sexual manner by a male CNA. Resident #501 reported she performed oral sex on the male staff and reported being touched by the staff member. Family Member K stated the CNA gave Resident #501 the attention that she wanted. Family Member K reported after her conversation with her mother she contacted the facility to inform them of the allegations and an investigation was begun. She reported that it is her understanding the male aide confessed and was charged. On 11/1/18 at 3:40 PM, an interview was conducted with Resident #501. She reported that she did write a note to CNA C informing him of what she needed in a man, if he was going to take her home and care for her. She reported CNA C never touched her breasts and she never performed masturbation on him. On 11/1/18 at 3:50 PM, an attempt was made to interview Facility Resident L (Roommate of Resident #501). This writer was informed by Social Worker I that this resident was currently at an acute care hospital. On 11/1/18 at 3:55 PM, an interview was attempted with Facility Resident M (Roommate of Resident #501) this resident reported she did not realize that she had a roommate. It was verified via Social Worker I that this resident is not cognitively intact. On 11/1/18 at 4:30 PM, the Immediate Jeopardy (IJ) was presented to the facility (Administrator and DON), as it was identified on 11/1/18. The facility provided a Past Non-Compliance Plan and stated the plan has already been enacted and the immediacy removed. The Past Non-Compliance plan was accepted by the Survey Manager on 11/2/18. The plan is as follows: Description of Incident: Resident #501 alleged that she had sexual contact on two separate occasions with CNA C approximately two weeks ago. She cannot give specific times or dates. Element #1: The staff member that was accused of inappropriate touching of a female resident was immediately suspended on the afternoon of 10/13/18, before he was to report for the start of the shift. Resident #501 was assessed for any apparent injuries and none were noted by the nurse. The Responsible Party and Attending Physician were notified immediately following the allegation. The Argentine Police Department was contacted on 10/14/18 and the resident who made the allegation was interviewed by the responding officer and the Director of Nursing (DON). On 10/15/18 the staff member was interviewed by the DON and the Administrator. The staff member agreed to be questioned by the Argentine Township Police and submit to a polygraph test. On 10/29/18 the staff member was terminated from employment after failing a polygraph exam and confessing to the allegations. Resident #501 continues to be seen by contracted psychiatric services for counseling and medication management. She denies pain or trauma from the incident. At the request of the Administrator, the Argentine Township Police has issued a no trespass order to the staff member to prevent the staff member from entering facility property. Element #2: All female residents are at risk. Social Services conducted interviews with female residents in the facility. Female residents interviewed indicated that they had no concerns with their care or that any staff member(s) made them uncomfortable in any manner. Element #3: Staff has been educated on the facility's policies for Abuse and Neglect Prohibition and reporting allegations of abuse and neglect on (MONTH) 31, (YEAR). The facility's policies on Abuse, Neglect and The Elder Justice Act has been reviewed by the Director of Nursing and deemed appropriate as written. Information will continue to be presented regularly to Resident Council on where State Agency contact information is located and how and who to report concerns to. The facility's Social Services Director has informed residents that they can report any concerns immediately to the Director of Nursing, Social Services Director and/or Administrator. Staff will be interviewed randomly on abuse and neglect with emphasis on recognition and reporting. Element #4: The Social Services Director or designee is responsible to conduct a minimum of 5 resident interview audits for any concerns of inappropriate contact or forms of abuse. Audits will be conducted weekly for four weeks, then monthly for three months then quarterly for three quarters. The Social Services Director will report the findings to the QA/QAPI committee for any recommendations. The Director of Nursing is responsible for compliance. Completion Date: 10/31/18 On 11/1/18 at approximately 5:00 PM, a review was completed of the facility policy entitled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 2/18/18, the policy revealed: .Abuse. The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish .it includes sexual abuse, physical abuse and mental abuse .Exploitation taking advantage of a resident for personal gain through manipulation, intimidation, threats or coercion . The immediacy was removed on 10/13/18, when CNA C was suspended by the facility, pending the outcome of the investigation. On 11/1/18, it was verified that the facility had completed all elements of their IJ removal plan and, as a result, was in compliance as of 10/31/18. The facility requested Past Non-Compliance and the deficient practice is being cited at Past Non-Compliance. The State Operations Manual under Guidance for F-600 states in part, Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged a consensual relationship, is not consistent wit the staff member's role as a caregiver and will be considered an abuse of power.

