Every finding on record at Autumnwood of McBain

Based on interview and record review, the facility failed to ensure safety during transport of one Resident (#10) of three residents reviewed for falls resulting in a fractured 1st cervical (neck) fracture, prolonged pain and fear of paralysis and failed to implement interventions for one Resident (#51) of one resident reviewed for handling of hot liquids, who was deemed unsafe to handle hot liquids without supervision and/or interventions in place.Findings include:Resident #10 (R10) On 6/9/2026 at 11:32 AM, an interview was conducted with R10 regarding her history of falls in the facility. R10 indicated she fractured her atlas (the first neck vertebra) as a result of tipping backward in a wheelchair in a transport vehicle and striking her head on the van floor. R10 explained she was coming back to the facility from a dialysis appointment when the driver suddenly accelerated. R10 revealed the transport driver had forgotten to tie down the front of the wheelchair causing her to tip backward when the van accelerated. R10 stated she was ultimately taken to the hospital where she was diagnosed with a cervical (neck) fracture. R10 indicated she had to wear a cervical collar for six weeks to protect her neck while the fracture healed. When asked if she still had pain, R10 replied, My neck is stiff. It's not as supple as it used to be. I just keep thinking; I could have been paralyzed. I could have died. Review of an Incident and Accident Investigation Form, dated 82[sic]/29/25, read, in part: On 8/29/25, [R10] was transported by a contracted transport company to attend her Dialysis appointment. Upon completion of dialysis, [R10] was loaded onto the contracted transporting van to return to [facility]. Driver stated she accelerated forward onto to [sic] roadway, [R10's] wheelchair tipped backwards, and [R10] was observed on the van floor on her back, legs toward the driver seat and head toward the back of the van with her arms at her sides. [R10] states she went backwards and that she had hit her head on the van floor. Physician Findings: Traumatic Fracture of the Cervical Spine. Conclusion: RCA [root cause analysis] determined that [R10's] front wheel securement belt was not positioned correctly allowing her wheelchair to tip backwards. Review of an investigation report prepared by Unit Manager/RN O, undated, read in part: On 8/29/25, [R10] was transported by a contracted transport company to attend her Dialysis appointment. Upon completion of dialysis, [R10] was loaded onto the contracted transporting van to return to [facility]. Driver stated she accelerated forward upon entering roadway, [R10's] wheelchair tipped backwards, bending her anti-tip units outward, and [R10] was observed on the van floor on her back.The driver pulled over and observed for immediate injury. The driver was unable to safely return [R10] to upright position, to secure her in an upright position, so driver secured her in supine position, supporting her head and neck in an inline position. The driver then returned to [facility] and requested assist from [facility] staff. A resident assessment was completed. [R10] stated she had pain on her posterior head from the impact. [R10] was assisted by staff into an alternative wheelchair and was agreeable for the transport company to transfer her to the [local emergency room]. CT [computed tomography scan] and MRI [magnetic resonance imaging scan] were completed revealing a Fracture Lateral Mass C1 [a break in the first cervical vertebra at the two thick, weight-bearing sections that connect the skull to the neck] . MRI revealed bone marrow edema associated with the patient's known fracture of the lateral masses of C1. On 6/9/26 at 1:10 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated she responded to R10's fall when the transport vehicle arrived at the facility following the incident. The ADON verified R10 was tipped over in the wheelchair, on her back in the transport vehicle, and reported posterior head pain. The ADON recalled facility staff were able to lift the wheelchair into an upright position with R10 still in it and subsequently transferred her to an undamaged wheelchair. The ADON reported the contract driver then transported R10 to the hospital. Review of the Emergency Department Report, dated 8/29/25, read, in part: Assessment/Plan. Traumatic fracture of cervical spine. Multiple attempts were made to interview the transport company with no return calls. Review of R10's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. Review of R10's most recent Minimum Data Set (MDS) assessment, submitted 6/2/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of R10's EMR revealed the following entries post-incident: Nurses Notes on 8/29/25 at 22:29 [10:29 PM]: Resident returned from [hospital] via EMS [emergency medical services] wearing cervical collar. Resident states she has some neck pain and a headache. Progress Note on 8/30/25 at 8:00 AM: .[R10] reports her head hurts. She is on [opioid] but was considering if she could have an increase for short term. she reports it hurts when she coughs and she was nauseated this morning, she believes from the pain . Psychiatry Follow-Up on 9/10/25 at 20:38 [8:38 PM]: .[R10] had a recent fall and fracture and has been dealing with worse moods due to increased pain. Progress Note on 9/23/25 at 8:00 AM: .[R10] is being seen for elevated pain from her fracture. Resident #51 (R51) During a room visit on 6/9/2026 at 8:15 AM, R51 was observed eating breakfast in bed. No staff were present and/or providing assistance. R51 lifted an uncovered coffee mug to take a sip, his hand was shaking, and he spilled coffee onto his bed sheet and t-shirt. R51 exclaimed, Dammit and tried to place the cup back on the breakfast tray. A review of R51's Electronic Medical Record (EMR) Minimum Data Set (MDS) assessment dated as submitted 5/21/26, revealed the most recent admission date as 11/10/2024, with a primary medical diagnosis of Parkinson's disease with dyskinesia (involuntary erratic movements) and also included unspecified dementia. The Brief Interview for Mental Status (BIMS) score for R51 was 5/15 indicating severe cognitive impairment. The EMR was reviewed and concerns for use of hot liquids were not found. During an interview on 6/9/2026 at 1:55 PM, Occupational Therapist (OTR) N stated R51 had not been treated by therapy for a while. OTR N stated she would review her notes in the EMR. During an interview on 6/9/2026 at 2:00 PM, the Director of Nursing (DON) stated she would review the EMR for a nursing assessment for hot liquid safety. On 6/9/2026 at 2:15 PM, OTR N presented the admission assessment titled Interdisciplinary Therapy Screen dated 11/14/2024. The Physical Function/ROM (Range of Motion) section included the question 9. Resident is observed to be safe handling hot liquids. The box for this question was checked NO. OTR N stated the evaluation had not changed for R51 over the course of his stay and each Interdisciplinary Therapy Screen assessed R51 to be unsafe when handling hot liquids. During an interview on 6/9/2026 at 2:19 PM, Dietary Manager M stated there was no indication for coffee to be covered on R51's meal card, but all liquids leave the kitchen covered. During an interview on 6/9/2026 at 2:21 PM, the DON had no further assessments from the nursing department regarding hot liquids for R51, but presented the Hot Liquids and Foods Policy. The DON reviewed the Interdisciplinary Therapy Screen in the EMR and agreed action should be taken as R51 was evaluated to be unsafe with hot liquids. The facility policy titled Hot Liquids and Foods Policy dated as last approved 3/11/2026 was reviewed. This policy read in part, . The facility will provide supervision to residents who receive hot food and beverages in an attempt to prevent hot liquid/food spills which may result in burns.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessments of four Residents (R5, R1, R2, R3) of 18 residents reviewed for MDS accuracy. Findings include: Resident #5 (R5) Review of the electronic medical record (EMR) on 6/9/26 at 7:56 AM revealed that the comprehensive MDS assessment with an Assessment Reference Date (ARD) of 3/24/26 coded R5 as having schizophrenia. In contrast, the previous quarterly MDS assessment with an ARD of 12/29/25 indicated R5 did not have a diagnosis of schizophrenia. Further review of the EMR did not identify documentation of behavioral symptoms, clinical findings, or psychiatric assessments supporting a diagnosis of schizophrenia or schizoaffective disorder. The resident's diagnosis list reflected that schizoaffective disorder, bipolar type, was added on 1/6/26; however, the source and clinical basis for the diagnosis could not be verified through review of the medical record. During an interview on 6/9/26 at 3:17 PM, Social Services Representative (SS) C stated a counselor affiliated with the facility's contracted Behavioral Health Services (BHS) provider diagnosed R5 with schizoaffective disorder, bipolar type, during a telemedicine encounter on 11/3/25. SS C provided a BHS document dated 11/3/25 authored by a social worker and identified as a psychology follow-up telemedicine visit. The documentation described R5 as having a euthymic mood [a neutral mood without disturbances], bright and congruent affect, and intact orientation, attention, insight, and judgment. The note listed schizoaffective disorder, bipolar type, but did not include documentation of diagnostic criteria, symptomatology, behavioral manifestations, or clinical findings supporting the diagnosis. Additionally, the note did not identify the source of the diagnosis or indicate that a diagnostic evaluation had been performed. On 6/9/26 at 3:42 PM, MDS Coordinator E stated that the diagnosis of schizoaffective disorder, bipolar type was added to R5's medical record on 1/6/26 after receipt of a diagnosis report from BHS and was subsequently coded on the MDS. MDS E confirmed the facility did not verify supporting documentation before coding the MDS with the diagnosis. During an interview on 6/9/26 at 4:02 PM, the Director of Nursing (DON) provided a BHS note dated 1/14/26 authored by a Physician Assistant (PA) and stated that the PA had the authority to diagnose the condition. However, the diagnosis had been documented by the social worker more than two months earlier. When asked whether documentation existed demonstrating a clinical assessment supporting the diagnosis prior to the 11/3/25 social work note, the DON stated she would provide additional records if available. On 6/10/26 at 8:34 AM, the DON reported that the PA had determined the diagnosis of schizoaffective disorder was entered in error. The DON further stated that both the PA and social worker would amend their documentation and that a correction request would be submitted for the 3/24/26 MDS assessment because the psychiatric diagnosis coded on the assessment was inaccurate. Resident #1 (R1) R1 was admitted to the facility on [DATE]. The diagnoses list reviewed in R1's electronic medical record (EMR) included heart failure and adult failure to thrive. Review of R1's EMR revealed an order, dated 3/4/26, which read, in part, Admit to [Hospice Company Name] Hospice. DX (diagnosis): HF (heart failure). R1's care plan, dated 12/8/25, read, in part, .[Resident Name] receives hospice end-of-life care.Revision on: 04/02/2026.Consult with hospice as needed/appropriate. Review of Section O – Special Treatments, Procedures, and Programs on the Significant Change MDS assessment dated [DATE] and R1's MDS was completed on 3/20/26 and revealed in section K1. Hospice care while a Resident coded No (meaning he was not receiving Hospice services) during his current stay at the facility on the MDS. Resident #2 (R2) R2 was admitted to the facility 1/8/26. The diagnoses list reviewed in R2's EMR included acute kidney failure and renal abscess. Review of R2's EMR revealed an order dated 3/18/26 through 5/7/26, which read Heparin [an anticoagulant] Lock Flush Solution 10 UNIT/ML (milliliter). Use 5 ml intravenously at bedtime for IV (intravenous) maintenance following the 10 ml normal saline flush after infusion of IV medication IV Ceftriaxone 2 g, (grams). Review of Center for Medicare and Medicaid Services (CMS) Form-802, facility Resident Matrix, dated 6/8/26, read in part, .Section 4 – Medications: Insulin (I), Anticoagulant (AC). incorrectly indicating R2 was currently receiving an anticoagulant. Resident #3 (R3) R3 was admitted to the facility 1/13/26. The diagnoses list reviewed in R3's EMR included end stage renal disease and dependence on renal dialysis. Review of section O – Special Treatments, Procedures, and Programs on a Significant Change MDS assessment dated [DATE] and completed on 2/23/26 revealed in Section J1. Dialysis while a Resident coded No (indicating he was not receiving services) during his current stay at the facility on the MDS. Review of R3's scanned documents revealed a dialysis communication sheet, dated 2/9/26 when R3 received a dialysis treatment at a local outpatient dialysis clinic. Review of R3's scanned documents revealed several (fifty-four) dialysis communication sheets, dated 1/14/26 through 6/8/26 when R3 received a dialysis treatments at a local outpatient dialysis clinic. On 6/9/26 at 12:35 PM, an interview was conducted with RN (Registered Nurse)/MDS E who was asked if R1 was on Hospice and replied, Yes. RN/MDS E was asked if R1's MDS was coded correctly and replied, No. I accidently hit no. RN/MDS E was asked if R2's anticoagulant should be reflected on the current CMS Form-802 and replied, No. I should have taken that off when his Heparin discontinued. RN/MDS E was asked if R3 was receiving dialysis services and replied, Yes. RN/MDS E was asked if his MDS was coded correctly and replied, Unfortunately not. Review of policy titled, Accuracy of MDS dated 2/22/23, read in part: Purpose: The Accuracy of the MDS must be verified to ensure that the residents strengths, weaknesses, status and areas of actual decline or risk of decline are addressed to provide quality care and to develop and individualized plan of care for the resident. Accuracy is also necessary as the MDS is directly responsible and linked to the Medicare Prospective Payment System, state Medicaid reimbursement programs, Quality Indicator Reports, Public Reporting, Research and development of Policies. Procedure: 1. Each individual that completes a section of the MDS must verify accuracy of the MDS as specified by the MDS 3.0 User's manual.2. Prior to signing or completion of a section of the MDS to ensure that all the information accurately represents the resident's status as of the Assessment Reference Date.

Based on interview and record review, the facility failed to report an allegation of neglect to the State Agency for one Resident (#10) of five residents reviewed for accident hazards and supervision.Findings include: Resident #10 (R10)Review of R10's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. Review of R10's most recent Minimum Data Set (MDS) assessment, submitted [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On [DATE] at 11:32 AM, an interview was conducted with R10 regarding her history of falls in the facility. R10 indicated she fractured her atlas (the first neck vertebra) as a result of tipping backward in a wheelchair in a transport vehicle and striking her head on the van floor. R10 explained she was coming back to the facility from a dialysis appointment when the driver suddenly accelerated. R10 revealed the transport driver had forgotten to tie down the front of the wheelchair causing her to tip backward when the van accelerated. R10 stated she was ultimately taken to the hospital where she was diagnosed with a cervical (neck) fracture. R10 indicated she had to wear a cervical collar for six weeks to protect her neck while the fracture healed. When asked if she still had pain, R10 replied, My neck is stiff. It's not as supple as it used to be. I just keep thinking; I could have been paralyzed. I could have died. Review of R10's EMR revealed a progress note written by Registered Nurse (RN) E, dated [DATE] at 13:50 [1:50 PM] that read, in part: This nurse and ADON [assistant director of nursing] were notified that while with the transport company for an appointment, [R10] fell backward while in her w/c [wheelchair] in the van, hitting the back of her head. She had complaints of neck and head pain.Resident requested to be taken to the ER [emergency room] for further evaluation in which she was taken by the transport company.On [DATE] at approximately 12:30 PM, the Director of Nursing (DON) was asked for the investigation report surrounding the events of the incident which occurred on [DATE]. The DON indicated an internal investigation was conducted but the incident was not reported to the State Agency (SA) because it occurred off facility premises with contracted staff.Review of an Incident and Accident Investigation Form, dated 82[sic]/29/25, read, in part: On [DATE], [R10] was transported by a contracted transport company to attend her Dialysis appointment. Upon completion of dialysis, [R10] was loaded onto the contracted transporting van to return to [facility]. Driver stated she accelerated forward onto to [sic] roadway, [R10's] wheelchair tipped backwards, and [R10] was observed on the van floor on her back, legs toward the driver seat and head toward the back of the van with her arms at her sides. [R10] states she went backwards and that she had hit her head on the van floor. Physician Findings: Traumatic Fracture of the Cervical Spine. Conclusion: RCA [root cause analysis] determined that [R10's] front wheel securement belt was not positioned correctly allowing her wheelchair to tip backwards.Review of an investigation report prepared by Unit Manager/RN O, undated, read in part: On [DATE], [R10] was transported by a contracted transport company to attend her Dialysis appointment. Upon completion of dialysis, [R10] was loaded onto the contracted transporting van to return to [facility]. Driver stated she accelerated forward upon entering roadway, [R10's] wheelchair tipped backwards, bending her anti-tip units outward, and [R10] was observed on the van floor on her back.The driver pulled over and observed for immediate injury. The driver was unable to safely return [R10] to upright position, to secure her in an upright position, so driver secured her in supine position, supporting her head and neck in an inline position. The driver then returned to [facility] and requested assist from [facility] staff. A resident assessment was completed. [R10] stated she had pain on her posterior head from the impact. [R10] was assisted by staff into an alternative wheelchair and was agreeable for the transport company to transfer her to the [local emergency room]. CT [computed tomography scan] and MRI [magnetic resonance imaging scan] were completed revealing a Fracture Lateral Mass C1 [a break in the first cervical vertebra at the two thick, weight-bearing sections that connect the skull to the neck] . MRI revealed bone marrow edema associated with the patient's known fracture of the lateral masses of C1.Review of the Emergency Department Report, dated [DATE], read, in part: Assessment/Plan. Traumatic fracture of cervical spine.On [DATE] at 9:32 AM, an interview was conducted with the Nursing Home Administrator (NHA) who verified the incident involving R10 was not reported to the SA. The NHA stated the incident wasn't reported to the SA because R10 was alert and oriented, could explain what happened, and because the event did not occur on company property. After discussion, the NHA agreed not properly securing a wheelchair resulting in a neck fracture could be considered neglect, and all allegations of neglect should be reported to the SA, even if the event did not occur on company property. Review of the facility policy titled, Abuse Prohibition Policy, revised [DATE], read, in part: . Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a guest/resident that are necessary to avoid physician harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, good or services that a guest/resident(s) requires but the facility fails to provide them to the guest(s)/residents(s), resulting in physical harm, pain, mental anguish, or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress. The staff will report any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator and DON immediately. The Administrator or designee will notify the guest's/resident's representative. Also, any State or Federal agencies of allegations per state guidelines.

Based on observation, interview, and record review, the facility failed to provide fingernail hygiene for one Resident (#66) of two residents reviewed for activities of daily living (ADL).Findings include:Resident #66 (R66)On 6/8/2026 at 12:12 PM, R66 was observed in bed eating her lunch. R66's fingernails had copious amounts of beige residue packed under her approximately one half inch long bilateral thumb nails. Her other fingernails were varying in length and had a black line of residue present under each. R66 stated she cleaned her own nails, and no one offered to help her do that.On 6/9/2026 at 11:56 AM, R66 was observed again with her fingernails containing a rust-colored residue on the underside of her untrimmed bilateral thumbnails and all fingernails continued to have a blackish deposit present under each. R66 stated she has not had time to clean them, and no one has helped her with her nailcare. R66 said she used to have a nail clipper and would clip them as the fingernails were too long, but someone took the clipper out of her purse. Review of R66's Electronic Medical Record (EMR) Minimum Data Set (MDS) assessment dated as submitted 3/25/26, revealed an admission to the facility on [DATE], with medical diagnoses including osteoarthritis (painful condition whereby cartilage has worn down and bones rub together with joint use) and unspecified severe dementia. The Brief Interview for Mental Status (BIMS) score for R66 was 5/15 indicating severe cognitive impairment. The MDS section E assessment for rejection of care such as ADL assistance, indicated R66 did not reject care. Section GG Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands. revealed R66 required Substantial/maximal assistance.The EMR for R66 contained a task sheet titled Manicures. It revealed for the last 30 days a manicure had not been performed. Task sheets titled Beauty Shop and Pamper Me also had no documentation for the last 30 days.During an interview on 6/9/2026 at 12:41 PM, Certified Nurse Aide (CNA) L explained the task Pamper me was when a resident received services from the hairdresser and the Manicure task was used when we do nails. CNA L said, We would document if they refused (nail care). CNA L did not remember R66 refusing nail care. CNA L observed R66 fingernails and acknowledged there was residue present under her fingernails. CNA L asked R66 if she would like her nails cleaned, trimmed and stated she could even have color. R66 agreed to a manicure and asked that the nails be rounded when they were done. R66 said No one has ever done that here.The care plan for R66 contained a focus area which read: (R66) has a functional ability deficit and requires assistance with self care/mobility R/T (related to): weakness, multiple falls. Date Initiated: 11/04/2023. Interventions in this area included: Encourage to participate in self-care as much as able, provide positive reinforcement for all activities attempted, praise resident for all efforts and accomplishments. Date Initiated: 11/04/2023 Keep finger nails trimmed and clean. Date Initiated: 11/04/2023 Report refusals of ADL care, personal hygiene, nail care, bathing, and showers to the nurse Date Initiated: 04/11/2023The facility policy titled Activities of Daily Living (ADL) Program and dated as last approved 5/1/2024, read in part, A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. and .may be provided by nursing assistance and other staff trained in provision of ADL care. A resident may benefit from a restorative ADL program if one of the following exists: .g. Residents who require supervision to extensive assistance with grooming. 3. Determine specific task and areas of ADLs. x. Trimming nails.

Based on interview and record review, the facility failed to ensure a comprehensive admission skin assessment was completed, pressure injuries were accurately identified and assessed upon admission, physician orders for treatments were timely obtained, and preventive measures were initiated without delay for one Resident (#104) of three residents reviewed for pressure injury prevention and treatment. Findings include:Resident #104 (R104) R104 was admitted to the facility on [DATE] and was assessed on the Minimum Data Set (MDS) dated [DATE] as cognitively impaired and dependent on staff for bed mobility and transfers.The MDS further documented R104 had one stage 1 pressure injury (an area of intact skin with localized, non-blanchable redness, often over a bony prominence, indicating early tissue damage), one stage 2 pressure injury (partial-thickness loss of skin with exposed dermis, presenting as a pink or red, moist wound bed or a serum-filled blister) present on admission, two unstageable-deep tissue injuries (DTI - localized damage to intact or non-intact skin and underlying soft tissue, usually over a bony prominence, presenting as persistent non-blanchable deep red, maroon, or purple discoloration, often with epidermal separation or blood-filled blisters).The admission skin assessment of R104, completed by the wound nurse, Licensed Practical Nurse (LPN) A on 5/29/26, documented bruising, abrasions, crusting, swelling, and skin irritation; however, no pressure injuries or other significant wounds were identified, assessed, measured, or documented.A nursing progress note entered on 6/1/26 at 5:33 PM, three days after R104 was admitted , documented additional wounds including a right heel DTI, left lateral foot DTI, left gluteal Stage 2 pressure injury, right gluteal Stage 1 pressure injury, and venous ulcers to the right shin and right lateral calf. The note indicated that these findings were added after the admission assessment had been locked. The admission assessment was locked on 5/31/26. The progress note read: Late Entry: Note Text: This is an addendum to the skin assessment on the Nursing comp [comprehensive] evaluation. These following skin issues were also noted after eval [evaluation] was locked, Right shin Venous ulcer, right lateral calf venous ulcer, Right heel DTI, left lateral foot DTI, left gluteus stage 2, right gluteus stage 1. The medical record lacked evidence of wounds to the right lateral calf, right heel, left lateral foot, left gluteus, and right gluteus being assessed, measured, or described on the date of admission. The first documented wound assessments occurred on 6/1/26.Additionally, treatment records revealed no wound treatments for the right lateral calf, right heel, left lateral foot, left gluteus, and right gluteus until 6/1/26 despite the wounds later being classified as present on admission. Additional preventive interventions, including a low air loss mattress, were not ordered until 6/3/26, five days after erythema to the gluteal area was reportedly observed by LPN A.Review of the resident's care plan revealed interventions including a pressure reduction mattress, nutritional consultation, pressure-reducing wheelchair cushion, offloading boots, and heel floating were not implemented until 6/1/26 or later.During interview on 6/10/26, LPN A confirmed she completed the admission skin assessment and acknowledged she didn't really see the resident's heels during the assessment. LPN A further acknowledged that the gluteal wounds may not have been present on admission and admitted Stage 1 and Stage 2 pressure injuries could develop within hours in a resident who is dependent on staff for bed mobility. LPN A confirmed she observed erythema to the buttocks upon admission but could not determine whether the areas were blanchable. Despite recognizing the redness, LPN A admitted the low air loss mattress intended to reduce pressure was not implemented until 6/3/26. LPN A did not respond when asked the reason the offloading boots, wheelchair cushion, heel floatation, and treatment orders were not initiated on 5/29/26 when R104 was admitted .The policy Skin Management dated as effective and revised 1/28/26 read, in part: . Upon admission/re-admission all residents are evaluated for skin integrity by completing abaseline total body skin evaluation documented in the electronic medical record on the nursing comprehensive evaluation . Residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Skin impairment location, measurements and characteristics documented .

Based on interview and record review, the facility failed to ensure the physician reviewed medication orders for accuracy for one Resident (#3) of three residents reviewed for physician visits. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. Upon admission to [Nursing Home Facility], the medication frequencies were transposed which resulted in R3 receiving the incorrect dosage of both Carbidopa/Levodopa and Levothyroxine. When R3 arrived at the nursing home they were ambulatory, able to function, able to make themselves lunch and care for self. When R3 was discharged , R3 was unable to ambulate, appeared confused, and could not have a conversation. Review of complaint intake number MI00153196 to the SA, dated [DATE], revealed R3 was admitted to (skilled nursing facility name) on [DATE]. On [DATE], the facility reversed the order for thyroid medicine and Carbidopa/Levodopa medications which resulted in R3 receiving five times the dose of the Levothyroxine for five consecutive days ([DATE] through [DATE]). Further review of the intake indicated R3 expired at home the next day days after discharge from the facility. Review of R3's progress note, dated [DATE] at 1:00 PM, read in part, Resident admitted .for 5-day respite care by wife in personal vehicle. A & O x 3 (alert and oriented to person, place and situation) ambulated to room with walker. Lungs CTA (clear to auscultation) . Review of R3's progress note generated by the electronic medical record, dated [DATE] at 3:14 PM, read in part, This order is outside the recommended dose or frequency. (Levothyroxine) oral tablet 200 mcg, give 2 tablets by mouth on time a day for thyroid and give 2 tablets by mouth one time a day for Parkinson's and give 1 tablet by mouth one time a day for Parkinson's .exceeds the usual dosing regimen .daily .exceeds the usual frequency of daily . Review of R3's progress note created by Physician Assistant (PA) P, dated [DATE] at 6:39 PM, read in part, Patient is a new admission to the facility. Patient medications were reviewed/verified against discharge summary which nursing had supplied. Pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing . On [DATE] at 9:35 AM, an interview was conducted with Family Member (FM) J' who was asked about R3 respite stay at the facility and replied, On [DATE], I received a phone call from the NP (Nurse Practitioner) at the facility and was told (R3's) condition had changed and developed a fever, increased heart rate, receiving fluids, was on oxygen, and had taken a turn for the worst. The facility told me that (R3) had gotten a couple extra doses of Levothyroxine. Several extra doses of Levothyroxine. When I asked why (R3) got extra doses the facility would not answer me. The facility said that (R3) could not go home as scheduled and that they were keeping (R3) for an extra night, maybe two. Then finally the facility told me what happened that they switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. More than one nurse gave (R3) the incorrect medication scheduling. (R3's) condition change was related to the medication errors. The nurse transcribed the medications wrong, and the doctor signed off and sent a note to nursing and then nursing never changed the orders. (R3) walked into the facility and when I went to go get (R3) they had to be taken out of the facility via wheelchair and two-person assistance. (R3) was so mentally out of it he could not walk. (R3) was rambling on from the time I picked him up and continued all through the remainder of the day until (R3) finally fell asleep. (R3) was hallucinating and talking to our dog like it was (R3's) sister-in-law calling the dog by her name. (R3) was disoriented totally. (R3) was mentally and physically not normal and could not stand on his own. (R3) fell in the middle of the night, Hospice had to come out, he was incontinent, and the Hospice doctor recommended comfort care. (R3) passed away around 5:30 AM the next day on [DATE]. After (R3) passed the Hospice nurse and the medical examiner came out. (R3's) body was sent down state to a hospital for an autopsy and then was sent back to a local funeral home for cremation. On [DATE] at 10:40 AM, an interview was conducted with Medical Examiner (ME) G who was asked if they recalled R3's respite care at the facility and replied, I didn't know about (R3) until I was called to his house after he passed. I know that his wife took him in on [DATE] for respite care to the facility. (R3's) wife told me that 2 to 3 days into the stay that (R3) was acting strange and not making much sense. After 4 or 5 days (R3's) wife was like, 'What's going on with (R3)?' and apparently the facility nurse transcribed the wrong medications. The facility switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. (R3) was incoherent and talked to the dog as if it was his sister-in-law. (R3) received a God-awful amount of Levothyroxine in a short amount of time. (R3) had elevated temperature and was shaky. The facility admitted to wrongdoing. Review of R3's Hospice plan of care and admission medication list, dated [DATE], revealed the following orders: 1.) Carbidopa 25 mg (milligram) /Levodopa 100 mg, disintegrating tablet, oral, one tablet three times daily, morning one pill, at noon two pills, and one pill in the evening, 2.) Levothyroxine 200 mcg, one tablet one time daily. Review of facility physician orders, dated [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. Review of R3's medication administration record (MAR), dated [DATE] through [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. R3 received two extra doses of Levothyroxine on [DATE], four extra doses on [DATE], four extra doses on [DATE], and four extra doses on [DATE], equating a total of 2800 mcg within a 96-hour time period. Review of R3's originally transcribed medication orders for Levothyroxine and Carbidopa /Levodopa, dated [DATE] at 3:14 PM, revealed orders to be transcribed/created by RN / Unit Manager B and confirmed by RN B. On [DATE] at 10:40 AM, an interview was conducted with the Medical Director (MD) E who was asked what the normal dose was for Levothyroxine and replied, Dose varies with lab work. If the dose is more than 200 mcg then I normally refer the patient to an endocrinologist. However, 200 mcg is the cut off. MD E was asked what the signs and symptoms are of a thyroid storm and replied, Tachycardia (increased heart rate), muscle aches, elevated temperature, difficulty sleeping, feeling hot, palpitations and weight loss. MD E was asked about the transcription error for R3 and their Levothyroxine and Carbidopa /Levodopa and replied, The physician assistant should have discontinued the order and made a new order to reflect the correct instructions and not left it as pending. The pharmacist should have caught the errors. I would expect nursing to know better because you only give Levothyroxine once a day in the morning before breakfast. It is basic nursing 101. On [DATE] at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who was asked about the progress note in R3's medical record dated [DATE] created by Physician Assistant (PA) P stating pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing and who was responsible for how the confirmation was made and replied, PA P should have discontinued or changed the medication orders with verification of R3 medication list. Thyroid storm is a rare life-threatening condition of the thyroid gland. It develops in cases of untreated hyperthyroidism, or overactive thyroid (thyrotoxicosis) [or overdosing of a synthetic medication designed to act to supplement the decreased activity of the thyroid gland in the case of synthroid/levothyroxine use]. Retreived from: https://medlineplus.gov/ency/article/000400.htm Review of Levothyroxine, retrieved from website: http://www.synthroid.com/starting/taking-synthroid-the-right-way?cid=ppc_ppd_MSFT_Synthroid_Branded_when_is_best_time_of_day_to_take_synthroid_Phrase_USSYNT210334&gclid=9df9ab0c7de2146322dec3334cfd7502, date retrieved [DATE], read in part, Taking [Levothyroxine] the right way: In order for Synthroid to be effective, it should always be taken the same way every day. This is important because the amount of medicine you need is very precise. And even the way you take Synthroid can affect how much medicine your body is getting. It's important to always take your medication exactly as your doctor prescribed. The right way, every day. Take [Levothyroxine] once a day, every day at the same time before breakfast. Take [Levothyroxine] with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water .Use and Important Safety Information .Taking too much levothyroxine may affect your heart, especially if you are elderly or have heart disease. Tell your doctor immediately if you have any signs of increased heart rate, chest pain, or an irregular heartbeat .Tell your doctor if you start experiencing any of the following symptoms: rapid or abnormal heartbeat, chest pain, difficulty catching your breath, leg cramps, headache, nervousness, irritability, sleeplessness, shaking, change in appetite, weight gain or loss, vomiting, diarrhea, increased sweating, difficulty tolerating heat, fever, changes in menstrual periods, swollen red bumps on the skin (hives) or skin rash, or any other unusual medical event .Use SYNTHROID only as ordered by your doctor. Take SYNTHROID as a single dose, preferably on an empty stomach, one-half to one hour before breakfast .