Based on observation, interview and record review, the facility failed to prevent a facility acquired pressure ulcer from increasing in size for 1 (#402) of 3 sampled residents from a total sample of 14 residents evaluated for pressure ulcers, resulting in a stage 4 pressure ulcer (an injury to the skin and underlying tissue resulting from pressure or shear), and worsening of pressure ulcer. On 9/11/17, at 10:00 AM, record review revealed that Resident 402 was admitted into the facility with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment (MDS), dated [DATE], revealed resident 402 had severe impaired cognition and required extensive assistance of 1 person for transfers and bed mobility. On 9/11/17, at 11:10 AM, observed Resident #402 sitting up in wheelchair (w/c) in room and at 1:15 PM, the resident was sitting up in a w/c in dining room. On 9/12/17, at 11:30 AM, Resident #402's wound care was observed with nurse A and nurse I. Resident #402 was observed lying on the right side in the bed. The wound had a small amount of serous drainage to the old dressing with no odor present. The wound was cleansed with normal saline and observed to have a pink wound bed with edges slightly macerated and white in color. The wound appeared to be approximately an inch long, a half a centimeter wide and about a centimeter deep. Nurse I applied the dressing. On 9/12/17, at 3:30 PM, the resident was observed resting in the bed supine leaning to right side. There were no wedges or pillows placed under resident's sides. The resident's heels were not elevated off the bed to relieve pressure. On 9/12/17, at 3:40 PM, nurse A was interviewed regarding resident's coccyx pressure ulcer and stated, the pressure ulcer was acquired here. On 9/13/2017, at 8:20 AM, a review of the resident's care plans revealed the following: apply wedge pillow under each lateral side to keep off coccyx while in bed. Rotate wedge pillow as needed .approach start date: 01/19/17. pressure relieving mattress in place at all times to aide in healing of coccyx wound .approach start date 01/03/17. off load heels while in bed .approach start date 02/10/17. Bed mobility-assist of 1(person) .how the resident moves to and from lying position, turns side to side, and positions body while in bed .approach start date 05/12/16. Transfer assist of 1 .how resident moves between surfaces including to or from; bed, chair, wheelchair, standing position .approach start date 05/12/16. On 9/13/17, at 8:30 AM, a review of resident #402's progress notes dated 01/03/17 by nurse A, revealed previous shearing area to coccyx now a stage 3. Resident #402 remained a one person assist with transfers, repositioning and bed mobility during the time of recognition of the shearing incident to the coccyx area, to the development of a stage 4 pressure ulcer until the time of the survey. On 9/13/17, at 8:35 AM, a review of the resident's Braden scale, dated 10/24/16, revealed the resident is at risk for skin breakdown. On 9/13/17, at 8:50 AM, a review of the resident's wound notes revealed the pressure ulcer started on 1/3/17 from a previous shearing and is now a stage 3. Resident #402's coccyx wound measurements on 1/19/17 was 4.4 centimeters long by 1.0 centimeters wide and 2.2 centimeters deep with yellow slough (tissue that adheres to the ulcer bed in strings) with moderate amount of clear drainage. Resident #402's wound measurements on 9/12/17 was 2.0 centimeters long by 0.3 centimeters wide and 0.2 centimeters deep. On 9/13/17, at 10:20 AM, resident #402 was observed in the bed supine leaning towards the right side. There was no wedge pillows in place to relieve pressure off their coccyx. The resident's air mattress was off and deflated. On 9/13/17, at 10:22 AM, nurse B was queried as to why the air mattress was deflated. Nurse B stated I didn't know I will call maintenance. Nurse B was further queried as to why wedge pillows aren't being used at this time and nurse B stated I guess we could use wedge cushions to keep (the resident) on their side but not sure if we aren't using them so (the resident) doesn't fall out. On 9/13/2017, at 11:15 AM, The Director of Nursing (DON) was asked as to their expectations of staff following care guide and positioning residents. The DON stated, I expect they turn every two hours and to look at the care guide at least every day.

This citation pertains to MI Based on observation, interview, and record review, the facility failed to provide monitoring and supervision to prevent the elopement from the facility of one (#701) of five residents reviewed for elopement risk, out of a total sample of five residents. An Immediate Jeopardy (IJ) arose when the facility identified Resident #701 as a risk for elopement, but failed to develop and implement effective interventions and monitoring to prevent actual elopement from the facility and facility staff were unaware of Resident #701's whereabouts for approximately 28 minutes, resulting in the potential for serious harm, injury, or death. The Immediate Jeopardy was identified on 6/13/17 at 4:12 p.m. The administrator was notified of the IJ on 6/15/17 at 11:25 a.m. A plan to remove the immediacy was requested. The IJ was removed on 6/15/17 based on the facility's implementation of the plan removal as verified onsite. Although the IJ was removed, the facility's deficient practice remains at isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 6/15/17 at 10:30 a.m., an interview was completed with the Administrator outside where Resident #701 had been on 6/13/17. According to the Administrator, she viewed the outside camera footage and noted that Resident #701 left the facility patio at 4:12 p.m. The Administrator stated, We allow the residents to freely use the patio when the weather is nice. According to the Administrator, Resident #701 ambulates independently and walked out on the patio, then reached over and unlatched the unlocked gate to open it. Resident #701 then walked down the ramp onto grass and walked across the yard to another fence and opened the unlocked gate and walked outside of the gate. Neither of the gates were locked at the time of the incident, however during the interview the outside fence and gate area was locked with a pad lock, the patio gate was not locked and did not have a working alarm on it. The administrator also stated that the Resident (#701) had walked across the street to the gas station where the facility was notified of the elopement by a police officer. On 6/15/17 at 10:45 a.m., an interview was completed with Co-Owner A. Co-Owner A stated, We have an estimate already in place for a new fence to cover all the exits. We are just waiting for the company to come out and do it, they are busy right now so they are backed up. On 6/15/17 at 10:55 a.m., a record review of Resident #701's face sheet, care plans and minimum data set (MDS) assessment was completed. According to the face sheet, Resident #701 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] stated that Resident #701 had daily episodes of wandering, received supervision for ambulation and was cognitively impaired. According to the Elopement care plan created on 3/9/15 and revised on 6/14/17, Resident #701 was a risk for elopement and included the