Based on interview and record review, the facility failed to accurately transcribe and double check admission medications per standards of practice for one Resident (#3) of three residents reviewed for new admissions. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. Upon admission to [Nursing Home Facility], the medication frequencies were transposed which resulted in R3 receiving the incorrect dosage of both Carbidopa/Levodopa and Levothyroxine. R3 was supposed to receive Carbidopa/Levodopa five times a day, and Levothyroxine once a day 200 mcg (micrograms). The nursing home flipped R3's medications. R3 was provided Levothyroxine five times a day, and Carbidopa/Levodopa once a day. When R3 arrived at the nursing home they were ambulatory, able to function, able to make themselves lunch and care for self. When R3 was discharged , R3 was unable to ambulate, appeared confused, and could not have a conversation Review of complaint intake number MI00153196 to the SA, dated [DATE], revealed R3 was admitted to (skilled nursing facility name) on [DATE]. On [DATE], the facility reversed the order for thyroid medicine and Carbidopa/Levodopa medications which resulted in R3 receiving five times the dose of the Levothyroxine for five consecutive days ([DATE] through [DATE]). Further review of the indicated R3 expired at home the next day after discharge from the facility. Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of R3's progress note, dated [DATE] at 1:00 PM, read in part, Resident admitted .for 5-day respite care by wife in personal vehicle. A & O x 3 (alert and oriented to person, place and situation) ambulated to room with walker. Lungs CTA (clear to auscultation) . Review of R3's progress note, dated [DATE] at 3:14 PM, read in part, This order is outside the recommended dose or frequency. (Levothyroxine) oral tablet 200 mcg, give 2 tablets by mouth on time a day for thyroid and give 2 tablets by mouth one time a day for Parkinson's and give 1 tablet by mouth one time a day for Parkinson's .exceeds the usual dosing regimen .daily .exceeds the usual frequency of daily . Review of R3's progress note, dated [DATE] at 6:39 PM, read in part, Patient is a new admission to the facility. Patient medications were reviewed/verified against discharge summary which nursing had supplied. Pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing . Review of R3's Hospice visit note, dated [DATE], read in part, Vital signs: Blood pressure 160/84, pulse 78, respiratory rate 24, temperature 98.2, pain 3/10, and oxygen saturation 95%. Patient (R3) arrived at the facility 1:15 PM. (R3) is in his room, resting on his bed. He stated the transport went well. Patient said he is good with his room .Went over meds (medications) with nurse . On [DATE] at 9:00 AM, an interview was conducted with the Hospice Licensed Practical Nurse (LPN) O who was asked to verify their visit note when R3 was admitted on [DATE]. LPN O replied, Yes, I went over the medication list with the unit manager (Registered Nurse [RN] B), but I was not with them when the medication orders were transcribed. LPN O was asked if R3 at the time of admission was at their baseline and replied, Yes, (R3) walked into the facility with their walker and no assistance. (R3) was fine then. (R3's) lungs were clear and showed no signs or symptoms of a urinary tract infection of any other infection. The facility screwed up their medications and instead gave them one Carbidopa/Levodopa once a day and Levothyroxine three times a day with a total of five tabs. I was surprised the facility had released (R3). I thought the facility would have kept (R3) until returning to their baseline. I feel like (R3) was discharged too soon. I would have done things differently and made the medication error right. LPN O was asked if they were present at the time R3 was discharged and replied, Not at the facility, but I did go to see (R3) at home later. (R3) was not quite up to their normal self. I was surprised and sad to hear that (R3) had passed away. I did not expect that. LPN O was asked if they recalled how R3 was when they came to visit R3 on [DATE] and replied, (R3) had increased fever, and their vital signs were all messed up. (R3) was not normal. (R3's) temperature changed because they were getting too much Levothyroxine. Review of R3's vital signs, dated [DATE] at 12:53 PM, revealed the following: Blood pressure 127/71, pulse 91, respiratory rate 16, temperature 98.6, and oxygen saturation 93%. Weight 228.6 pounds obtained on [DATE] at 4:05 PM. Review of R3's progress note, dated [DATE] at 5:50 AM, read in part, At 0510 (5:10 AM) CNA (Certified Nurse Aide) reported resident to be confused and shaking. VSS (vital signs) were taken and BP (blood pressure) 180/84 T (temperature) 101.6 P (pulse) 116 R (respirations) 22 BS (blood sugar) 165 O2 (oxygen) 93%-86% (acetaminophen) administered at 0524 (5:24 AM) (lorazepam) at 0516 (5:16 AM). Cold wash cloths applied to neck and O2 applied at 2 L (liters) nc (nasal cannula) . Review of R3's progress note, dated [DATE] at 1:04 PM, read in part, Resident noted to have increased confusion, abnormal vitals (sic) signs. N.O. (new order) from .NP (nurse practitioner) for NS (normal saline) IV at 125 ml/hr (milliliters/hour) for 24 hours, vitals (sic) signs every 4 hours for 24 hrs (hours), Labs ordered . Review of R3's progress note, dated [DATE] at 3:34 PM, read in part, Patient being seen today as he is febrile, tachycardic, and increase confusion .overnight he became febrile, tachycardic and lethargic with need for oxygen .It was also noted he was receiving more than double of dose of his levothyroxine as well .Due to the unsureness of cause of symptoms will order labs as well as give a liter of IV Normal Saline and continue to monitor vitals .not been drinking very much the last couple days .patient was supposed to be discharged home today .would like to keep him overnight to be monitored and possibly discharge home tomorrow . On [DATE] at 9:20 AM, an interview was conducted with Hospice RN I who was asked if she recalled R3 being at the facility for respite care and replied, Yes. I found out on [DATE] of the medication errors. (R3) was getting Levothyroxine the same as they would with their Carbidopa/Levodopa. So (R3) was getting one Carbidopa/Levodopa once a day and Levothyroxine three times a day with a total of five tabs (two in the morning, one in the afternoon and two in the evening). On [DATE] at 9:27 AM, an interview was conducted with Hospice Case Manager K who was asked if they recalled R3 being at the facility for respite care and replied, Yes. (R3) was supposed to be at the facility for respite care including five nights and six days, but (R3) was discharged on [DATE] on the seventh day. The facility notified her (Case Manager K) of the medication error and R3 needing to stay an extra day because of requiring IV fluids. The medication error was between two medications that were transcribed incorrectly by the facility staff. R3 was getting one Carbidopa/Levodopa once a day and Levothyroxine three times a day with a total of five tabs (two in the morning, one in the afternoon and two in the evening). The facility Nurse Practitioner (NP) assessed and ordered the normal saline fluids, monitoring, and labs to be drawn. Labs ordered were a comprehensive metabolic (CMP), thyroid stimulating hormone (TSH), triiodothyronine (T3), and a thyroxine (T4). The facility has the results. I notified my supervisor regarding the medication errors and interventions. On [DATE] at 9:35 AM, an interview was conducted with Family Member (FM) J' who was asked about R3 respite stay at the facility and replied, On [DATE], I received a phone call from the NP (Nurse Practitioner) at the facility and was told (R3's) condition had changed and developed a fever, increased heart rate, receiving fluids, was on oxygen, and had taken a turn for the worst. The facility told me that (R3) had gotten a couple extra doses of Levothyroxine. Several extra doses of Levothyroxine. When I asked why (R3) got extra doses the facility would not answer me. The facility said that (R3) could not go home as scheduled and that they were keeping (R3) for an extra night, maybe two. Then finally the facility told me what happened that the switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. More than one nurse gave (R3) the incorrect medication scheduling. (R3's) condition change was related to the medication errors. The nurse transcribed the medications wrong, and the doctor signed off and sent a note to nursing and then nursing never changed the orders. (R3) walked into the facility and when I went to go get (R3) they had to be taken out of the facility via wheelchair and two-person assistance. (R3) was so mentally out of it he could not walk. (R3) was rambling on from the time I picked him up and continued all through the remainder of the day until (R3) finally fell asleep. (R3) was hallucinating and talking to our dog like it was (R3's) sister-in-law calling the dog by her name. (R3) was disoriented totally. (R3) was mentally and physically not normal and could not stand on his own. (R3) fell in the middle of the night, Hospice had to come out, he was incontinent, and the Hospice doctor recommended comfort care. (R3) passed away around 5:30 AM the next day on [DATE]. After (R3) passed the Hospice nurse and the medical examiner came out. (R3's) body was sent down state to a hospital for an autopsy and then was sent back to a local funeral home for cremation. On [DATE] at 10:40 AM, an interview was conducted with Medical Examiner (ME) G who was asked if they recalled R3's respite care at the facility and replied, I didn't know about (R3) until I was called to his house after he passed. I know that his wife took him in on [DATE] for respite care to the facility. (R3's) wife told me that 2 to 3 days into the stay that (R3) was acting strange and not making much sense. After 4 or 5 days (R3's) wife was like, 'What's going on with (R3)?' and apparently the facility nurse transcribed the wrong medications. The facility switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. (R3) was incoherent and talked to the dog as if it was his sister-in-law. (R3) received a God-awful amount of Levothyroxine in a short amount of time. (R3) had elevated temperature and was shaky. The facility admitted to wrongdoing. On [DATE] at 9:10 AM, an interview was conducted with LPN L who was asked what the process was for adding new admission orders in for medications and replied, The unit managers normally add them in and then they are checked by a second manager. If it is the weekend or the managers are gone then the floor nurses must do it but there should always be a second check. Review of R3's Hospice plan of care and admission medication list, dated [DATE], revealed the following orders: 1.) Carbidopa 25 mg (milligram) /Levodopa 100 mg, disintegrating tablet, oral, one tablet three times daily, morning one pill, at noon two pills, and one pill in the evening, 2.) Levothyroxine 200 mcg, one tablet one time daily. Review of facility physician orders, dated [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. Review of R3's medication administration record (MAR), dated [DATE] through [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. R3 received two extra doses of Levothyroxine on [DATE], four extra doses on [DATE], four extra doses on [DATE], and four extra doses on [DATE], equating a total of 2800 mcg within a 96-hour time period. Review of R3's originally transcribed medication orders for Levothyroxine and Carbidopa /Levodopa, dated [DATE] at 3:14 PM, revealed orders to be transcribed/created by RN / Unit Manager B and confirmed by RN B. On [DATE] at 10:40 AM, an interview was conducted with the Medical Director (MD) E who was asked what the normal dose was for Levothyroxine and replied, Dose varies with lab work. If the dose is more than 200 mcg then I normally refer the patient to an endocrinologist. However, 200 mcg is the cut off. MD E was asked what the signs and symptoms are of a thyroid storm and replied, Tachycardia (increased heart rate), muscle aches, elevated temperature, difficulty sleeping, feeling hot, palpitations and weight loss. MD E was asked about the transcription error for R3 and their Levothyroxine and Carbidopa /Levodopa and replied, The physician assistant should have discontinued the order and made a new order to reflect the correct instructions and not left it as pending. The pharmacist should have caught the errors. I would expect nursing to know better because you only give Levothyroxine once a day in the morning before breakfast. It is basic nursing 101. On [DATE] at 11:45 AM, an interview was conducted with RN M who was asked what the normal time and frequency was for Levothyroxine and replied, It is given in the morning and once a day. RN M was asked if they recalled R3 and their Levothyroxine dose, time, and frequency and replied, I didn't think it was strange to give it three times a day because (R3) was on Hospice. RN M was asked why they never checked the electronic medical record for the admission paperwork to double check the Levothyroxine frequency and dosing and replied, I don't know. I just assumed the order was put in correctly. On [DATE] at 12:05 PM, an interview was conducted with Pharmacist F who was asked what their process is for medication regimen reviews for new admissions and replied, I have to run a report for verification of orders on new admissions in the electronic medical records system. I try to get in there Monday through Friday everyday to see who a new admission is or if someone was transferred out. Or pull the report and look to see if they have documentation to verify the orders. Pharmacist F was asked if they were the pharmacist that did the medication regimen review for R3 on [DATE] and replied, Yes. Pharmacist F was asked why they did not address the pending confirmation for R3's Levothyroxine, Carbidopa-Levodopa and Trazodone dosing and replied, I think the orders may have been pending confirmation, so it was not official yet, so it did not show up on the order profile. On [DATE] at 12:45 PM, an interview was conducted with RN C who was asked what pending confirmation meant from a physician who signed off on a medication review for a new admit and replied, The physician should have compared the admit instructions with the transcribed orders and made a change if a change needed to be made. RN C was asked why the nurse practitioner had ordered normal saline for R3 and replied, For fluid resuscitation related to dehydration potential and medication errors. RN C was asked for what medication error for R3 and replied, The Levothyroxine error I think. RN C was asked what the process was for new admission medications and replied, Orders are transcribed by the unit managers and double checked with the original admission paperwork to the orders transcribed by another unit manager or nurse if one is not available. Then after the second check the on-call or house physician verifies the orders. RN C verified that the created by and the confirmed by should be two different nurse signatures. On [DATE] at 1:00 PM, an interview was conducted with RN B who was asked about the process for new admissions and transcribing medication orders and replied, The unit manager normally puts them in if they are at the facility and then the orders are double checked by a second nurse usually another unit manager. RN B was asked if she put the orders in for R3 and replied, Yes. RN B was asked who did the second check on R3's medication orders and replied, RN 'C'. On [DATE] at 1:10 PM, and interview was conducted with RN C who was asked if they recalled double checking the medication orders transcribed by RN B for R3 and replied, I can't recall double checking (R3's) medication orders. There needs to be a better process. RN C was asked if there was a check off list that must be completed for new admissions that certain things were completed and initialed off by staff and replied, No, there is not a check off list. We just use the medication list provided by the receiving hospital or where the resident comes from. RN C confirmed that there was no progress note for R3 that medications transcribed were double checked. On [DATE] at 1:20 PM, an interview was conducted with Nurse Practitioner (NP) D who was asked if they recalled R3 and replied, Yes. (R3) was admitted to the facility for respite care. (R3) became tachycardic, febrile, and lethargic. When it was discovered that (R3) was receiving more Levothyroxine I ordered normal saline and (R3) perked up. I wish nursing would have asked about and questioned the frequency of (R3's) Levothyroxine and they never did. I put a hold on the Levothyroxine for five days. I ordered a TSH, T3, T4, and CMP. NP D was asked if they got all the results back of the lab work for R3 and replied, The TSH result was 0.02, which is low, and I did order a T4, but we never got results. NP D was asked where in the human body Levothyroxine was metabolized and replied, I'm not sure. NP D was asked if poison control was notified of the medication error for direction and replied, No. NP D stated, There should have been better communication with pending confirmation and reviewed the admitting medications and made changes on order entry failures. NP D was asked if R3 had a medical diagnosis of end stage liver failure and replied, Yes, decreased liver function and would not have excreted the Levothyroxine as fast as a normal healthy liver. The medication would have had more of a build up in (R3's) system. My first presentation I did think (R3) was possibly in a thyroid storm because (R3) had increased heart rate, increased fever, lethargy, and confusion. Review of R3's medication audit report, dated [DATE] at 1:54 PM, revealed that RN B queued the Levothyroxine 200 mcg, give 2 tablets by mouth upon rising, give 2 tablets by mouth at lunch, and give 1 tablet by mouth at dinner for Parkinson's order for R3 on [DATE] at 11:23 AM and then created and confirmed the same order on [DATE] at 3:14 PM. On [DATE] at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who was asked about the process for new admissions and transcribing medication orders and replied, We receive a referral and get the discharge summary with a list of medications currently being taken and confirm if the person is coming. The unit manager who receives the referral enters the medication orders in the electronic medical record and a second unit manager double checks the orders entered. The DON was asked if there was anyway to know who did the second check on R3's medication order entry and replied, No, there is no way to know who did the second check in the electronic medical record. The DON was asked about the progress note in R3's medical record dated [DATE] created by Physician Assistant (PA) P stating pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing and who was responsible for how the confirmation was made and replied, PA P should have discontinued or changed the medication orders with verification of R3 medication list. The DON was asked if there is a policy for transcribing medication orders and replied, No policy just a process. I am not sure how the provider or the pharmacist did not catch the errors either. On [DATE] at 2:52 PM, an interview was conducted with LPN N who was asked what the normal time and frequency was for Levothyroxine and replied, It is given in the morning and once a day. LPN N was asked if they recalled R3 and their Levothyroxine dose, time, and frequency and replied, I assumed because (R3) was on Hospice that it was correct. LPN N was asked if they ever checked the electronic medical record for the admission paperwork to double check the Levothyroxine frequency and dosing and replied, I don't think of that. I just assumed the order was put in correctly. Review of R3's laboratory requisition from the facility, dated [DATE] at 10:20 AM, revealed R3's labs were to be drawn for a CMP, CBC (complete blood count), T3, T4, and TSH. Check boxes on the laboratory requisition were marked with a black X. Review of R3's laboratory results dated , [DATE] at 10:20 AM, revealed the lack of a T4 result. On [DATE] at 3:15 PM, a request was sent to the local laboratory for R3's original laboratory blood draw requisition. On [DATE] at 3:25 PM, R3's original laboratory requisition was obtained and revealed the lab for the T4 was never marked by the facility staff to be tested. On [DATE] at 3:45 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked why the laboratory requisition that the facility had on file was different from the original one that the local laboratory had on file and replied, I don't know. That is a good question. I will go ask the DON. On [DATE] at 3:55 PM, an interview was conducted with the DON who was asked why the discrepancy between the local laboratory requisition and the facility requisition and replied, I called the nurse who filled out the laboratory requisition for R3's blood to be drawn and they stated that after the original laboratory requisition was filled out and blood was drawn they noted the error and then later marked it after the laboratory requisition was sent. The DON was asked if the local laboratory was called to add the lab test for the T4 and replied, It was an oversight on the nurse and no malice was intended. Review of facility document titled, Medication Incident Report, dated [DATE] at 12:10 PM, revealed the following: 1.) Two medication transcription errors with Levothyroxine and Carbidopa-Levodopa. 2.) Incorrect dose times were entered incorrectly in eMAR (electronic medication administration record) upon admission. 3.) As noted by PA P and dosage times for Levothyroxine entered for Carbidopa-Levodopa and vice versa. 4.) Physician notified on [DATE] at 9:40 AM. 5.) Order changes: Lab draw. 6.) Corrective action taken: Nurse educated to ensure new admission orders are entered correctly. Follow up with physician verifying orders for any resident corrections. On [DATE] at 4:00 PM, an interview was conducted with the DON who was asked if any other nurses were educated or written up and replied, No, just the one who transcribed the orders incorrectly. Thyroid storm is a rare life-threatening condition of the thyroid gland. It develops in cases of untreated hyperthyroidism, or overactive thyroid (thyrotoxicosis) [or overdosing of a synthetic medication designed to act to supplement the decreased activity of the thyroid gland in the case of synthroid/levothyroxine use]. Retreived from: https://medlineplus.gov/ency/article/000400.htm Review of policy titled, Medication Administration, dated [DATE], read in part, Resident medication are administered in an accurate, safe, timely, and sanitary manner .Procedure .2. Verify the medication label against the medication administration record for resident name, time, drug, dose, and route. a. The nurse is responsible to read and follow precautionary instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved . Review of Levothyroxine, retrieved from website: http://www.synthroid.com/starting/taking-synthroid-the-right-way?cid=ppc_ppd_MSFT_Synthroid_Branded_when_is_best_time_of_day_to_take_synthroid_Phrase_USSYNT210334&gclid=9df9ab0c7de2146322dec3334cfd7502, date retrieved [DATE], read in part, Taking [Levothyroxine] the right way: In order for Synthroid [Levothyroxine's brand name] to be effective, it should always be taken the same way every day. This is important because the amount of medicine you need is very precise. And even the way you take Synthroid can affect how much medicine your body is getting. It's important to always take your medication exactly as your doctor prescribed. The right way, every day. Take [Levothyroxine] once a day, every day at the same time before breakfast. Take [Levothyroxine] with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water .Use and Important Safety Information .Taking too much levothyroxine may affect your heart, especially if you are elderly or have heart disease. Tell your doctor immediately if you have any signs of increased heart rate, chest pain, or an irregular heartbeat .Tell your doctor if you start experiencing any of the following symptoms: rapid or abnormal heartbeat, chest pain, difficulty catching your breath, leg cramps, headache, nervousness, irritability, sleeplessness, shaking, change in appetite, weight gain or loss, vomiting, diarrhea, increased sweating, difficulty tolerating heat, fever, changes in menstrual periods, swollen red bumps on the skin (hives) or skin rash, or any other unusual medical event .Use SYNTHROID only as ordered by your doctor. Take SYNTHROID as a single dose, preferably on an empty stomach, one-half to one hour before breakfast . Review of Thyroid Storm: Causes, Symptoms, Diagnosis & Treatment, retrieved from website: https://my.clevelandclinic.org/health/diseases/23203-thyroid-storm, date retrieved [DATE], read in part, .Diagnosis and tests. How is thyroid storm diagnosed? A healthcare provider diagnoses thyroid storm if the person has severe and life-threatening symptoms, such as extreme fever and heart issues, and high levels of thyroid hormone and low levels of thyroid-stimulating hormone (TSH) in their blood . Review of Thyroxine Poisoning, retrieved from website: http://www.ncbi.nih.gov/books/NBK279036/, dated retrieved [DATE], read in part, Clinical recognition . Ingested thyroxine, which is itself probably of modest physiologic significance, is rapidly partially converted to triiodothyronine (T3), the active form of thyroid hormone .Both thyroxine and triiodothyronine levels in serum rise within 1-2 hours of ingestion. Rarely, the overdose is discovered immediately, and the patient is brought to the hospital 6-12 hours after the ingestion. At this time, the common clinical signs and symptoms include nervousness, insomnia, mild tremor of hands, tachycardia, mild elevation of body temperature, blood pressure elevation, and loose stools . Cardiac effects aside from tachycardia are seldom seen in young adults but may occur in middle age and older adults, with reported arrhythmias and acute myocardial infarction . One-time ingestion of up to 3 mg thyroxine .As already mentioned serious complications are not common, but they can appear days after ingestion, and therefore the patients should be closely monitored .Diagnosis and differential: Elevated levels of total and free T4 and T3 have been described with suppressed serum TSH levels and otherwise typically a normal biochemical profile. The half-life of serum T4 may be shortened. In one study the half-life of LT4 was 5.7 days which is slightly shorter than the usual half-life of L-thyroxine . n many cases, there is a progressive rise in both serum total T4 and total T3 levels in the first 24 hours following the overdose, caused by continued absorption of the ingested LT4 .Follow-up: Patients should be monitored for several days to be sure that serum T4 and T3 levels are falling . Review of A Study of Thyroid Dysfunction in Cirrhosis of Liver and Correlation with Severity of Liver Disease, retrieved from website: http://pmc.ncbi.nlm.gov/articles/PMC6166553/, date retrieved [DATE], read in part, Introduction: Liver plays an important role in the metabolism of thyroid hormones . Moreover, the liver is involved in thyroid hormone conjugation and excretion .End-stage liver disease can significantly impact the metabolism of levothyroxine, a synthetic thyroid hormone .