following approaches: One to one safety/elopement every shift. Check ID band every shift. Photo placed by room. Wander precaution list. On 6/15/17 at 11:00 a.m., the Director of Nursing (DON) was interviewed in regards to Resident #701's whereabouts on 6/13/17. According to the DON, Resident #701 was recognized as an elopement risk because she met the criteria because she was confused, ambulatory and would wait by the doors. Originally a wanderguard (a bracelet worn by a resident that would alarm and notify the facility staff if the resident went thru the protected doors) was placed on the Resident (#701), however, Resident #701 had cried for two days so they took off the wanderguard bracelet. The DON also stated that Resident #701 had never verbalized wanting to leave the building so they put her on every 15 minute checks to check on the whereabouts of Resident #701. When asked how long Resident #701 was gone out of the facility premises on 6/13/17, the DON stated, She got back to the facility around 4:40 p.m. and left at 4:12 p.m The DON was queried in regards to the staff no doing the every 15 minute checks on Resident #701 as stated in the care plan, the DON stated, That is where the education piece comes in. There was an activity going on at the time so the staff missed the checks. We immediately put her on one on one with a staff member and she remains to be one on one. The DON also explained that Resident #701 had went across the street to the gas station because she thought her son had worked there. Eventually the store owner called the police and the police called the facility. The DON had stated that the gate should have been locked outside but had not been at the time of the incident. On 6/15/17 at 12:15 p.m., Resident #701 was observed in the hallway with a certified nursing assistant. There was no wanderguard bracelet on her. Resident #701 stated, They had one on me but took it off for some reason. On 6/15/17 at 1:00 p.m., a record review of the Elopement Risk assessment dated for 3/30/17 stated that Resident #701 had moderately impaired cognition and made poor decisions requiring supervision and cueing. The assessment also stated that Resident #701 needed 15 minute checks and to redirect away from doorways. On 6/15/17 at 3:50 p.m., an interview was completed with Social Worker (SW) B. According to SW B, She was told that Resident #701 was at the gas station across the street from the facility on 6/13/17. SW B went across the street to retrieve Resident #701 who was found to be sitting on a stool behind the register next to a police officer. SW B stated that Resident #701 was confused and did not want the facility to tell her son about what had happened. SW B stated, We put a wanderguard on her when she got back to the facility but then we eventually took it off because we wanted her to be comfortable. On 6/15/17 at 4:00 p.m., Co-Owner A was queried in regards to the gate on the deck not having an alarm on it. Co-Owner A stated, There is a professional company coming in at 11:30 in the morning tomorrow to put in an alarm. The one we got on there now doesn't sound. On 6/15/17 at 4:20 p.m., the DON was queried in regards to the locking of the door that goes out to the deck. The DON stated, The door will be locked at all times unless there are activities going on outside. The DON stated that the residents will be able to go outside only when there is supervision and that the nurses will have the keys to the door to go outside. On 6/15/17 at 4:40 p.m., a record review of the facility policy titled, Missing Resident-Elopement Prevention, revised 2017 states, It is the policy of this facility to reasonably protect the residents from harm through the prevention of elopements. The procedure part of the policy states the following: #3. All residents identified as high risk for wandering/elopement attempts will: a. Be placed on facility 15-minute safety checks. b. Will receive a Wanderguard band to wear to set off door alarms for early detection. #4. a. Staff is to monitor that all door alarms are activated 24/7. The facility submitted the following plan of correction: Element 1 Resident #701 was assessed for physical injuries and none were detected. Resident #701 has been re-assessed for elopement risk with care plans reviewed and updated as needed. Resident #701 was put on a 1:1 super vision after the event while being reassessed and observed for patterns, habits, and potential behavioral triggers. Wanderguard use was again attempted per facility policy, however has since been removed per resident request as it is a dignity issue for this resident. Element 2 All residents in facility have been reassessed using Elopement Assessment tool. Resident identified with potential to be affected have similar characteristics as Resident #701, assessed with [REDACTED].e. elope). These residents will continue to be identified during the MDS/RAI process. Residents residing in the facility sharing these characteristics have been reassessed and care plans revised as needed . An alarm has been placed on the gate by the deck that was identified as the passage used by Resident #701. A quote has been obtained and a date of July 26, 2017 has been set for installation of a fence to allow residents freer access to the campus while maintaining boundaries and residents' safety. A daily schedule has been developed for residents to be on the outside deck with supervision at different times during the day. Element 3 The facility's Elopement policies and procedures have been reviewed, updated and deemed appropriate. The list of Residents at Risk for Elopement has been updated and posted in accordance to the Elopement Reduction Protocol. Team members have been re-educated on elopement reduction protocols. Lists of identified residents of Element Two have been discussed during the re¿ education process. Team members that have not been present in the facility since event have been contacted by phone. Team members must receive education prior to the start of their next working shift. The leadership team reviewed physician orders for placement of alarms, Wanderguards, and functionality verification of both; 15 minute checks and 1:1 supervision to determine services are in place and in accordance to the care plan. The CNA point of care records have been updated as needed. Licensed Nurses and nursing staff have been in-serviced on