Based on interview and record review, the facility failed to identify harmful dosing parameters and recognize the resulting side effects for an incorrectly prescribed thyroid medication for one Resident (#3) of 3 residents reviewed for .three residents reviewed for new admissions. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. Upon admission to [Nursing Home Facility], the medication frequencies were transposed which resulted in R3 receiving the incorrect dosage of both Carbidopa/Levodopa and Levothyroxine When R3 arrived at the nursing home they were ambulatory, able to function, able to make themselves lunch and care for self. When R3 was discharged , R3 was unable to ambulate, appeared confused, and could not have a conversation Review of complaint intake number MI00153196 to the SA, dated [DATE], revealed R3 was admitted to (skilled nursing facility name) on [DATE]. On [DATE], the facility reversed the order for thyroid medicine and Carbidopa/Levodopa medications which resulted in R3 receiving five times the dose of the Levothyroxine for five consecutive days ([DATE] through [DATE]). Further review of the indicated R3 expired at home the next day after discharge from the facility. Review of R3's vital signs, dated [DATE] at 12:53 PM, revealed the following: Blood pressure 127/71, pulse 91, respiratory rate 16, temperature 98.6, and oxygen saturation 93%. Weight 228.6 pounds obtained on [DATE] at 4:05 PM. Review of R3's progress note, dated [DATE] at 1:00 PM, read in part, Resident admitted .for 5-day respite care by wife in personal vehicle. A & O x 3 (alert and oriented to person, place and situation) ambulated to room with walker. Lungs CTA (clear to auscultation) . Review of R3's progress note, dated [DATE] at 3:14 PM, read in part, This order is outside the recommended dose or frequency. (Levothyroxine) oral tablet 200 mcg, give 2 tablets by mouth on time a day for thyroid and give 2 tablets by mouth one time a day for Parkinson's and give 1 tablet by mouth one time a day for Parkinson's .exceeds the usual dosing regimen .daily .exceeds the usual frequency of daily . Review of R3's progress note, dated [DATE] at 6:39 PM, read in part, Patient is a new admission to the facility. Patient medications were reviewed/verified against discharge summary which nursing had supplied. Pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing . Review of R3's progress note, dated [DATE] at 5:50 AM, read in part, At 0510 (5:10 AM) CNA (Certified Nurse Aide) reported resident to be confused and shaking. VSS (vital signs) were taken and BP (blood pressure) 180/84 T (temperature) 101.6 P (pulse) 116 R (respirations) 22 BS (blood sugar) 165 O2 (oxygen) 93%-86% (acetaminophen) administered at 0524 (5:24 AM) (lorazepam) at 0516 (5:16 AM). Cold wash cloths applied to neck and O2 applied at 2L (liters) nc (nasal cannula) . Review of R3's progress note, dated [DATE] at 1:04 PM, read in part, Resident noted to have increased confusion, abnormal vitals (sic) signs. N.O (new order) from .NP (nurse practitioner) for NS (normal saline) IV at 125 ml/hr (milliliters/hour) for 24 hours, vitals (sic) signs every 4 hours for 24 hrs (hours), Labs ordered . Review of R3's progress note, dated [DATE] at 3:34 PM, read in part, Patient being seen today as he is febrile, tachycardic, and increase confusion .overnight he became febrile, tachycardic and lethargic with need for oxygen .It was also noted he was receiving more than double of dose of his levothyroxine as well .Due to the unsureness of cause of symptoms will order labs as well as give a liter of IV Normal Saline and continue to monitor vitals .not been drinking very much the last couple days .patient was supposed to be discharged home today .would like to keep him overnight to be monitored and possibly discharge home tomorrow . On [DATE] at 9:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) L who was asked what the process was for adding new admission orders in for medications and replied, The unit managers normally add them in and then they are checked by a second manager. If it is the weekend or the managers are gone then the floor nurses must do it but there should always be a second check. Review of R3's Hospice plan of care and admission medication list, dated [DATE], revealed the following orders: 1.) Carbidopa 25 mg (milligram) /Levodopa 100 mg, disintegrating tablet, oral, one tablet three times daily, morning one pill, at noon two pills, and one pill in the evening, 2.) Levothyroxine 200 mcg, one tablet one time daily. Review of facility physician orders, dated [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. Review of R3's medication administration record (MAR), dated [DATE] through [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. R3 received two extra doses of Levothyroxine on [DATE], four extra doses on [DATE], four extra doses on [DATE], and four extra doses on [DATE], equating a total of 2800 mcg within a 96-hour time period. On [DATE] at 11:45 AM, an interview was conducted with Registered (RN) M who was asked what the normal time and frequency was for Levothyroxine and replied, It is given in the morning and once a day. RN M was asked if they recalled R3 and their Levothyroxine dose, time, and frequency and replied, I didn't think it was strange to give it three times a day because (R3) was on Hospice. RN M was asked why they never checked the electronic medical record for the admission paperwork to double check the Levothyroxine frequency and dosing and replied, I don't know. I just assumed the order was put in correctly. On [DATE] at 2:52 PM, an interview was conducted with LPN N who was asked what the normal time and frequency was for Levothyroxine and replied, It is given in the morning and once a day. LPN N was asked if they recalled R3 and their Levothyroxine dose, time, and frequency and replied, I assumed because (R3) was on Hospice that it was correct. LPN N was asked if they ever checked the electronic medical record for the admission paperwork to double check the Levothyroxine frequency and dosing and replied, I don't think of that. I just assumed the order was put in correctly. Review of policy titled, Medication Administration, dated [DATE], read in part, Resident medication are administered in an accurate, safe, timely, and sanitary manner .Procedure .2. Verify the medication label against the medication administration record for resident name, time, drug, dose, and route. a. The nurse is responsible to read and follow precautionary instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved . Review of Levothyroxine, retrieved from website: http://www.synthroid.com/starting/taking-synthroid-the-right-way?cid=ppc_ppd_MSFT_Synthroid_Branded_when_is_best_time_of_day_to_take_synthroid_Phrase_USSYNT210334&gclid=9df9ab0c7de2146322dec3334cfd7502, date retrieved [DATE], read in part, Taking [Levothyroxine] the right way: In order for Synthroid [Levothyroxine's brand name] to be effective, it should always be taken the same way every day. This is important because the amount of medicine you need is very precise. And even the way you take Synthroid can affect how much medicine your body is getting. It's important to always take your medication exactly as your doctor prescribed. The right way, every day. Take [Levothyroxine] once a day, every day at the same time before breakfast. Take [Levothyroxine] with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water .Use and Important Safety Information .Taking too much levothyroxine may affect your heart, especially if you are elderly or have heart disease. Tell your doctor immediately if you have any signs of increased heart rate, chest pain, or an irregular heartbeat .Tell your doctor if you start experiencing any of the following symptoms: rapid or abnormal heartbeat, chest pain, difficulty catching your breath, leg cramps, headache, nervousness, irritability, sleeplessness, shaking, change in appetite, weight gain or loss, vomiting, diarrhea, increased sweating, difficulty tolerating heat, fever, changes in menstrual periods, swollen red bumps on the skin (hives) or skin rash, or any other unusual medical event .Use SYNTHROID only as ordered by your doctor. Take SYNTHROID as a single dose, preferably on an empty stomach, one-half to one hour before breakfast .

This citation pertains to Intakes MI00150419 and MI00151063. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 19 residents (#37, #51, #7, #87, #35, #36, #42, #48, #65, #81 and nine confidential residents) reviewed for staffing. This deficient practice resulted in actual harm for Residents #37, #7, #35, #42, and #48 who were forced to lay in their own excrement or urine for extended periods of time or delay a bowel movement due to insufficient staffing, resulting in reported feelings of frustration, helplessness, humiliation, and anger and/or inference of these feelings based on the reasonable person concept. Findings include: Resident #37 (R37) Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R37 was admitted to the facility on [DATE]. R37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for ADLs (activities of daily living), including toileting hygiene, bathing and all mobility. Review of the Brief Interview for Mental Status (BIMS) assessment revealed R37 scored ,d+[DATE], indicating the Resident was cognitively intact. On [DATE] at 7:40 a.m., a strong, offensive odor was noted in the hallway outside of R37's room. Upon entering R37's room and approaching the Resident in bed, it was noted the odor was stronger and was coming from the area of R37's bed. When asked when the last time staff had been in to administer care, R37 reported staff were last in during the night because her ostomy bag was leaking. R37 was observed pulling down the blanket and sheet, which was sticking to R37's abdomen and covered with a light brown substance. R37's colostomy bag was observed attached to her mid-abdomen and was three-quarter full of light brown stool and was taut due to gas collection. The outside of the bag was noted to be covered with light brown stool. R37's left side lower abdomen and left upper thigh had dried stool present and stool was observed leaking from the left side of the colostomy, soiling the sheet the resident was lying on. R37 reported staff did not have time to change the ostomy bag when it was found leaking overnight and just patched it. On [DATE] at 8:40 a.m., R37 was observed seated in bed with a strong odor of stool present when standing next to R37's bed. Light brown stool was observed on the exposed white sheet resting on R37's left hip. When asked if staff had been in to assist her with cleaning up and changing the leaking ostomy bag, R37 reported staff brought in her breakfast tray and when R37 asked about getting cleaned up, was told she would have to wait until after staff were finished serving breakfast. When asked if she would prefer to be cleaned up before eating, R37 shrugged and stated, what can I do? During an interview on [DATE] at 2:35 p.m., Certified Wound Care and Registered Nurse (RN) L reported she was asked to change R37's ostomy bag on the morning of [DATE]. RN L confirmed R37's colostomy bag was found leaking with the bed and clothing soiled with stool. RN L reported she was unaware R37's bag began leaking on the previous shift and that it was not changed. LPN L stated she was also unaware R37 was served breakfast with the colostomy visibly leaking, soiling the sheets and clothes, and that R37 was told she would need to wait to be cleaned up until after the meal. RN L reported they were short staffed on the previous shift due to a call in. Review of R37's [DATE] Treatment Administration Record (TAR) revealed R37's colostomy appliance and bag were documented as changed on [DATE] at 10:01 a.m. During an interview on [DATE] at 2:45 p.m., a confidential staff member, reported a concern there were not enough staff scheduled on a daily basis to address resident care needs. The confidential staff member reported out of the 36 residents residing on the Maple Unit (200 Hall), 22 were on a two-hour check and change schedule and many of those resident's required two-person assistance. Staff GG reported staff were feeling burned out and defeated with being unable to meet resident needs. Review of R37's care plan report (Kardex) revealed the following: Check q 2 hr [every two hours] and prn [as needed] for incontinence. Resident #51 (R51) Review of the MDS assessment, dated [DATE], revealed R51 was admitted to the facility on [DATE]. R51 required substantial/maximal assistance (helper does more than half the effort) with bed mobility. Review of the BIMS assessment revealed R51 scored ,d+[DATE], indicating moderate cognitive impairment. An observation upon entering the Maple Unit on [DATE] at 7:35 a.m. revealed the call light activation indicator above R51's door was illuminated, indicating a call light was activated. R51 was observed lying in bed with the head of the bed at approximately a 70-degree angle. R51 was slouched down in the bed with her head positioned near the bottom of the head of the bed with two pillows above and hanging over her head. R51's right foot was hanging off the right side of the bed and her left foot was touching the foot board. During an interview at the time of the observation, R51 reported she activated the call light for assistance with a boost to be repositioned farther up in the bed. Continuous observation from 7:35 a.m., revealed R51's call light remained unanswered at 7:50 a.m. at which time four staff were observed in the Maple Unit dining room and two nurses were observed working at the nurse's station. At 8:00 a.m., Certified Nursing Assistant (CNA) U was observed delivering R51's breakfast tray to her room, delivered the meal tray and exited with the call light still activated. During an interview at the time of the observation, R51 reported she asked CNA U for assistance repositioning in bed. R51 reported CNA U informed R51 she needed to wait until another staff person was available to assist. R51 was observed to be in the same position in the bed as previously observed at 7:35 a.m. It was noted R51's call light remained activated. At 8:04 a.m., CNA U was observed in Maple Unit dining room assisting two Activity Aides and one CNA with delivering meal trays. During an interview at the time of the observation, CNA U was asked if she was aware R51's call light was activated and that R51 was requesting to be repositioned. CNA U stated she was aware but needed to assist with passing meal trays. CNA U appeared flustered as she then left to seek another staff person to assist R51. R51 received assistance at 8:05 a.m., 30 minutes after the Resident's light was first observed activated. Resident #7 (R7) Review of the MDS assessment, dated [DATE], revealed R7 was admitted to the facility on [DATE]. R7 required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance) with transfers and walking, and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, including adjusting clothes before and after using the toilet. Review of the MDS revealed R7 scored ,d+[DATE], indicating moderate cognitive impairment. An observation upon entering the Maple Unit on [DATE] at 1:45 p.m., revealed the call activation indicator above R7's door was illuminated, indicating a call light was activated. Upon entering the room, R7 reported she activated her call light for assistance to go to the bathroom. R7's right hand was observed holding onto her abdomen and while wincing, R7 stated, I have to move my bowels. At the time of the observation, no staff were visible on the Maple Unit, including the halls, dining area or nurse's station. At 1:53 p.m. CNA P was observed walking down the hall from the area of room [ROOM NUMBER]. CNA P was alerted to R7's call light by this Surveyor. CNA P was observed entering room [ROOM NUMBER], where a bathroom call light was observed activated. Upon exiting room [ROOM NUMBER], CNA P entered R7's room, at which time the call light was deactivated. CNA P then exited R7's room. CNA P was interviewed immediately following the observation and reported she had to wait for another staff person to become available to assist in transferring R7 to the bathroom. CNA P reported the nurse assigned to the unit was caring for another resident, two other CNAs were providing care to another resident and one CNA was at lunch. CNA P stated providing cares after lunch was a challenge due to so many of the residents requiring assistance with transfers and toileting. CNA P reported there were no other staff available to cover for staff lunches and the Residents often had to wait for assistance. At 2:05 p.m. CNA V was observed approaching CNA P near the [NAME] Unit dining room asking for assistance with another resident. CNA P was observed walking down the hallway away from R7's room with CNA V. Immediately after CNA P left to assist CNA V, R7 was observed sitting in bed, as previously observed. When asked if she had received assistance, R7 held her right hand over her abdomen and stated she had not received assistance and stated I really need to go. At 2:12 p.m., RN L and CNA Q entered R7's room and R7 was heard stating I really need to move my bowels. A total of 27 minutes elapsed between the time R7's call light was observed activated and the time R7 was assisted to the bathroom. Resident #87 (R87) Review of the MDS assessment, dated [DATE], revealed R87 was admitted to the facility on [DATE] with a diagnosis of right hip fracture. R87 required substantial/maximal assistance with toileting hygiene, partial/moderate assistance with transfers and was dependent on staff for ambulation and wheelchair mobility. Review of the MDS Section H - Bladder and Bowel, revealed R87 was always continent of bladder and bowel. Review of the BIMS assessment revealed a score of ,d+[DATE], indicating moderate cognitive impairment. During a telephone interview on [DATE] at 6:54 p.m., R87's Family Member (FM) GG reported R87 was a resident at the facility until she discharged on [DATE]. FM GG stated R87 expressed concern with staff assistance at the facility. FM GG reported witnessing staff not responding to call lights in a timely manner with wait times up to 45 minutes for assistance. FM GG reported R87 fell on multiple occasions while attempting to go to the bathroom unassisted. When asked about the falls FM GG stated, R87 told him she had called for assistance, but no one responded and she would not pee the bed. R87 reported his concerns prompted him to take R87 out of the facility and home to follow up with her own physicians. When asked if R87 was available for interview, FM GG reported the Resident expired on [DATE]. Review of R87's fall reports, provided by the Director of Nursing (DON) revealed the following: [DATE], 7:55 a.m. resident noted on the floor by passing nurse. Resident stated she was attempting to go to the bathroom. [DATE], 1:26 p.m. opened door and observed resident on the floor . resident stated she was trying to go to the bathroom. [DATE], 12:06 a.m. Resident was attempting to stand and then started sliding out of her [wheelchair] . she said she was going to the bathroom . fell [related to] weakness [and] did not wait for assist. Confidential Group Meeting During a confidential group meeting conducted on [DATE] at 10:30 a.m., nine out of nine residents in attendance reported concerns with staffing levels in the facility and all reported consistent and extensive call light response times. Confidential Resident #9 (CR9) reported waiting on the toilet for more than 30 minutes for assistance after pulling the call light cord. CR9 reported when they expressed concern over how long the wait was, they were told staff had other duties that took priority. CR1 reported he was told he could not attend breakfast in the dining room unless he requested to do so the night before. When asked if he was allowed request to attend breakfast in the dining room the morning of the meal, CR1 reported there were no staff available to assist in cleaning up or transfers before or during mealtime. CR7 reported if they call for assistance to the bathroom close to or during a mealtime, they are consistently informed by staff they must wait for assistance until things die down. CR7 reported waiting 30 minutes or more for assistance after activating the call light only for staff to enter his room to say they will need to wait until staff are free to assist and at times, staff never come back to help. CR2 reported being left on the toilet for an extended period of time after activating the call light and stated my legs went numb. Review of the PBJ (Payroll Based Journal) Staffing Data Report, for FY (Fiscal Year) Quarter 1, 2025 ([DATE] - [DATE]), revealed the facility was flagged for excessively low weekend staffing based upon data submitted by the facility. Review of the Daily Schedule Sheet(s), for [DATE] through [DATE], provided by the DON, revealed the following: Saturday, [DATE] Evening Shift (7:00 p.m. - 7:00 a.m.): three licensed nurses and five CNAs scheduled for a total census of 73. Actual working schedule revealed two CNAs listed as CI (called-in) and three CNAs out of five scheduled worked the shift, for total of six staff for 73 residents. Friday, [DATE] Evening Shift: three licensed nurses and five CNAs scheduled for a total census of 78. Actual working schedule revealed one CNA only worked 7:00 p.m. - 11:00 p.m., leaving staff of three licensed nurses and two CNAs from 11:00 p.m. - 7:00 a.m., for a total of five staff for 78 residents. Saturday, [DATE] Evening Shift: three licensed nurses and five CNAs scheduled for a total census of 83. Actual working schedule revealed one CNA listed as CI, and one CNA worked 7:00 p.m. - 4:00 a.m., leaving staff of three licensed nurses and three CNAs for a total of six staff for 83 residents. During an interview on [DATE] at 8:51 a.m., the DON was queried regarding the facility process for scheduling nursing and direct care staff. The DON reported scheduling was conducted based on the facility census and resident needs. When asked if she thought three CNAs were sufficient to care for 73 residents, the DON reported nursing staff are available to assist the CNAs with care on the evening shift because there are not many meds to pass. The DON was informed of the survey team's observations of long wait times and resident's left soiled for long periods of time, to which she responded staff were not acting usual due to surveyors being in the building. When asked if she felt she had enough staff scheduled to competently care for the residents, the DON did not offer a response. The DON reported nurse managers are included in the daily staffing numbers and generally workday shift, eight-hour days, Monday through Friday. A review of resident required assistance listing, reflecting the current census of 89 residents and provided by the DON, revealed the following: Residents requiring one person assistance with transfers: 41. Residents requiring two persons assistance with transfers: 12. Residents requiring use of the sit-to-stand mechanical lift: 5. Residents requiring use of the total mechanical lift: 15. 49302 On [DATE] at 11:25 AM, the lunch time meal was observed ready to serve in the steam table in the main dining room. On [DATE] at 11:43 AM, Culinary Aide Z was observed standing by the steam table. Culinary Aide Z stated, Lunch is ready, but I can't start serving food until a CNA is present in the dining room. When asked if kitchen staff must frequently wait for nursing staff to begin serving hot food, Culinary Aide Z said, Yes. It definitely goes in streaks. On [DATE] at 11:48 AM, CNA AA entered the dining room and communicated to Culinary Aide Z, I'll be down as soon as I can to serve trays, I am helping a resident with toileting needs. On [DATE] at 12:00 PM, CNA AA returned to the dining room and began serving lunch trays. At 12:14 PM, the last tray was served in the dining room, 49 minutes after the food was initially placed in the steam table. On [DATE] at 11:10 AM, the lunch time meal was observed ready to serve in the steam table in the main dining room. A total of 14 residents were seated in the dining room awaiting the lunch time meal. On [DATE] at 12:04 PM, the last tray was served in the dining room, 54 minutes after the food was initially placed in the steam table. On [DATE] at 11:11 AM, an interview was conducted with Dietary Manager (DM) Y regarding timeliness of food service expectations. DM Y stated food is placed into the steam table by 11:15 AM to allow for prompt service of the mid-day meal at 11:30 AM. DM Y stated the expectation is to serve food within 15 minutes of placing it in steam table for ideal palatability. DM Y confessed, If it's any longer than that, I myself wouldn't want to eat it. DM Y endorsed ongoing issues successfully serving meals in an acceptable timeframe due to the lack of nursing staff. DM Y speculated nursing staff may be too busy performing cares or transporting residents down to the dining to start serving at the expected time. On [DATE] at 11:58 AM, an interview was conducted with Resident #58 (R58) while waiting to be served lunch. R58 stated, They serve us the cheapest [expletive] they can buy. I was served a Salisbury steak recently and I couldn't even tell what it was . The food here ain't fit for man nor beast. Review of facility document titled Meal Schedule read, LUNCH: dining room [ROOM NUMBER]:,d+[DATE]:30. 45123 On [DATE] at 10:20 AM, an intense noxious odor was detected from the locked dementia unit. A tour of the locked unit was conducted and the noxious odor increased in intensity. Resident #35 (R35) Review of R35's annual Minimum Data Set (MDS) assessment, dated [DATE], revealed R35 required substantial/maximal assistance for toileting, indicating the helper completed more than half the effort and R35 was occasionally incontinent. R35 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe cognitive impairment. On [DATE] at 11:56 AM, an observation was made of R35 in their room lying in bed. R35 reached out in an attempt for help. Certified Nurse Aide (CNA) H was made aware of R35 needing assistance. CNA H was asked if R35 was incontinent and the last time they were checked on. CNA replied, Yes, I was in here around 8:00 AM this morning. CNA H confirmed that R35 was soiled in urine and needed incontinence care. Resident #36 (R36) Review of R36's quarterly MDS assessment, dated [DATE], revealed R36 required substantial/maximum assistance for personal hygiene, indicating the helper completed more than half the effort. R36 scored a 02 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On [DATE] at 11:41 AM, an observation was made of R36 being assisted to the dining room. R36's hair was not brushed, and they had hair sticking up in the back right side of their head. On [DATE] at 12:20 PM, an interview was conducted with CNA J who was asked if residents were provided with assistance for brushing hair. CNA J replied, Some residents need assistance and others won't let you. So, it just depends on their mood. Resident #42 (R42) Review of R42's admission MDS assessment, dated [DATE], revealed an admission to the facility on [DATE], with active diagnoses that included: hypertension, type two diabetes mellitus, and amputation below the knee of the right leg. R42 scored an 8 of 15 on the BIMS assessment, reflective of moderately impaired cognition. R42's quarterly MDS, dated [DATE], revealed R42 required total assistance for toileting and was frequently incontinent. On [DATE] at 10:26 AM, an interview was conducted with Family Member (FM) HH who stated that they wished the staff would get R42 up out of bed more often. FM HH stated R42 had lost weight since being admitted to the facility, and they don't even have a TV they can watch so R42 just lays in bed all day doing nothing. On [DATE] at 7:28 AM, an observation was made of R42 in their room lying in bed with the bed sheets half off. R42 was observed to be lying on a soaker pad that was soaked with urine and had a yellow/brown stain on the outer edges of the urine mark and the room had a noxious smell of urine. On [DATE] at 7:30 AM, an interview was conducted with CNA F who was asked if they were working on the dementia unit. CNA F replied, I worked last night, and my shift is done at 7:30 AM . CNA F was asked when the last time they had checked and changed R42. CNA F replied, I did a check and change on them at 3:00 AM. On [DATE] at 8:30 AM, an observation was made of CNA H who was delivering a breakfast tray to R42 in their room. CNA H was asked if they would provide incontinence care for R42 before they ate breakfast. CNA H replied, Yes, of course. CNA H was asked how they were going to accomplish the task as R42 was a two person assist, and they were the only CNA working on the unit. CNA H looked very overwhelmed and about to break down. CNA H replied, I guess I will just have to do it myself. Staffing is not the greatest. The nurse was supposed to mandate another staff member, but I guess that didn't happen. It is just me and an activities aide who is not certified and can't help me. I know the nurse won't help me. During the observation and interview at this time, R42 stated his back was uncomfortably itchy and driving him crazy due to skin irritation from the urine-saturated soaker pad. Resident #48 (R48) Review of R48's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R48 required total assistance for toilet and was always incontinent. R48 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe impairment in cognition. On [DATE] at 10:15 AM, an observation was made of R48 in their room and lying in bed with a sheet on and a soaker pad underneath them. A noxious smell was detected when entering R48's room. R48's soaker pad was soiled with urine, extending to the outer edges of the pad. R48's bed sheets were visibly soiled with food stains and crumbs. On [DATE] at 10:18 AM, an interview was conducted with CNA H who was asked when they had last checked on R48 for incontinence care. CNA H replied, I got here at 7:00 AM and I have not been in to provide care for them yet. CNA stated, 19 Residents are a lot to provide care for with one [on duty]. On [DATE] at 10:36 AM, an interview was conducted with CNA H and Licensed Practical Nurse (LPN) E who were asked if there was enough staff on the unit to care for all 19 Residents. LPN E and CNA H both replied, Most days it is like one nurse and one aide. CNA H stated that the night shift aide left trash and linens in the rooms. CNA H continued, Ideally every resident is a check and change every two hours, but we can't get to them on time. Review of R48's care plan, dated [DATE], read in part, .[Resident's name] is incontinent of bladder and bowel r/t (related to): Dementia process .Check q (every) 2 hr (hours) and prn (as needed) for incontinence .Resident uses disposable brief. Change q2h (every two hours) .Provide incontinence care with each episode . Resident #65 (R65) Review of R65's quarterly MDS assessment, dated [DATE], revealed R65 required partial/moderate assistance with personal hygiene. R65 scored a 04 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On [DATE] at 11:48 AM, an observation was made of R65 in the hallway, and she had visible whiskers on her chin that were approximately a quarter of an inch long. Resident #81 (R81) Review of R81's quarterly MDS assessment, dated [DATE], revealed an uncompleted personal hygiene required assistance level. R81 scored a 04 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On [DATE] at 11:40 AM, an observation was made of R81 walking in the hallway with disheveled and greasy hair. On [DATE] at 8:15 AM, no fresh water was observed in any of the 19 resident rooms on the locked unit. An interview was conducted with CNA H who was asked when residents get fresh water. CNA H replied, It usually gets passed right away at the beginning of each shift, but usually no later than 10:00 AM. Water was not passed until 12:30 PM on this day. On [DATE] at 10:40 AM, an interview was conducted with Housekeeper K who was asked if there was usually noxious odors on the locked unit. Housekeeper K replied, It smells strong of urine this morning and yesterday morning. I sprayed some air freshener on the curtains as I was cleaning the rooms. On [DATE] at 7:45 AM, an interview was conducted with Registered Nurse (RN) A who was asked if there was enough staff to care for residents on the locked unit and if they were able to mandate staff to stay over. RN A replied, No, I can't mandate staff to stay over. We had a call-in this morning. So, we are working short staffed again. I don't have time to call other staff. The front [office] does that if they are here. On [DATE] at 8:35 AM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) who were made aware of the staffing situation on the locked unit where there was one nurse, one licensed CNA, and one non-licensed staff. The locked unit had several Residents that required two-person assistance. The NHA replied, Residents should not be left incontinent for extended periods of time, should be receiving fresh water, and are provided with activities of daily living care. The DON replied, . there was a staff member who was mandated to stay over and should be on that locked unit working now. On [DATE] at 9:05 AM, an interview was conducted with RN D who confirmed that CNA F, who was mandated to stay over, punched out and left the facility. Review of policy titled, Activities of Daily Living (ADL) Program, dated [DATE], read in part, Purpose: A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. ADL may include, but are not limited to, bathing, grooming, and dressing. Restorative ADL program may be provided by nursing assistants and other staff trained in provision of ADL care under the supervision of the licensed nurse . Review of policy titled, Oral Hydration, dated [DATE], read in part, Policy: It is the policy of this facility to assist residents to maintain adequate hydration whenever possible .Procedure .5. Each resident will be provided bedside water unless contraindicated . Review of policy titled, Mandated after shift coverage, dated [DATE], read in part, .The procedure is as follows: 1. Whenever a staff member calls in or a no call / no show occurs a 12-hour employee will stay over and report to the unit that the call / no show occurred on. 2. The charge nurse will call anyone not working that day and ask if they would be willing to come in to work .4. If no one is willing to stay we will move on to the mandating list .6. The on-coming nurse will make sure staff stays over for coverage .