documentation practices and work review at the end of shift . Elopement drills continue in place and have been conducted and documented. The Interdisciplinary Team has been provided with the like lists outlined in element 2 and will review the identified residents during the MDS/RAI process for the next 90 days. The list of similar residents has been provided to employees, licensed nurses have been re-educated on their responsibility to monitor that elopement interventions are implemented, in place and that documentation is completed each shift . Nurses will check to ensure that Wanderguards and 1:1 attendants are in place each shift and will document on the electronic Treatment Administration Record (TAR) that such checks have been completed. One to one supervision and supporting documentation is implemented immediately per facility policy for a resident who displays exit seeking behavior until interdisciplinary team (IDT) review to determine the least restrictive interventions appropriate to maintain the safety of the resident.

This citation has two Deficient Practice Statements. This pertains to Intake # MI 025 Deficient Practice #1 Based on observation, interview and record review, the facility failed to monitor residents to prevent a fall and serious injury for 1 (#701) of 4 residents reviewed for safety and falls, resulting in resident #701 sustaining a fall and femur fracture. Findings include: On 2/21/17 at 9:45 AM, resident # 701 was observed sitting in the therapy gym with two therapists. On 2/21/17 at 11:20 AM, record review revealed that resident #701 was initially admitted into the facility on [DATE], discharged on [DATE] and readmitted on [DATE], after being hospitalized for [REDACTED]. Other [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 2/9/17, indicated that the resident had experienced a significant decline in the ability to transfer and walk after the fall and was severely cognitive impaired. The resident's medications were, Aricept for dementia, clonazepam for anxiety, nuedexta for depression and dementia, Namenda for dementia, Lisinopril for high blood pressure, escitalopram for depression. On 2/21/17 at 11: 40 AM, record review revealed that on 1/28/17 at approximately 9:30 PM, resident # 701 was sitting near the first floor nurses desk in a wheelchair for close supervision by the nurse, because the resident was agitated. When the nurse ( RN A) walked away to give medication to another resident, Resident #701 fell from the wheelchair on 1/28/17 at about 9:30 PM. The resident's left leg was outstretched forwards on the floor and externally rotated. The physician was contacted and the resident was transferred to the hospital. On 2/21/17 at 12:00 PM, review of the resident's care plans indicated: an Activity of Daily Living (ADL) Care Plan, dated 11/28/16, stated, Place sensor alarm on bed, clip alarm on wheelchair (w/c) , check every shift by nursing, check weekly by restorative, Q (every) 15 minute checks for safety/Elopement. A Behavioral Care plan dated 11/30/16, stated, Initiate 1:1 supervision as needed for increased agitation or exit seeking behaviors, Q (every) 15 minute checks for safety. A Falls Care plan, dated 11/28/16 stated, keep call light in reach at all times, sensor alarm on bed, check every shift by nursing, checked weekly by restorative. On 2/21/17 at 12:10 PM, resident #701 was observed in the dining room with supervision for lunch. The Occupational Therapist (OT D) was interviewed on 2/21/17 at 1:30 PM and indicated that resident ( 701) received therapy that morning and stood for the first time, since the 1/28/17 fall with femur fracture. An observation on 2/21/17 at 2:07 PM revealed the resident was alone at the nurse's desk, trying to wheel self in the wheelchair and asking for assistance. The nurse was passing medications in another resident's room. On 2/21/17 at 3:00 PM, a review of the Incident report dated/timed 1/28/17 at 9:30 PM, indicated Resident #701 had a tab alarm on the wheelchair that did not alarm, intact, lying on floor next to (the resident). On 2/21/17 at 3:30 PM, a review of the facility safety documentation, for the resident revealed the alarm checks were not completed as scheduled, nor were the 1:1 person with resident all shift for supervision when up in wheelchair or 15 minute checks/elopement when in bed, per the nurse aide required documentation history. From 1/21/17 - 1/28/17 the documentation indicating the measures were in place and followed was completed 3 out of 7 days. The resident fell on the 8 th day. An interview with the Director of Nursing (DON) on 2/21/17 at 3:45 PM revealed, The resident was agitated eating a snack, on the day of the fall, 1/28/17. When queried on what measures were in place to ensure the resident's safety at the time of the fall, the DON responded, The nurse was watching the resident. When asked if the nurse could watch the resident, while in another resident's room giving medications, the DON responded, She was only gone a few minutes. When the Director of Nursing was queried on the missing documentation of safety measures for Resident #701, she responded, We have some work to do. On 2/21/17 at 4:00 PM, the Director of Nursing was asked to provide a Fall risk assessment for the resident, completed prior to the fall on 1/28/17. At the time of exit no Fall risk assessments were provided, nor was the Fall prevention policy. A Fall Event and Investigative Protocol form, dated 3/1/16 was provided. A completed Fall Investigative form was not provided for the incident dated 1/28/16. This pertains to Intake # MI 078 Deficient Practice #2 Based on observation, interview and record review, the facility failed to ensure safety measures were in place to prevent elopement from the building for 1 (#702) of 4 resident's reviewed for safety, resulting in Resident #702 exiting the building, alone at night, on 1/28/17 at 9:30 PM, and walking within feet of the road, prior to staff assistance. Findings include:: An observation at 9:45 AM revealed, resident # 702 sleeping in bed, with Certified Nurse Assistant (CNA) E sitting at the bedside and stated, We sit with (the resident) 1 to 1. On 2/21/17 at 10:40 AM a record review revealed, resident 702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data set assessment, dated 2/9/17, indicated the resident had severe cognitive impairment. The following medications