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety as evidenced by: A. Failure to ensure expired food was discarded. B. Failure to ensure adequate labeling of potentially hazardous food. C. Failure to ensure cabinetry surrounding an ice machine was maintained in good repair. This deficient practice had the potential to result in food borne illness among any or all of the 89 residents in the facility. Findings include: The following were observed during the initial tour of the kitchen: 1. On [DATE] at 10:06 AM, undated heads of wilted cabbage were observed in a cardboard box in dry storage. An undated cardboard box of raw potatoes was observed next to the cabbage with numerous rotten potatoes scattered throughout the box. 2. On [DATE] at 10:07 AM, a broken raw egg was observed next to intact eggs inside a carton in the reach-in refrigerator. 3. On [DATE] at 10:08 AM, four pints of undated, moldy, cherry tomatoes were observed in the reach-in refrigerator. 4. On [DATE] at 10:10 AM, undated vegetarian burger patties were observed in the reach-in freezer. The open plastic bag was unsecured and open to air with five patties exposed to the environment. When Culinary Aide W was asked about the contents of the bag, they replied, These should have an expiration date and be in a sealed bag. 5. On [DATE] at 10:11 AM, hot dogs were observed in a stainless-steel pan in the reach-in refrigerator. A tag affixed to the container read, use by ,d+[DATE]. When Culinary Aide W was asked if the use-by date was correct, they replied, I don't know, I hope not. I just got back from a week vacation. On [DATE] at 11:11 AM, an interview was conducted with Dietary Manager (DM) Y regarding food labeling and storage expectations. DM Y stated all foods should be labeled with a use-by date and subsequently discarded on that date. DM Y stated the vegetarian patties should have been sealed and unexposed to the environment. DM Y' stated the expectation for visibly spoiled food or broken eggs is for them be discarded immediately. On [DATE] at 11:39 AM, the cabinetry adjacent to the ice machine in the main dining room was observed to be damaged and rotted through. On [DATE] at 11:44 AM, the damaged cabinetry was observed with Maintenance Director (MD) I who verified the facility had issues with the ice machine leaking in the past. After observing the water damage, MD I stated, That [cabinet] needs to be replaced . I will put in a work order right now. The Food and Drug Administration (FDA) 2022 Food Code states: ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). ,d+[DATE].11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE].

Based on observation, interview, and record review, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms on one hall, serving 19 of a total 89 residents. This deficient practice resulted in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable. Findings include: On 3/23/25 at 10:30 AM, noxious odors were noted throughout the 300 Hall. On 3/24/25 at 7:20 AM, noxious odors were noted throughout the 300 Hall. On 3/24/25 at 8:45 AM, in response to the presence of continued noxious odors on the 300 Hall, an investigation was initiated into determining the functioning of the exhaust ventilation system for resident bathrooms. The bathrooms serving the following rooms were inspected for functioning exhaust by placing a paper towel over the cling mounted duct cover and determining if there was adequate negative pressure to hold the paper in place. The failure to hold the towel in place was deemed a failure for that bathroom's exhaust system. This failure was noted in the bathrooms serving the following resident rooms: A.) 300 Hall: 302, 303/304, 305, 306, 307/308, and 309. On 3/24/25 at 9:30 AM, an interview was conducted with Maintenance Director (MD) I who conducted a similar test for bathroom exhaust function and confirmed there was not any negative pressure in the duct resulting in a failure of exhaust from the bathroom. MD I stated she was unaware of the non-functioning exhaust system. When asked about the frequency of the testing and observing for the functioning of the exhaust, MD I stated she observed the exhaust system motors once a month and tested on e bathroom exhaust at the same time. When asked when the last check of the exhaust had been conducted, MD I stated I think this month. MD I was requested to investigate the cause of the failure and share the information with the survey team. On 3/24/25 at 10:15 AM, an interview was conducted with the Maintenance Assistant G who confirmed the motors responsible for the exhaust ventilation for the 300 Hall had a broken belt and that he had replaced it when he went up on the roof to check if they were functioning properly. Maintenance Assistant G stated that he had not been up on the roof since November related to the Winter season. A computer-generated report sheet was provided and indicated the exhaust fans had been checked on 3/5/25 by MD I. Review of policy titled, Maintenance Department, dated 9/19/24, read in part, Policy: To assure proper maintenance of the physical plant. I. Preventive Maintenance: The Maintenance Department is responsible for maintaining the facility's ventilation systems and temperature control .

This citation pertains to intake MI00150419. Based on observation, interview and record review, the facility failed to ensure residents were cared for in a dignified and respectful manner for five residents (#37, #51, #7, #38 and #2) of five residents reviewed for dignity, resulting in feelings of frustration, humiliation and low self-worth based on a reasonable person standard. Findings include: Resident #37 (R37) Review of the Minimum Data Set (MDS) assessment, dated 2/10/2025, revealed R37 was admitted to the facility on [DATE] and had diagnoses including diabetes, colocutaneous fistula (abnormal tract leading from the intestine to an opening in the abdomen), history of MRSA (Methicillin Resistant Staphylococcus Areus) infection, and major depressive disorder. Further review revealed R37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for ADLs (activities of daily living), including toileting hygiene, bathing and all mobility. A review of the Brief Interview for Mental Status (BIMS), revealed a score of 13/15, indicating R37 was cognitively intact. On 3/24/2025 at 7:40 a.m., a strong, offensive odor was noted in the hallway outside of R37's room. Upon entering R37's room and approaching the Resident in bed, it was noted the odor was stronger and was coming from the area of R37's bed. An observation at that time revealed R37 seated in bed, wearing a short-sleeved shirt with a white sheet and blanket pulled up to her mid-torso. When asked when the last time staff had been in to administer care, R37 reported staff were last in during the night because her ostomy bag was leaking. R37 pulled down the blanket and sheet, which were observed sticking to R37's abdomen and covered with a light brown substance. R37's ostomy bag was observed attached to her mid-abdomen and was three-quarter full of light brown stool and taut due to gas collection. The outside of the bag was noted to be covered with light brown stool. R37's left side lower abdomen and left upper thigh were noted to have dried stool present and stool was observed leading from the Resident's left side soiling the sheet the resident was lying on. R37 reported the bag was not changed when it was found leaking overnight and indicated staff reported to R37, they had patched it. On 3/24/2025 at 8:40 a.m., R37 was observed seated in bed eating breakfast from an tray table positioned over R37 in bed. A strong odor of stool was noted to be present when standing next to R37's bed and light brown stool was observed to be on the exposed white sheet resting on R37's left hip. When asked if staff had been in to assist her with cleaning up and changing the leaking colostomy bag, R37 reported staff brought in her breakfast tray and when asked about getting cleaned up she was told, after breakfast. When asked if she would prefer to be cleaned up before eating, R37 shrugged and stated, what can I do? Review of R37's March 2025 Treatment Administration Record (TAR) revealed R37's colostomy appliance and bag were documented as changed on 3/24/2025 at 10:01 a.m. No changes were documented on 3/23/2025. During an interview on 3/25/2024 at 2:35 p.m., Certified Wound Care and Registered Nurse (RN) L reported she was asked to change R37's colostomy bag on the morning of 3/24/2025. RN L confirmed R37's colostomy bag was found leaking and the bed and clothing were soiled with stool. RN L reported she was not made aware R37's bag had begun leaking on the previous shift and was not changed. RN l was also not aware R37 was served breakfast and was told she would need to wait to be cleaned up until after the meal. RN L stated R37 was on the list for check and change incontinence care and colostomy care, which should be provided every two hours. RN L reported it was unacceptable for R37 to have to sit in stool while eating her meal and added that R37 refused care at times. A review of R37's point of care documentation for ADL Care Statement and Behavior Monitoring/Interventions, revealed no resident refusals of care for the period of 3/2/2025 through 3/25/2025. Resident #51 (R51) Review of the MDS assessment, dated 1/17/2025, revealed R51 was admitted to the facility on [DATE] and had diagnoses including orthostatic hypotension, gastroesophageal reflux disease (GERD), arthritis, anxiety, and chronic obstructive pulmonary disease (COPD). Further review revealed R51 required substantial/maximal assistance (helper does more than half the effort) with bed mobility. A review of the BIMS, revealed a score of 11/15, indicating R51 had mild cognitive impairment. Upon entering the Maple Unit on 3/25/2025 at 7:35 a.m. a call light activation indicator was observed illuminated above the door to R51's room. R51 was observed lying in bed with the head of the bed at approximately a 70-degree angle. R51 was slouched down in the bed with her head positioned near the bottom of the head of the bed with two pillows above and hanging over her head .R51's right foot was hanging off the right side of the bed and her left foot was touching the foot board. During an interview at the time of the observation, R51 reported she activated the call light for assistance for a boost to reposition her further up in the bed. A continuous observation which started at 3/25/25 at 7:35 a.m., revealed R51's call light remained unanswered at 7:50 a.m. During this time, four staff were observed in the Maple Unit dining room and two nurses were present at the nurse's station. Licensed Practical Nurse (LPN) O was observed standing at the medication cart inside the nurse's station, directly facing the control panel with R51's room number indicator on the panel lit up, indicating the call light was activated. RN L was seated at the desk at the nurse's station. It was noted there was an audible alert at the nurse's station, indicating a call light was activated. At 8:00 a.m., Certified Nursing Assistant (CNA) U was observed delivering R51's breakfast tray to her room and positioning the Resident's meal tray on an tray table to the left of the R51 in bed. CNA U then exited with the call light still activated. During an interview at the time of the observation, R51 reported asking CNA U for assistance with repositioning in bed. R51 stated she told CNA U she could not eat slouched down in the bed. R51 was observed in the same position in the bed as previously observed at 7:35 a.m. It was noted R51's call light remained activated. At 8:04 a.m., CNA U was observed in the Maple Unit dining room assisting three other staff with delivering meal trays. RN L and LPN O were observed at the nurses stating with the call light bell still audible and R51's room number lit up. During an interview at the time of the observation, CNA U was asked if she was aware R51's call light was activated and if CNA U was aware R51 requested to be repositioned. CNA U answered, she was aware. CNA U then left the dining room to seek another staff person to assist R51. R51's call light was observed being deactivated and R51 was observed receiving assistance at 8:05 a.m., 30 minutes after R51's light was first observed activated. Resident #7 (R7) Review of the MDS assessment, dated 2/6/2025, revealed R7 was admitted to the facility on [DATE] and had diagnoses including dementia and arthritis. R7 required supervision or touching assistance (helper provides verbal cures or touching/steadying assistance) with transfers and walking, and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, including adjusting clothes before and after using the toilet. Review of the MDS Section H Bladder and Bowel revealed R7 was frequently incontinent of urine and occasionally incontinent of bowel. Review of the BIMS, revealed a score of 8/15, indicating R7 had moderate cognitive impairment. An observation upon entering the [NAME] Unit on 3/25/2025 at 1:45 p.m., revealed a call light activation indicator was observed illuminated above the door to R7's room. Upon entering the room, R7 reported she activated her call light for assistance to go to the bathroom. R7's was observed with her right hand on her abdomen wincing stated, I have to move my bowels. At 1:53 p.m. CNA P was alerted to R7's call light by this Surveyor. CNA P entered R7's room, at which time the call light was deactivated. CNA P exited R7's room and reported she needed assistance from another staff person to transfer R7 to the bathroom. R7 immediately reactivated the call light. CNA P entered the Resident's room and was heard telling R7 I know you have to go to the bathroom, but I have to wait for someone to help. CNA P deactivated the call light and left R7's room. At 2:05 p.m., CNA V was observed approaching CNA P near the Maple Unit dining room asking for assistance. CNA P was observed walking down the hallway away from R7's room with CNA V. Immediately after CNA P left to assist CNA V, R7 was observed sitting in bed, as previously observed. When asked if she had received assistance, R7 held her right hand over her abdomen and stated she had not received assistance and I really need to go. At 2:10 p.m., CNA P was observed approaching the nurses station and stating she was leaving for lunch and immediately walked down the hall and off the unit, without alerting staff present at the nurse's station of R7's need for assistance to the bathroom. LPN O, RN L and CNA Q were present at the nurse's station at the time CNA P announced she was leaving the unit for lunch. On 3/25/2025 at 2:12 p.m., a query was made of LPN O, RN L and CNA Q as to whether CNA P had alerted them to R7's need for assistance to the bathroom to which they all reported no. RN L and CNA Q then left to enter R7's room and R7 was heard stating I really need to move my bowels. 27 minutes had elapsed between the time R7's call light was observed to be activated and the time R7 was assisted to the bathroom. Resident #38 (R38) Review of the MDS assessment, dated 3/5/2025, revealed R38 was admitted to the facility on [DATE] and had diagnoses including dementia and malnutrition. Review of the BIMS, revealed a score of 2/15, indicating R38 had severe cognitive impairment. R38 required supervision for eating. An observation on 3/23/2025 at 12:40 p.m., revealed R38 seated at the dining room table in the Maple dining room with her meal tray positioned on the table in front of her. Further observation revealed two soiled meal trays containing partially eaten foods and a tray of used, soiled water cups, coffee cups and juice cups half consumed, atop the end of the table at which R38 was seated for her meal. During an interview at the time of the observation, Activity Aide (AA) N reported the soiled trays and cups were removed from resident's rooms upon delivery of the noon meal and fresh water pass earlier that day. Resident #2 (R2) Review of the MDS assessment, dated 12/20/2024, revealed R2 was admitted to facility on 12/14/2024 and had diagnoses including malnutrition, anxiety, depression, and failure to thrive. Review of the BIMS, revealed a score of 7/15, indicating R2 had severe cognitive impairment. On 3/23/2025 at 12:10 p.m., R2 was observed seated at the end of the long dining table in the Maple Unit dining room. Further observation revealed a tray of used water cups with straws, juice cups half consumed and used, soiled coffee cups atop the end of the dining table and within view of R2. At 12:15 p.m., an unidentified staff member placed R2's meal tray at the end of the table with R2 seated in a wheelchair approximately two feet away from the end of the table and out of reach of the meal. During an interview at the time of the observation, R2 was asked if he was hungry to which he replied, yeah, I'm hungry. R2 was then observed reaching toward the meal that was out of reach from R2's current position in the wheelchair. R2 was observed making several attempts to move toward the table, grasping the edge of the table and pulling himself toward his meal, only to roll backward again in the wheelchair out of reach of the food. R2 attempted to reach a fork on his meal tray and proceeded to drop the fork on the floor with no attempt by staff to replace the soiled fork. CNA H was present in the dining room at the time of the observation. At 12:36 p.m. R2 stretched out his right hand to retrieve a bowl of mashed potatoes from the table and proceeded to hold the bowl in his lap. At 12:58 p.m., CNA H approached R2 and asked him do you want to try some of these? R2 was observed nodding his head and CNA H then took the bowl from R2. As CNA H began to pick up a spoon from the table to assist R2 with the potatoes, another resident in the dining room attempted to self-transfer and CNA H ceased assisting R2 to aid the other resident and never returned to assist R2. At 1:02 p.m., R2 was observed reaching from approximately two feet away from the table to grasp a cup of pudding. R2 then dipped his right index finger into the cup and into his mouth. Further observation revealed R2 attempting to pour the pudding from the cup into his mouth, at which time the pudding spilled and landed on R2's shirt and lap. CNA H was observed in the dining room at the time of the observation and offered no further assistance to R2. During an interview on 3/26/2025 at 8:51 a.m., the Director of Nursing (DON) was alerted to the referenced observations. The DON reported staff were not acting as usual due to surveyors being in the building. The DON reported it was the responsibility of all staff to answer call lights, and if unable to assist the resident they were expected to alert a staff member who could meet the resident's need. When asked about the soiled items taken from resident rooms and housed on the dining room table during meal service, the DON stated housing soiled items on the table during dining was unacceptable and staff had been educated on the topic prior to the survey. Review of the facility policy titled, Resident Dignity & Personal Privacy, last revised 3/28/2024, revealed the following: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy . Dignity mean that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.

This deficient practice pertains to intake MI00151063. Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for six dependent Residents (#35, #36, #42, #48, #65, and #81) out of 19 residents reviewed for personal hygiene and incontinence care. Findings include: Resident #35 (R35) Review of R35's annual Minimum Data Set (MDS) assessment, dated 12/12/24, revealed R35 required substantial/maximal assistance, indicating the helper completed more than half the effort and R35 was occasionally incontinent. R35 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:56 AM, an observation was made of R35 in their room lying in bed. R35 reached out in an attempt for help. Certified Nurse Aide (CNA) H was made aware of R35 needing assistance. CNA H was asked if R35 was incontinent and the last time they were checked on. CNA replied, Yes, I was in here around 8:00 AM this morning. CNA H confirmed that R35 was soiled in urine and needed incontinence care. Resident #36 (R36) Review of R36's quarterly MDS assessment, dated 12/6/24, revealed R36 required substantial/maximum assistance for personal hygiene, indicating the helper completed more than half the effort. R36 scored a 02 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:41 AM, an observation was made of R36 being assisted to the dining room. R36's hair was not brushed, and they had hair sticking up in the back right side of their head. On 3/23/25 at 12:20 PM, an interview was conducted with CNA J, who was asked if residents were provided with assistance for brushing hair. CNA J replied, Some residents need assistance and others won't let you. So, it just depends on their mood. Resident #42 (R42) Review of R42's admission MDS assessment, dated 11/15/25, revealed an admission to the facility on [DATE], with active diagnoses that included: hypertension, type two diabetes mellitus, and amputation below the knee of the right leg. R42 scored an 8 of 15 on the BIMS assessment, reflective of moderately impaired cognition. R42's quarterly MDS, dated [DATE], revealed R42 required total assistance for toileting and was frequently incontinent. On 3/23/25 at 10:26 AM, an interview was conducted with Family Member (FM) HH who stated that they wished the staff would get R42 up out of bed more often. FM HH stated R42 had lost weight since being admitted to the facility, and indicated R42 didn't have a TV to watch which led to R42 just lying in bed all day doing nothing. On 3/25/25 at 7:28 AM, an observation was made of R42 in their room lying in bed with the bed sheets half off. R42 was observed lying on top a soaker pad which was saturated with urine as evidenced by a yellowish stain that extended to the outer edges of the pad. A noxious odor of urine was detected from outside the room. On 3/25/25 at 7:30 AM, an interview was conducted with CNA F who was asked if they were working on the dementia unit. CNA F replied, I worked last night, and my shift is done at 7:30 AM. CNA F was asked when the last time they had checked and changed R42. CNA F replied, I did a check and change on them at 3:00 AM. CNA F asked what time it was and was told the current time of 7:31 AM. CNA F replied, Oh, I better go and punch out. CNA F left the unit and the facility at that time. On 3/25/25 at 8:30 AM, an observation was made of CNA H who was delivering a breakfast tray to R42 in their room. CNA H was asked if they would provide incontinence care for R42 before they ate breakfast. CNA H replied, Yes, of course. CNA H was asked how they were going to accomplish the task as R42 was a two person assist, and they were the only CNA working. CNA H looked very overwhelmed and about to break down. CNA H replied, I guess I will just have to do it myself. Staffing is not the greatest. The nurse was supposed to mandate another staff member, but I guess that didn't happen. It is just me and an activities aide who is not certified and can't help me. I know the nurse won't help me. During the observation and interview at this time R42 stated his back was uncomfortably itchy and driving him crazy due to skin irritation from the urine-saturated soaker pad. Resident #48 (R48) Review of R48's quarterly Minimum Data Set (MDS) assessment, dated 1/2/25, revealed R48 required total assistance for toilet and was always incontinent R48 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe impairment in cognition. On 3/23/25 at 10:15 AM, an observation was made of R48 in their room and lying in bed with a sheet on and a soaker pad underneath them. A noxious smell was detected when entering R48's room. R48's soaker pad was soiled with urine, extending to the outer edges of the pad. R48'd bed sheets were visibly soiled with food stains and crumbs. On 3/23/25 at 10:18 AM, an interview was conducted with CNA H who was asked when they had last checked on R48 for incontinence care. CNA H replied, I got here at 7:00 AM and I have not been in to provide care for them yet. 19 Residents are a lot to provide care for with one CNA [on duty]. On 3/23/25 at 10:36 AM, an interview was conducted with CNA H and Licensed Practical Nurse (LPN) E who were asked if there was enough staff on the unit to care for all 19 Residents. LPN E and CNA H both replied, Most days it is like one nurse and one aide. CNA H stated that the night shift aide left trash and linens in the rooms. CNA H continued, Ideally every resident is a check and change every two hours, but we can't get to them on time. Review of R48's care plan, dated 12/4/23, read in part, . [Resident's name] is incontinent of bladder and bowel r/t (related to): Dementia process .Check q (every) 2 hr (hours) and prn (as needed) for incontinence .Resident uses disposable brief. Change q2h (every two hours) . Provide incontinence care with each episode . Resident #65 (R65) Review of R65's quarterly MDS assessment, dated 2/21/25, revealed R65 required partial/moderate assistance with personal hygiene. R65 scored a 04 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:48 AM, an observation was made of R65 in the hallway, and she had visible whiskers on her chin that were approximately a quarter of an inch long. Resident #81 (R81) Review of R81's quarterly MDS assessment, dated 12/6/24, revealed an uncompleted personal hygiene required assistance level. R81 scored a 04 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:40 AM, an observation was made of R81 walking in the hallway with disheveled and greasy hair. Review of policy titled, Activities of Daily Living (ADL) Program, dated 5/1/24, read in part, Purpose: A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. ADL may include, but are not limited to, bathing, grooming, and dressing. Restorative ADL program may be provided by nursing assistants and other staff trained in provision of ADL care under the supervision of the licensed nurse .