were ordered: Remeron an antidepressant, Seroquel an antipsychotic, xanax for anxiety, Megace to stimulate appetite and metoprolol, lisinopril and lasix for high blood pressure. A review of the resident's Care plan-Behavioral symptoms, dated 10/2/15, on 2/21/17 at 11:00 am indicated, the resident had a history of [REDACTED]. Interventions included- Resident placed on elopement precautions list .q (every) 15 (minutes) checks for safety and location, staff to monitor alarms are operational 24/7, attempt to redirect as needed. Cognitive Loss/Dementia car plan dated 10/2/15-The resident has signs or symptoms of increased agitation, such as increased wandering, easily upset, provide a quiet area for resident away from other residents. The Falls care plan, dated 9/21/15- Clip alarm at all times, check q (every) shift and weekly by rehab, while in w/c (wheelchair) clip alarm to be attached to anti-tip bars ., If resident agitated or wandering provide 1:1 staff for supervision, keep call light in reach at all times. The Certified Nursing Assistant (CNA) Care Guide, dated 9/21/15- Place clip alarm on at all times, check every shift by nursing, check weekly by restorative, q (every) 15 minute checks for safety/elopement. On 2/21/17 at 11:20 AM revealed, a progress note written by Registered Nurse (RN) A, dated 1/29/17 at 3:11 AM, Late entry for 1/28/17 10:40 PM, Resident was being monitored by author due to reported exit seeking behavior. While author was assisting another resident, staff alerted to exterior alarm sounding approximately 9:30 PM. Author reported to exterior door alarm site and opened door and observed resident walking away from building approximately 10 feet from exterior stairs .immediately followed resident and was attempting to redirect back into building .resident highly agitated .resident non receptive .became verbally physically combative . RN A and Resident #702 crossed the road to the gas station, where RN A called the facility for assistance to return the resident to the facility. An observation on 2/21/17 at 2:00 PM, revealed, a tab alarm for fall prevention, sounding at the bedside for confidential resident #1. No staff were observed in the hallway. The resident was moving closer to the edge of the bed, when 2 minutes later, CNA C ran to the room and stated, Did I take too long. Nurse B was asked if there were other staff on the hall, she stated, They must be in a room. An observation on 2/21/17 at 2:15 PM, revealed resident 702 was in the dining room. Nurse B was asked who was providing 1:1 observation of the resident, the nurse stated, Activities is watching (the resident). The activities staff were observed assisting other resident's with a bowling activity. An interview with CNA G, on 2/21/17 at 2:20 PM revealed, I'm relieving the other aide for a break. I have the first assignment, on the hallway, as the CNA was observed providing 1:1 observation for the resident, in the dining room during the activity. On 2/21/17 at 2:45 PM, a review of the facility safety documentation for Resident #702 provided, there was no documentation for alarm checks, 1:1 supervision for agitation or every 15 minute checks as required in the Care Plan, prior to Resident #702's 1/28/17 elopement from the facility. A review of the safety documentation for Resident #702 after the elopement on 1/28/17 revealed no documentation of alarm checks and 8 of 14 days lacked documentation of 15 minute checks and 1:1 observation of the resident. An interview with the Director of Nursing (DON) on 2/21/17 at 12:40 PM revealed, I'm not sure, when asked what measures were in place to prevent the resident's elopement on 1/28/17. When asked what measures were currently in place the DON responded, We have alarmed doors and the resident has 1:1 supervision. When asked how the care was confirmed to be provided, the DON responded, It is documented. The DON was then shown the missing safety documentation and responded, We have work to do. An interview with the facility Administrator on 2/21/17 at 4:15 PM revealed, We will provide 1:1 supervision for as long as we need to. On 2/21/17 at 4:30, a review of the facility Elopement Prevention Policy, dated, 8/08 provided, To identify, prevent and protect residents from wandering out of Argentine Care Center .Identify all residents with the potential for elopement and especially those with a history of elopement .be placed on 15 minute checks .the Charge Nurse will document in the clinical record the time, door, residents mood and reason for wandering.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE STAFF REMAINED PRESENT DURING TOILETING AND ENSURE ALRMS ON WHEELCHAIRS WERE WORKING FOR ONE (#507) OF TWO SAMPLED RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL OF 14 SAMPLED RESIDENTS, RESULTING IN THE RESIDENT SUSTAINING FRACTURED ELBOW AS THE RESULT OF A FALL. FINDINGS INCLUDE: ON 11/14/12 AT 3:35 PM, THE DIRECTOR OF NURSING (DON) WAS OBSERVED AS SHE ASSISTED RESIDENT #507 TO THE RESTROOM THAT WAS LOCATED NEAR THE FIRST FLOOR NURSING STATION. AS THE DON OPENED THE DOOR, RESIDENT #507 JUMPED UP OUT OF HER WHEELCHAIR. THE DON TOLD RESIDENT #507, "SLOW DOWN, SLOW DOWN". THERE WAS A SENSOR PAD IN THE SEAT OF THE WHEELCHAIR AND AN ALARM BOX ON THE BACK OF THE WHEELCHAIR. WHEN RESIDENT #507 STOOD, THE ALARM DID NOT SOUND. THE DON REPLACED THE BATTERIES IN THE ALARM. ON 11/14/12, A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #507 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #507 HAD MODERATELY IMPAIRED COGNITION, AND REQUIRED SUPERVISION WITH TRANSFERS AND AMBULATION. THE QUARTERLY MDS, dated [DATE], INDICATED THAT RESIDENT #507 HAD SUSTAINED A FALL THAT RESULTED IN A MAJOR INJURY. THE MDS FURTHER REVEALED THAT RESIDENT #507 WAS FREQUENTLY INCONTINENT OF URINE AND REQUIRED SUPERVISION WHEN GOING TO THE BATHROOM. THE FALL RISK ASSESSMENT, DATED 4/26/12, REVEALED OR FALLS. THE NURSING CARE PLAN TITLED "ALTERATION IN MOBILITY", DATED 4/26/12, STATED, "... CLIP ALARM ON WHEELCHAIR, CHECK EVERY SHIFT (NURSING), CHECK EVERY WEEK REHAB (REHABILITATION DEPARTMENT)." A REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. ON 11/15/12, REVIEW OF A NURSING NOTE, DATED 7/12/12 AT 10:15 AM, STATED, "AT 7:15 AM, AIDE BROUGHT RESIDENT TO BATHROOM WHICH WAS OCCUPIED. AIDE WENT TO DO SOMETHING WHILE RESIDENT WAITED. WHEN SHE RETURNED RESIDENT WAS ON BATHROOM FLOOR. (RESIDENT) STATES, "I HAD TO GO TO BATHROOM." COMPLAINED OF PAIN TO LEFT ELBOW. RANGE OF MOTION LIMITED. CALLING OUT, "OW, OW"...AIDES INSTRUCTED TO MAKE SURE ALARM IS ATTACHED WHEN RESIDENT IS IN CHAIR." ON 11/15/12 AT 11:00 AM, A REVIEW OF THE "UNUSUAL OCCURRENCE REPORT" REVEALED: "7/12/12 AT 7:15 AM, AIDE BROUGHT RESIDENT TO BATHROOM. IT WAS OCCUPIED SO RESIDENT WAS WAITING IN THE HALL WHILE AIDE LEFT TO GET SOMETHING. WHEN AIDE RETURNED RESIDENT WAS ON FLOOR IN BR (BATHROOM). WHEELCHAIR OUTSIDE DOOR WITH LOCK ON...COMPLAINED OF PAIN TO LEFT ELBOW ...SLIGHT SWELLING...CORRECTIVE MEASURES TAKEN TO AVOID REPETITION OF ACCIDENT...AIDE INSTRUCTED TO MAKE SURE ALARMS ARE ATTACHED...PHYSICIAN STATEMENTS: OLECRANON (ELBOW) FRACTURE." ON 11/15/12, A REVIEW OF THE RADIOLOGY REPORT, DATED 7/12/12, STATED, "THERE IS A RECENT SLIGHTLY DISPLACED FRACTURE AT THE LOWER PORTION OF THE OLECRANON PROCESS OF THE ULNA (ARM BONE)." A REVIEW OF THE NURSES NOTED, DATED 7/12/12 AT 2 PM, REVEALED THE PHYSICIAN ORDERED THAT RESIDENT #507 WEAR A SLING ON LEFT ARM. THE NURSES NOTES DATED, 7/21/12 AT 3:15 PM, STATED, "ATTENDING PHYSICIAN IN THIS AM. CAST APPLIED TO LEFT ARM." ON 11/15/12 AT 11:35 AM, DURING AN INTERVIEW REGARDING RESIDENT #507'S TOILETING ABILITY AND FALL IN JULY 2012, THE DON STATED, "SHE (RESIDENT #507) HAS IMPULSIVE BEHAVIORS. THAT IS NOT A NEW THING FOR HER." THE DON ALSO REVIEWED THE UNUSUAL OCCURRENCE REPORT FOR 7/12/12 AND STATED, "SO THE ALARM MUST NOT HAVE BEEN ATTACHED." THE DON REVEALED THAT A SENSOR ALARM SHOULD HAVE BEEN IN PLACE FOR RESIDENT #507'S WHEELCHAIR. HOWEVER, THE DON OFFERED NO EXPLANATION WHY NEITHER A CLIP ALARM NOR A SENSOR PAD ALARM WAS PUT IN PLACE BEFORE RESIDENT #507 WAS PLACED IN THE WHEELCHAIR, THEN LEFT ALONE OUTSIDE THE BATHROOM. ON 11/15/12, THE FACILITIES FALLS MANAGEMENT POLICY WAS REQUESTED FROM THE DON. ON 11/15/12, THE FACILITY POLICY ENTITLED "UNUSUAL OCCURRENCE", REVISED 3/2011, STATED, "IT IS THE POLICY OF THIS NURSING HOME TO PROVIDE A SAFE AND HEALTHFUL WORK ENVIRONMENT." THE POLICY PRESENTED FAILED TO IDENTIFY HOW RESIDENTS AT RISK FOR FALLS SHOULD BE ASSESSED, MONITORED, OR CARED FOR. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY, EVALUATE, AND REVISE INTERVENTIONS FOR FOUR OF SIX SAMPLED RESIDENTS REVIEWED FOR FALLS (#902, 905, 906, AND 908) FROM A TOTAL SAMPLE OF 14 RESIDENTS, RESULTING IN BRUISES AND LACERATIONS; AND FAILED TO STORE PORTABLE OXYGEN CANISTERS SAFELY, RESULTING IN THE POTENTIAL FOR AN EXPLOSION. FINDINGS INCLUDE: RESIDENT #905 WAS OBSERVED IN HER ROOM ON 2/23/11, 2/24/11, AND 2/25/11 EITHER IN HER BED OR HER RECLINER CHAIR. SHE SHARED LUNCH AND VISITED WITH THE FACILITY SOCIAL WORKER FROM APPROXIMATELY 11:30 TO 12:30 EACH OF THE DAYS. THE REMAINDER OF THE TIME, 2/23/11 AND 2/24/11 FROM 9:30 A.M. TO 3:30 P.M. THE RESIDENT WAS ALONE IN HER ROOM. ALARMS WERE NOTED ON THE BED AND RECLINER CHAIR. RESIDENT #905'S CLINICAL RECORD WAS REVIEWED ON 2/24/11 AT 9:45 A.M. ACCORDING TO THE FEBRUARY 2011 PHYSICIAN ORDERS [REDACTED]. THE MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], DESCRIBED THE RESIDENT WITH SEVERE COGNITIVE IMPAIRMENT AND WAS HARD OF HEARING. THE RESIDENT REQUIRED EXTENSIVE PHYSICAL ASSISTANCE OF ONE PERSON WITH TRANSFERS, DRESSING, AND BATHING AND CONTINENT OF URINE AND STOOL. THE RESIDENT WAS ASSESSED TO BE "HIGH RISK" FOR FALLS (ON 2/12/10, 6/08/10, 8/01/11, 11/22/10, AND 2/17/11) AND had a history of [REDACTED]. NURSING PROGRESS NOTES AND ACCIDENT AND INCIDENT REPORTS WERE REVIEWED AND THE FOLLOWING FALLS WERE IDENTIFIED FOR RESIDENT #905: 1. 4/24/10 AT 7:30 P.M.: "...RESPONDED TO ALARM TO FIND RESIDENT ON THE FLOOR. STATES SHE FORGOT TO LOCK CHAIR AND IT GOT AWAY FROM HER." THERE WERE NO INJURIES. THE RESIDENT WAS INSTRUCTED TO LOCK HER BRAKES. 2. 4/25/10 AT 12:50 P.M.: THE RESIDENT fell WHILE TRANSFERRING HERSELF FROM HER WHEELCHAIR TO RECLINER AND SUSTAINED A LACERATION ON HER HEAD. THE RESIDENT WAS INSTRUCTED TO USE HER CALL LIGHT AND ASK FOR ASSISTANCE. THERE WAS NO INDICATION AN ALARM WAS USED AT THIS TIME AS ORDERED BY THE PHYSICIAN. 3. 6/06/10 AT 7:30 P.M.: THE RESIDENT WAS FOUND ON HER KNEES NEXT TO HER BED. "ALARM WAS RINGING". THERE WERE NO INJURIES. STAFF WERE DIRECTED TO CHECK ON THE RESIDENT AND "ANTICIPATE HER NEEDS". 4. 8/14/10 AT 6:00 P.M.: "ALARM SOUNDING...RESIDENT WAS LYING ON THE FLOOR BESIDE HER BED WITH HER WHEELCHAIR NEARBY. THE RESIDENT STATED, "I WAS UP IN MY WHEELCHAIR AND I LEANED DOWN TO PICK SOMETHING UP AND I fell ." CALL LIGHT IN REACH BUT NOT USED." THE resident sustained [REDACTED]. THE RESIDENT WAS INSTRUCTED TO "USE CALL LIGHT". 5. 11/14/10 AT 4:00 A.M.: THE RESIDENT WAS FOUND ON THE FLOOR NEXT TO HER BED. HER RIGHT KNEE WAS BRUISED. THE RESIDENT WAS INSTRUCTED TO USE THE CALL LIGHT. NO OTHER INTERVENTION WAS IDENTIFIED AFTER THIS SECOND FALL FROM BED. 6. 11/19/10 AT 4:00 A.M.: THE RESIDENT "LEANED TOO FAR FORWARD" IN THE WHEELCHAIR AND fell HITTING THE LEFT SIDE OF HER FACE ON THE FLOOR RESULTING IN A BLOODY NOSE. STAFF WERE INSTRUCTED TO TRANSPORT THE RESIDENT BACK TO HER ROOM AND PLACE HER IN HER RECLINER AFTER SUPPER. 7. 1/06/11 AT 5:30 A.M.: THE RESIDENT WAS FOUND ON THE FLOOR NEXT TO HER BED. THE RESIDENT REPORTED SHE "SLIPPED" OUT OF BED AND HIT HER HEAD. THE resident sustained [REDACTED]. 8. 2/20/11 AT 9:00 A.M. AN ALARM WAS SOUNDING AND RESIDENT #905 WAS OBSERVED "FALLING" TO THE FLOOR. THE resident sustained [REDACTED]. THE RESIDENT RECEIVED TREATMENT WHICH INCLUDED THREE STAPLES. RESIDENT #905'S CARE PLAN, DATED 4/10 WAS REVIEWED. INTERVENTIONS INCLUDE REMINDING THE RESIDENT TO USE THE CALL LIGHT AND THE USE OF ALARMS. THERE WAS NO EVIDENCE OTHER INTERVENTIONS WERE USED TO PREVENT FALLS. THE CNA DAILY ASSIGNMENT SHEET WAS REVIEWED. THERE WERE NO INSTRUCTIONS TO STAFF REGARDING ALARMS ON BED AND RECLINER CHAIR, ANTICIPATING NEEDS, KEEPING ITEMS WITHIN HER REACH, OR REMINDERS TO USE THE CALL LIGHT AND LOCK BRAKES ON THE WHEELCHAIR. THE DIRECTOR OF NURSING (DON) AND RESTORATIVE NURSE WERE INTERVIEWED ON 2/26/11 AT APPROXIMATELY 10:30 A.M. IT WAS REPORTED THERE WAS NO FORMAL "FALL" OR "SAFETY COMMITTEE" AND RESIDENTS FALLS WERE DISCUSSED DAILY IN MORNING MEETINGS. THE DIRECTOR OF NURSING WENT ON TO SAY THAT THE FACILITY'S FOCUS WAS "NOT TO PREVENT FALLS", RATHER TO "PREVENT SERIOUS INJURY". A POLICY AND PROCEDURE WAS REQUESTED. REVIEW OF THE POLICY AND PROCEDURE ENTITLED, "ACCIDENTS AND INCIDENTS" (NO DATE) DIRECTED STAFF TO "CONDUCT" AN INVESTIGATION OF THE SITUATION AND DOCUMENT IT ON THE ACCIDENT /INCIDENT REPORT FORM. ( ) ACCORDING TO A REVIEW OF THE ADMISSION RECORD ON 2/24/11 AT 8:35 A.M., RESIDENT #906 WAS admitted TO THE FACILITY WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE], REVEALED THAT RESIDENT #906 WAS COGNITIVELY INTACT AND REQUIRED LIMITED ASSISTANCE WITH TRANFERS, DRESSING AND BATHING. THE MDS ALSO NOTED THAT THE RESIDENT WAS NOT STEADY WHEN MOVING FROM SEATED TO STANDING POSITIONS, ON AND OFF THE TOILET AND FROM SURFACE TO SURFACE. THE FALL RISK ASSESSMENT, DATED 1/10/11, SCORED THE RESIDENT AT A "14" (SCORES GREATER THAT 10 ARE CONSIDERED HIGH RISK FOR FALLS). A REVIEW OF THE INCIDENT AND ACCIDENT REPORTS FOR RESIDENT #906 FROM APRIL 2010 THROUGH FEBRUARY 2011, REVEALED THAT THE RESIDENT HAD FALLEN 10 TIMES AS LISTED BELOW: FALL #1 4/25/10 AT 10:00 A.M. DESCRIPTION OF FALL: WENT FROM BED TO WHEELCHAIR AND STARTED SLIPPING. LOWERED SELF/KNEES TO FLOOR. NO INJURY. INTERVENTION: REMINDED PT. TO USE CALL LIGHT FOR ASSIST. FALL #2 6/10/10 AT 6:20 P.M. DESCRIPTION OF FALL: OBSERVED RESIDENT ON FLOOR PARALLEL TO BED. SKIN TEAR RIGHT UPPER ARM AND RIGHT FOREARM. INTERVENTION: RESIDENT INSTRUCTED TO ASK FOR ASSIST. FALL #3 8/13/10 AT 10:30 P.M. DESCRIPTION OF FALL: STOOD UP FROM TOILET STOOL AND LOST BALANCE AND fell FORWARD...HIT FOREHEAD. SMALL SCRATCH ON FOREHEAD. INTERVENTION: USE CALL LIGHT AND WAIT FOR ASSISTANCE. FALL #4 8/29/10 7:00 A.M. DESCRIPTION OF FALL: SITTING ON FLOOR NEXT TO BED. STATED HE WAS GOING FROM WHEELCHAIR TO BED. TWO SMALL SCRATCHES ON LEFT ARM. INTERVENTIONS: REMINDED CNA'S (CERTIFIED NURSING ASSISTANTS) TO ASSIST. FALL #5 10/7/10 6:45 P.M. DESCRIPTION OF INCIDENT: TRANSFERRING SELF TO BED AND SLIPPED ON BUTTOCKS. NO INJURY INTERVENTION: MAKE SURE HE HAS RUBBER SOLE SHOES. FALL #6 10/24/10 3:45 A.M. DESCRIPTION OF INCIDENT: SITTING ON THE FLOOR BESIDE HIS BED. URINAL BESIDE HIM AND SPILLED ON THE FLOOR. NO INJURY INTERVENTION: ENCOURAGED TO USE CALL LIGHT FOR ASSISTANCE. FALL #7 10/29/10 2:30 A.M. DESCRIPTION OF INCIDENT: OBSERVED ON FLOOR. STATED "I ROLLED OVER ON THE FLOOR." NO INJURY INTERVENTION: NONE FALL #8 1/3/11 10:55 A.M. DESCRIPTION OF INCIDENT: AIDE ASSISTED RESIDENT TO BATHROOM AND RESIDENT ATTEMPTED TO GET INTO CHAIR WITH ASSISTANCE AFTER HE WAS DONE. KNEES GAVE OUT AND HE WAS LOWERED TO THE FLOOR. NO INJURY INTERVENTION: INSTRUCTED RESIDENT TO USE CALL BELL. FALL #9 2/6/11 1:15 A.M. DESCRIPTION OF INCIDENT: RESIDENT GOT UP UNASSISTED OUT OF BED. BED LOCKS WERE UNLOCKED AND THE BED ROLLED CAUSING THE RESIDENT TO FALL ONTO THE FLOOR. NO INJURY INTERVENTION: ENCOURAGE THE RESIDENT TO CALL FOR ASSISTANCE AT ALL TIMES. STAFF TO MAINTAIN THAT THE BED IS LOCKED. FALL #10 2/6/11 10:20 P.M. DESCRIPTION OF INCIDENT: RESIDENT FOUND ON FLOOR AT BEDSIDE. NO INJURY INTERVENTION: EXPLAINED TO RESIDENT TO PUT CALL LIGHT ON AND TO WAIT FOR HELP TO TRANSFER. THE RESIDENT'S NURSING CARE PLAN RELATED TO ALTERATIONS IN MOBILITY, DATED 7/27/10, LISTED SEVERAL INTERVENTIONS, THAT INCLUDED ONE PERSON STAND-BY ASSIST WITH TRANSFERS, ASSIST WITH TOILETING/TRANSFERS, AND REMIND RESIDENT TO USE CALL LIGHT. THERE WERE NO NEW INTERVENTIONS ADDED AFTER EACH OF THE FALLS THAT OCCURRED FOR RESIDENT #906. AN INTERVIEW WITH THE DIRECTOR OF NURSING AND THE RESTORATIVE NURSE "B", ON 2/25/11 AT 11:35 A.M., REVEALED THAT A BED ALARM WAS CONSIDERED IN MARCH OF 2010, BUT IT WAS THOUGHT THAT IT WAS NOT IN THE BEST INTEREST OF THE RESIDENT TO USE ONE. THEY ALSO INDICATED THAT BED RAILS WERE CONSIDERED, TO ASSIST WITH MOBILITY AND TRANSFER, BUT THE RESIDENT REFUSED THEM. THE DON INDICATED THAT OTHER INTERVENTIONS, SUCH AS A SCHEDULED TOILETING PROGRAM, MORE FREQUENT MONITORING, MAINTAINING A NONSLIP FLOOR SURFACES, AND A MEDICATION REVIEW HAD NOT BEEN INITIATED OR ADDED TO THE NURSING CARE PLAN FOR RESIDENT #906. ( ) ON 2/23/11 AT 1:30 PM, RESIDENT #902 WAS OBSERVED IN HER ROOM, SEATED ON A LOW BED. DURING AN INTERVIEW, AT THAT TIME RESIDENT #902 STATED THAT SHE FELT PAIN IN HER PELVIC AND LOWER BACK AREA. ON 2/23/11, AT 2:00 PM A REVIEW OF HER CLINICAL RECORD REVEALED THE FOLLOWING: ACCORDING TO THE FACE SHEET, RESIDENT #902 WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE ANNUAL RESIDENT ASSESSMENT INSTRUMENT, DATED 11/19/10 REFLECTED RESIDENT #902 HAD IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING, AND DISORGANIZED THINKING. RESIDENT #902 WAS NON-AMBULATORY, DEPENDANT ON STAFF FOR TRANSFER. THE FALL RISK ASSESSMENT, DATED 11/22/11 REFLECTED THAT RESIDENT #902 WAS AT HIGH RISK FOR FALLS. ON 2/24/11 AT 10:00 AM, ACCIDENT/INCIDENT REPORTS FOR RESIDENT #902, REFLECTED THE FOLLOWING: ACCIDENT/INCIDENT REPORT, DATED 1/29/11, 4:00 AM, RESIDENT #902 WAS FOUND LYING ON HER RIGHT SIDE ON THE FLOOR. THERE WERE NO NOTED INJURIES. ACCIDENT/INCIDENT REPORT, DATED 2/01/11, 3:30 A, REFLECTED RESIDENT #902 WAS FOUND LYING ON THE FLOOR, ON HER BACK, BESIDE HER WHEEL CHAIR. AT THAT TIME, RESIDENT #902 COMPLAINED OF PAIN TO THE LOWER BACK/COCCYX AREA AND PELVIC AREA. ON 2/24/11 AT 10:30 AM, A REVIEW OF RESIDENT #902'S CLINICAL RECORD REVEALED THAT INTERVENTIONS HAD NOT BEEN EVALUATED AND REVISED TO LIMIT THE POTENTIAL FOR FALLS AFTER THE INCIDENTS ON 1/29/11 AND 2/01/11. DURING AN INTERVIEW ON 2/25/11 AT 11:00 AM, THE DIRECTOR OF NURSING CONFIRMED THAT INTERVENTIONS TO LIMIT RESIDENT #902'S RISK FOR FALLS HAD NOT BEEN EVALUATED AND REVISED TO LIMIT THE POTENTIAL FOR REPEATED FALLS AND INJURIES. ( ) ON 2/23/11 AT 10:25 A.M., DURING THE INITIAL TOUR WITH THE DIRECTOR OF NURSING, THERE WERE FIVE PORTABLE OXYGEN TANKS OBSERVED SITTING ON THE FLOOR, INSTEAD OF IN THE CONTAINER THAT WAS PROVIDED IN THE FACILITY'S LOCKED OXYGEN STORAGE CABINET. THE FACILITY'S POLICY, ENTITLED "STORAGE OF OXYGEN TANKS", DATED 4/1/09, STATED: "OXYGEN TANKS WILL BE STORED IN APPROVED OXYGEN TANK HOLDERS. THIS INCLUDES FULL AND EMPTY TANKS." "OXYGEN TANKS WILL BE STORED AND KEPT IN OUR OXYGEN STORAGE CABINET IN THE APPROVED OXYGEN STORAGE RACK." ( ) ON 2/23/11 AT 12:00 P.M., RESIDENT #908 WAS IN THE ROOM IN A WHEELCHAIR WITH A TAB ALARM (PERSONAL ALARM) ATTACHED. RESIDENT #908 WAS ALERT WITH CONFUSION, AND REPORTED SHE HAD FALLEN FROM THE WHEELCHAIR WHILE IN THE FACILITY, BUT WAS UNABLE TO GIVE DETAILS. THERE WAS NO SAFETY MAT AT THE BEDSIDE. ON 2/24/11 AT 12:30 A.M., REVIEW OF FACILITY ACCIDENT/INCIDENT REPORTS REVEALED RESIDENT #908 HAD FALLEN SEVEN TIMES IN THE FACILITY SINCE APRIL OF 2010. ON 2/24/11 AT 2:30 P.M., REVIEW OF RESIDENT #908'S CLINICAL RECORD WITH THE DIRECTOR OF NURSING AND THE RESTORATIVE DIRECTOR REVEALED THE FOLLOWING: 1. A FACE SHEET DOCUMENTING THAT RESIDENT #908 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. 2. A MINIMUM DATA SET ASSESSMENT, DATED 1/24/11 REVEALED RESIDENT #908 HAD MODERATELY IMPAIRED COGNITION, NEEDED PHYSICAL ASSISTANCE OF ONE PERSON FOR TRANSFERRING FROM BED TO THE WHEELCHAIR, AND NEEDED EXTENSIVE STAFF ASSISTANCE FOR AMBULATION (WALKING), TOILETING AND HYGIENE. THE MDS ALSO DOCUMENTED THAT RESIDENT #908 'S BALANCE WAS POOR, AND NEEDED STAFF ASSISTANCE TO REMAIN STABLE DURING TRANSFERS AND AMBULATION. 3. FALLS RISK ASSESSMENTS DATED 2/8/10, 5/3/10, 7/28/10, 10/19/10 AND 1/14/11 DOCUMENTED THAT RESIDENT #908 WAS AT HIGH RISK FOR FALLING. 4. A NURSING CARE PLAN FOR FALLS, DATED 11/26/09, REVISED ON 2/8/10, 5/3/10, 7/28/10, 10/21/10 AND 1/14/11, DOCUMENTED RESIDENT #908 WAS AT RISK FOR FALLS DUE TO "POOR BALANCE, POOR SAFETY AWARENESS, NEEDS ATTENTION WITH ACTIVITIES OF DAILY LIVING (ADLS)", NOTING, "RESIDENT DOESN'T EXPRESS HER NEEDS. YOU MUST ASK." INTERVENTIONS INCLUDED: "LOW BED WITH MATS (DISCONTINUED); SENSOR ALARM ON BED, CHECK EACH SHIFT BY NURSING; CLIP ALARM ON WHEELCHAIR, CHECK EACH SHIFT NURSING." ON 2/24/11 AT 2:30 P.M., REVIEW OF FACILITY INCIDENT AND ACCIDENT (I&A) REPORTS FOR RESIDENT #908 WITH THE DON AND RESTORATIVE DIRECTOR REVEALED THE FOLLOWING FALLS: 1. AN UNDATED I&A DOCUMENTED THAT ON 1/4/10 AT 4:05 P.M., RESIDENT #908'S WAS FOUND ON THE FLOOR IN THE ROOM AFTER HER PERSONAL ALARM HAD SOUNDED. RESIDENT #908 SUFFERED A NINE CENTIMETER (CM) ABRASION ON HER BACK. "CORRECTIVE MEASURES" WERE NOTED AS "RESIDENT INSTRUCTED TO USE CALL LIGHT." WHEN QUERIED, THE DON AND RESTORATIVE DIRECTOR REPORTED THAT RESIDENT #908 WAS TOO CONFUSED TO REMEMBER TO USE HER CALL LIGHT. THE DON ALSO STATED THAT NO NEW SAFETY INTERVENTIONS WERE ADDED AFTER THIS FALL, AND NO REVISION TO THE CARE PLAN WAS MADE. WHEN QUERIED ABOUT THIS, THE DON STATED, "OUR GOAL IS NOT TO PREVENT FALLS, IT IS TO PREVENT INJURIES." 2. AN UNDATED I&A DOCUMENTED THAT ON 5/16/10 AT 2:45 P.M., RESIDENT #908 SUFFERED A FALL IN THE ROOM DURING A SELF TRANSFER FROM WHEELCHAIR TO BED. THE I&A NOTED, "CNA (CERTIFIED NURSING ASSISTANT) REPORTED CLIP ALARM WAS NOT HOOKED." "CORRECTIVE MEASURES" WAS NOTED AS, "INSTRUCTED RESIDENT TO REMEMBER NOT TO TRANSFER HERSELF .TO ASK CNA FOR HELP." WHEN QUERIED, THE DON AND RESTORATIVE DIRECTOR REPORTED THAT RESIDENT #908 OFTEN REMOVED HER CLIP ALARM, AND THIS MAY BE WHY THE CLIP ALARM WAS NOT HOOKED AT THE TIME OF THE FALL. WHEN QUERIED, THE DON AND RESTORATIVE DIRECTOR REPORTED NO NEW SAFETY INTERVENTIONS WERE IMPLEMENTED AND NO REVISIONS WERE MADE TO THE FALLS CARE PLAN AFTER THIS FALL. WHEN QUERIED WHY INTERVENTIONS TO PREVENT REMOVAL OF THE CLIP ALARM, OR ALTERNATIVES TO A CLIP ALARM WERE NOT CONSIDERED, THE DON AND THE RESTORATIVE DIRECTOR REPORTED THAT IT HAD NOT BEEN CONSIDERED. 3. AN UNDATED I&A DOCUMENTED THAT ON 7/2/10 AT 10:00 P.M., RESIDENT #908 HAD FALLEN WHILE SELF TRANSFERRING FROM BED TO THE WHEELCHAIR. REVIEW OF A NURSING NOTE DATED 7/2/10 AT 10:45 P.M., REVEALED THE STATEMENT, "OBSERVED RESIDENT SITTING ON FLOOR AT SIDE OF BED, ALARM OFF." THE I&A DOCUMENTED CORRECTIVE MEASURES AS, "PROVIDED PATIENT TEACHING ON USE OF CALL LIGHT AND IMPORTANCE OF WAITING FOR STAFF FOR ASSISTANCE." THE DON "COMMENTS" ON THE I&A DOCUMENTED, " RESIDENT DOES UNPLUG HER ALARMS AT TIMES . SHE IS IMPULSIVE." THE DON AND THE RESTORATIVE DIRECTOR REPORTED NO NEW SAFETY INTERVENTIONS WERE ADDED AND ALTERNATIVES TO THE CLIP ALARM HAD NOT BEEN CONSIDERED. THE RESTORATIVE DIRECTOR AND THE DON ALSO REPORTED THAT TELLING RESIDENT TO RING THE CALL LIGHT AND WAIT FOR STAFF WAS NOT AN EFFECTIVE INTERVENTION AS RESIDENT #908 WAS OFTEN TOO CONFUSED TO REMEMBER. 4. AN UNDATED I&A DOCUMENTED THAT ON 9/10/10 RESIDENT #908 HAD FALLEN WHILE GETTING UP FROM BED UNASSISTED. THE ALARM WAS NOT DOCUMENTED AS SOUNDING. "CORRECTIVE MEASURES " WERE NOTED AS, "MAKE SURE SHE TURNS LIGHT ON FOR HELP." THE DON AND THE RESTORATIVE DIRECTOR STATED NO NEW OR ALTERNATIVE SAFETY INTERVENTIONS WERE ADDED. 5. AN UNDATED I&A DOCUMENTED THAT ON 9/29/10 AT 10:20 A.M., STAFF HAD ENTERED THE ROOM IN RESPONSE TO A CALL LIGHT AND FOUND RESIDENT #908 ON THE FLOOR. "CORRECTIVE MEASURES" WAS BLANK (NO NOTATIONS). THERE WAS NO DOCUMENTATION OF AN ALARM SOUNDING IN THE I&A OR IN A 9/29/10 AT 9:00 P.M. NURSING NOTE DOCUMENTING THE FALL ON DAY SHIFT AT 10:20 A.M.. WHEN QUERIED, THE DON REPORTED NO NEW OR REVISED SAFETY INTERVENTIONS OR FALLS PREVENTION CARE PLAN UPDATES, STATING, "THERE WAS NO INJURY." 6. AN UNDATED I&A DOCUMENTED THAT ON 10/11/10 AT 2:10 A.M., RESIDENT #908 HAD FALLEN WHILE ATTEMPTING TO GET UP WITHOUT ASSISTANCE. "CORRECTIVE MEASURES" DOCUMENTED, "TAKE WHEELCHAIR OUT OF ROOM TO HAVE THE RESIDENT CALL FOR ASSISTANCE." WHEN QUERIED, THE DON AND THE RESTORATIVE DIRECTOR WERE UNABLE TO EXPLAIN WHY THIS INTERVENTION HAD NOT BEEN CONSIDERED AFTER THE FIRST FALL. 7. AN UNDATED I&A DOCUMENTED THAT ON 2/11/11 AT 9:00 P.M., RESIDENT #908 HAD FALLEN WHILE GETTING OUT OF BED UNASSISTED, SUFFERING A"SORE COCCYX (TAILBONE), ELBOW AND HEAD." CORRECTIVE MEASURES" WERE DOCUMENTED AS, "EXPLAINED THE NEED TO USE CALL LIGHT AND WAIT FOR HELP." THE DON AND THE RESTORATIVE DIRECTOR REPORTED NO NEW OR REVISED SAFETY INTERVENTIONS OR UPDATES TO THE FALLS PREVENTION CARE PLAN. 8. ON 2/24/11 AT 3;00 P.M., THE DON AND THERESTORATIVE DIRECTOR WERE INTERVIEWED ABOUT THE FACILITY RESPONSE TO RESIDENT #908'S FREQUENT FALLS. THE DON AND THE RESTORATIVE DIRECTOR STATED THAT MEDICATION REVIEWS WERE NOT DONE POST FALL TO ASSESS FOR MEDICATIONS THAT COULD INCREASE THE RISK OF FALLING. THE DON STATED THAT URINALYSIS (UA) WAS DONE TO RULE OUT POSSIBLE URINARY TRACT INFECTIONS CONTRIBUTING TO THE RISK OF FALLING. WHEN QUERIED, THE DON AND THERESTORATIVE DIRECTOR WERE UNABLE TO PROVIDE DOCUMENTATION THAT UA HAD BEEN DONE POST FALL FOR ANY OF RESIDENT #908'S FALLS. WHEN QUERIED AT THIS TIME, THE DON AND THE RESTORATIVE DIRECTOR WERE UNABLE TO STATE WHEN THE SAFETY MATS HAD BEEN DISCONTINUED, AND WERE UNABLE TO EXPLAIN WHY SAFETY MEASURES THAT DID NOT WORK TO PREVENT FALLS WERE NOT REVISED OR CHANGED. ( )