Based on observation, interview, and record review, the facility failed to 1. Obtain physician orders and administer oxygen at the prescribed flow rate, and; 2. Ensure respiratory equipment was changed, labeled, stored, and cleaned appropriately; for eight Residents (#243, #43, #3, #240, #245, #88, #44, and #18) of eight residents reviewed for oxygen and respiratory equipment services. Findings include: Resident #243 (R243) On 3/23/25 at 11:51 AM, R243 was observed with supplemental oxygen being delivered via nasal cannula (tube that delivers supplemental oxygen). The oxygen tubing was dated 3/15/25. The oxygen was set to be administered at 3 LPM (liters per minute). R243 said the oxygen should be set at 2 LPM. During an interview with Family Member (FM) II on 3/23/25 at 11:55 AM, concern was verbalized regarding the oxygen required by R243. FM II said R243 should always be on oxygen, but the facility had repeatedly failed to ensure the portable oxygen tank was turned on. FM II stated the facility would also forget to check the tank and confirm if there was oxygen left in it, or ensure the tank was set at the prescribed flow rate. On 3/24/25 at 11:28 AM, R243 was observed visiting with FM II. R243 was wearing the nasal cannula attached to a portable oxygen tank on the back of the wheelchair. The flow rate on the portable tank for R243 was set at 3 LPM but the gauge on the tank indicated the tank was empty and not providing R243 with any supplemental oxygen. FM II said, This keeps happening and summoned the nurse to the room to point out the empty tank. On 3/24/25 at 3:39 PM, R243 was observed with the nasal cannula tubing connected to an oxygen concentrator. The concentrator was set at a flow rate of 2.5 LPM. R243 was admitted to the facility on [DATE] with a primary diagnosis of respiratory failure with hypoxia (low oxygen level). Review of the Electronic Medical Record (EMR) revealed R243 had a physician's order dated 3/11/25 that read: O2 [oxygen] at 2 L [liters] via NC [nasal cannula] continuously to maintain sat [saturation of oxygen] above 88%. The March 2025 Medication Administration Record (MAR) for R243 contained nurses' initials each day documenting supplemental oxygen had been administered to R243 at a flow rate of 2 LPM, including 3/23/25 and 3/24/25 when the oxygen had been observed set at 3 LPM and 2.5 LPM. There were no physician orders in the EMR indicating parameters when the supplemental oxygen flow delivery could be increased. The care plan for R243 documented, in part: [R243] has a potential for difficulty breathing and risk for respiratory complications R/T [related to]: Chronic respiratory failure - requires cont. [continuous] O2 therapy . A care plan intervention read, in part: Administer medication & treatments per physician orders . Specify: Oxygen . Resident #43 (R43) R43 was admitted to the facility 12/30/24 with diagnoses including but not limited to chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of physician's orders in the EMR revealed an order dated 12/30/24: Ipratropium-Albuterol [a bronchodilator to ease breathing] solution 0.5-2.5 mg(milligrams)/3 ml (milliliters): 3 ml inhale orally every 6 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. On 3/23/25 at 10:10 AM, the nebulizer of R43 was observed assembled and lying on a heat register not sitting on a barrier, unbagged, and no dates were observed on the nebulizer cup or the nebulizer tubing. Resident #3 (R3) R3 was admitted to the facility on [DATE]. R3's diagnoses included acute respiratory failure with hypoxia. On 3/23/25 at 10:48 AM, R3 was observed wearing a nasal cannula attached to an oxygen concentrator set at 2 LPM. The tubing was dated 3/8/25. Review of physician's orders on 3/24/25 revealed R3 did not have a physician's order for supplemental oxygen. A care plan in the EMR initiated on 1/4/25 read, in part: . [R3] has a potential for difficulty breathing and risk for respiratory complications R/T: Recent Pneumonia, acute respiratory failure . The care plan did not include the use of supplemental oxygen. Resident #240 (R240) R240 was admitted [DATE] with a primary diagnosis of pneumonia. On 3/23/25 at 10:58 AM, R240 was observed wearing supplemental oxygen via nasal cannula. The cannula tubing was dated 3/5/25. R240 said she was admitted on [DATE] and the tubing was from the hospital and had not been changed since she was admitted to the facility. Physician's orders for R240 included an order dated 3/13/25 that read: 2 L O2 via nc at hs [night] in place of C-pap machine at bedtime for OSA (obstructive sleep apnea). There were no additional orders for delivery of supplemental oxygen during waking hours. Resident #245 (R245) R245 was readmitted to the facility on [DATE]. Diagnoses for R245 included a diagnosis of pulmonary embolism (blood clot in the lung). On 3/23/25 at approximately 11:45 AM, R245 was observed with an oxygen concentrator in the room. Nasal cannula tubing was attached to the concentrator. The tubing was undated and was draped over the top of the concentrator without a barrier. Review of physician's orders on 3/24/25 revealed R245 did not have a physician's order for supplemental oxygen. Resident #88 (R88) R88 was admitted to the facility on [DATE] with diagnoses including but not limited to acute respiratory failure with hypoxia and pneumonia. Physician's orders for R88 included an order dated 3/22/25 for Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml: 3 ml inhale orally every 6 hours as needed for SOB or wheezing via nebulizer. During medication administration on 3/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) O was observed administering medications to R88. Upon entering the room, the assembled nebulizer cup with attached mouthpiece was observed atop the bedside stand without a barrier beneath it. R88 had just finished eating lunch and had visible chewed up food particles around the mouth and on the teeth. LPN O did not assist R88 with oral care. LPN O did not clean the mouthpiece of the nebulizer that had been sitting atop the bedside stand nor was the mouthpiece replaced. LPN O did not perform pre-nebulizer or post-nebulizer respiratory assessments. After the medication was administered, LPN O rinsed off the mouthpiece and placed it back on the nebulizer before lying the reassembled nebulizer cup and mouthpiece back atop the bedside stand without a barrier beneath it. LPN O did not disassemble and rinse out the nebulizer. On 3/24/25 at 3:46 PM, the Director of Nursing (DON) was asked if nurses were expected to conduct respiratory assessments before and after nebulizer treatments. The DON said, I'm not going to answer that. A policy for the administration and maintenance of nebulizers was requested. The Director of Nursing (DON) was interviewed on 3/25/25 at 11:26 AM. The DON said oxygen tubing should be changed and dated weekly, and the flow rate of supplemental oxygen should be delivered in accordance with physicians' orders. The DON said nebulizers and oxygen tubing should be stored in a bag when not in use. The DON confirmed a physician's order was required to administer supplemental oxygen therapy. When asked regarding nebulizer cleaning and maintenance after use, the DON said nurses are expected to disassemble the nebulizer, rinse the parts in water, and place them on a paper towel to dry before storing them in a bag. 41978 Resident #44 (R44) Review of the Minimum Data Set (MDS) assessment, dated 1/20/2025, revealed R44 was admitted to the facility on [DATE] and had diagnoses including heart failure and chronic obstructive pulmonary disease (COPD). Further review revealed R44 was dependent on staff for personal hygiene, mobility and all transfers. R44 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. On 3/23/2025 at 11:41 a.m., R44 was observed seated in bed wearing a nasal cannula and receiving two liters of oxygen per minute (2 L/min) from a portable concentrator. R44 reported she recently became ill with an unknown respiratory illness requiring use of the oxygen. Further observation revealed a nebulizer atop the Resident's nightstand with tubing leading to a medicine reservoir cup and mask. The tubing, medicine reservoir cup and mask were lying directly on the surface of the nightstand with no barrier present and next to the Resident's personal belongings. R44 reported she received a nebulizer treatment earlier that morning. During an interview on 3/25/2025 at 9:26 a.m., the facility Infection Preventionist, RN D was queried regarding the facility protocol for storing nebulizer equipment. RN D reported nebulizer tubing, medication reservoirs and masks should be rinsed after use, left to dry on a clean barrier then stored in a clear plastic bag between uses to keep the equipment clean and prevent respiratory illness. 45123 Resident #18 (R18) Review of R18's quarterly MDS assessment, dated 1/30/25, revealed an admission to the facility on [DATE], with diagnoses including: hypertension, type two diabetes mellitus, and anxiety. R18 also had other health conditions that included shortness of breath with exertion and lying. R18 scored a 15 of 15 on the BIMS assessment, reflective of intact cognition. Review of R18's physician's order, dated 3/7/25, revealed an order for ipratropium-albuterol inhalation solution 3 milliliters, inhale orally two times a day for respiratory failure. Review of R18's physician's order, dated 1/20/25, revealed an order for oxygen at 2 liters via nasal cannula. On 3/23/25 at 10:48 AM, R18 was observed in their room, sitting in a recliner. A fully assembled nebulizer delivery device was observed in the room with condensation remaining in the medication chamber. The nebulizer delivery device was observed lying on R18's bed. R18 was asked if nursing staff rinse the nebulizer out after each use. R18 replied, No, they just leave it and add more for the next time I use it. R18 was observed using oxygen therapy with an oxygen concentrator at 2.5 liters. R18 had three separate lines of oxygen tubing observed in use in R18's room, all dated 3/15/25. One line of oxygen tubing was observed coiled around the handle of a wheelchair and the wheelchair foot pedals were noted to be resting on top the tubing. Another line of oxygen tubing was observed draped over the nightstand with no protective cover. Review of R18's care plan, dated 4/25/24, read in part, Focus .has a potential for difficulty breathing and risk for respiratory complications .Interventions: Administer medications and treatments per physician orders. Monitor for ineffectiveness, side effects and adverse reactions, report abnormal findings to the physician. SPECIFY: Oxygen, Encourage cough and deep breathing, nebulizer treatments . Review of policy titled, Oxygen Storage and Assembly, dated 9/22/23, read in part, Oxygen and oxygen equipment is stored in a safe manner . The DON provided an undated procedure Nebulizer therapy, small volume. The procedure read, in part: . Obtain the patient's vital signs, assess the respiratory status as ordered . After treatment, obtain the patient's vital signs, assess the respiratory status as instructed . rinse the nebulizer with water and allow it to air-dry . Documentation associated with small-volume nebulizer therapy includes: . vital signs, respiratory assessment findings, and peak flow or spirometry readings before and after treatment . The policy Physician's Order dated as effective 10/20/23 read, in part: . Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. Standing and written orders must be recorded in the resident record and be signed by the licensed health professional who issued the order .

Based on observation, interview, and record review the facility failed to maintain a medication error rate below 5% for two Resident (#11 & #26) of nine residents reviewed for medication administration. This deficient practice resulted in 2 medication errors out of 31 opportunities for error with a medication error rate of 6.4%. Findings Include: Resident #11 (R11) R11 was admitted to the facility on [DATE] with a primary diagnosis of osteoarthritis (a degenerative disease of the joints). Review of R11's physician orders revealed an order dated 10/13/24 that read: Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 mg (milligrams): Give 1 tablet by mouth three times a day for Arthritis pain. On 3/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) O was observed preparing medications to administer to R11. LPN O removed a tablet of Tylenol 8-Hour Arthritis Pain Extended Release and broke the tablet in half before placing both halves into a medication cup. LPN O was asked if extended-release tablets should be broken. LPN O responded, [R11] can't take a whole tablet. Resident #26 (R26) R26 was admitted to the facility on [DATE] with diagnoses that included glaucoma. R26 resided in the secured unit for residents who were cognitively impaired. Review of physician orders for R26 revealed on order for eye drops dated 6/26/24 that read: Timolol Maleate Ophthalmic Solution 0.5%: Instill 1 drop in both eyes two times daily for glaucoma. During medication administration observation on 3/25/25 at 7:11 AM, Registered Nurse (RN) A was observed in the dining room administering the eye drops to R26 with other residents present. RN A instilled one drop of medication in each eye, then handed R26 a tissue. R26 wiped both eyes then placed the tissue on the table. RN A did not instruct or assist R26 to hold the tissue to the lacrimal ducts to ensure proper absorption of the medication. The Director of Nursing (DON) was interviewed on 3/25/25 at 11:26 AM. The DON said extended release or sustained release tablets should never be broken or opened. The DON did not respond when asked if nurses should be instructing or assisting residents with holding the lacrimal ducts after administering Timolol eye drops. The DON was asked if nurses routinely administer medications in the dining room with other residents present. The DON said, As long as the residents are agreeable, they [nurses] can give meds (medications) in the dining room. When asked about residents who are cognitively impaired who may not understand they need to give permission, the DON said, They can always push the nurse away if they don't want them [medications] in the dining room. The policy titled Medication Administration dated as effective 10/17/23 documented, in part: . Resident medications are administered in an accurate, safe, timely, and sanitary manner . The nurse is responsible to read and follow precautionary instructions on prescription labels . Use a tablet-splitter to avoid contact with the tablet if the tablet must be broken . The instructions for administering Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release tablets, found at www.tylenol.com/products/arthritis/tylenol-8hr-arthritis-pain, include, in part: . swallow whole; do not crush, chew, split, or dissolve . The instillation of eye drops, according to the American Academy of Ophthalmology (www.aao.org/eye-health/treatments/how-to-put-in-eye-drops) and the American Society of Ophthalmic Registered Nurses (www.asorn.org/assets/Instillation-of-Eye-Drops-and-Ointments.pdf) included, in part: . 7. Gently squeeze the dropper between your thumb and forefinger to instill correct amount of medication into the lower cul-de-sac . 8. Punctual occlusion: a. Ask patient to close both eyes gently without squeezing. b. Alternatively, place your finger over the lacrimal sac and apply light pressure for one minute or more (or instruct patient to do this, if able) . Digital punctual occlusion is indicated when systemic absorption of medication may prove harmful to the patient (e.g. [example] .betablockers such as timolol .

Based on observation, interview, and record review, the facility failed to dispose of expired medications and ensure required medications were dated when opened on two medication carts of three medication carts reviewed for medication storage and labeling. Findings include: Maple Lane medication cart: On 3/24/25 at 1:04 PM, the 200-unit (Maple Lane) medication cart was reviewed with Licensed Practical Nurse (LPN) O. The cart was noted to contain a Novolin R FlexPen (insulin). The FlexPen contained an illegible date. LPN O said the FlexPen was dated as opened on 2/16/25 and said the FlexPen needed to be disposed 30 days after opening. LPN O said the FlexPen was expired and disposed of the FlexPen in a biohazard container. A bottle of ciprofloxacin (antibiotic) eye drops in the medication cart was dated as opened 3/12/25. The box containing the bottle of ciprofloxacin eye drops contained a pharmacy-generated label indicating the medication was dispensed from pharmacy on 3/19/25. LPN O said, That doesn't make any sense - that's concerning. The medication cart contained a bottle of Ibuprofen expired as of 2/2025. The bottle was labeled with an illegible expiration date. The expired medication was brought to the attention of LPN O, who said, Oh no! I need to get a new bottle and disposed of the expired medication. LPN O was asked about dating medications when opened. LPN O said over-the-counter (OTC) medications were not dated when opened but eye drops, insulins, and inhalers were expected to be dated when opened due to having shortened expiration dates. Ivy Lane medication cart: The 300-unit (Ivy Lane) medication cart was reviewed with Registered Nurse (RN) A on 3/24/25 at 12:04 PM. The medication cart contained a bottle of liquid acetaminophen with an expiration date of 2/2025. RN A disposed of the expired medication. Three opened, undated inhalers of Albuterol (Ventolin) were found in the medication cart. RN A said the inhalers would be reordered from pharmacy. Two bottles of nitroglycerin sublingual tablets that expired 2/2025 were identified in the medication cart. RN A said the tablets would be disposed and the medication would be reordered from the pharmacy. RN A was asked about dating medications when opened. RN A replied, All meds should be dated when opened except OTC medications. The Director of Nursing (DON) was interviewed on 3/25/25 at 8:29 AM. The DON said the facility determines medication expiration dates by the expiration dates written on medication containers. The DON was asked for a policy or procedure for dating and labeling of medications and disposing of expired medications. The DON said, We don't have anything like that. The DON provided a policy titled Medication Management dated as effective 9/22/23. The policy read, in part: .Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws . Medications will be dated and discarded per manufacturers guidelines . The DON said they did not have any additional policies, procedures, or documents used in the facility regarding labeling or dating medications. She said they did not utilize any references for medications with modified expiration dates because the contracted pharmacist routinely reviews the medication carts. On 3/25/25 at 8:45 AM, LPN O was asked how she knew what medications to date when opened and the length of time until disposing after opening. LPN O provided a multi-page, undated document she said was used by the nurses that read Medications with Shortened Expiration Dates. The document included a four-page list of medications with expiration notations. The form read, in part: .Once these products are opened, they must be used within a specific timeframe to avoid reduced stability and sterility and potentially reduced efficacy. All of these medications should be labeled in such a way that the beyond use date is securely attached to a part of the package and will not be discarded . Under the section of the document Injectable Diabetes Medications - Insulins, Novolin R FlexPen was listed with a use-by date 28 days after being opened. The section of the document for Asthma/COPD/Allergy medications listed Ventolin as requiring a label to indicate a date opened due to modified expiration dates when opened. The document reflected the medication was considered expired after 12 months.

Based on observation and interview, the facility failed to ensure meals were served at a palatable and appetizing temperature for two Residents (#51, #71) of two residents reviewed for food palatability, and nine out of 10 residents from the confidential group meeting, resulting in decreased meal satisfaction and the potential for decreased food acceptance and nutritional decline. Findings include: An observation of morning meal service in the [NAME] Unit dining room on 3/24/2025 revealed meals trays were delivered in an insulated cart from the main kitchen at 7:50 a.m. Temperatures taken from the first two trays off the cart revealed the following: pancakes temped at 106 degrees Fahrenheit (F); scrambled eggs temped at 102 degrees F. The last meal from the cart was observed to be delivered at 8:09 a.m. with the following temperatures taken: pancakes 98 degrees F; and oatmeal 128 degrees F. On 3/24/2025 at 7:55 a.m., Activities Aide (AA) EE was observed assisting with meal tray delivery in the [NAME] Unit dining room. AA EE reported some residents often complained of hot foods being received cold. When asked what measures staff used to ensure food is served hot after delivery to the unit, AA EE reported it was difficult to get the trays delivered quickly due to frequent staff call ins. AA EE reported the facility sent down the meals in waves this day, in an attempt to keep the food hot. Resident #51 (R51) and Resident #71 (R71) During an interview on 3/23/2025 at 2:16 p.m., R51 reported her meals to be unappetizing due to the foods meant to be hot being served at cool temperatures. R51 stated her food was never hot. R71, present at the time of the interview, reported the food temperatures to be an ongoing issue in the facility. R71 reported the meals to be unappealing and unappetizing due to the food being served at unpalatable temperatures. R71 reported she often ordered and paid for takeout to be delivered for herself and R51 which are hotter than what we get here. On 3/25/2025 at 8:00 a.m., a morning meal tray was observed to be delivered to R51's room. R51 was observed to be seated in bed, slouched down with her head positioned near the bottom of the head of the bed with two pillows above and hanging over her head, her right foot hanging off the right side of the bed and her left foot touching the foot board. R51's meal tray was observed to be on the overbed table positioned to the left of the Resident in bed. During an interview at the time of the observation, R51 reported she needed a boost up in the bed and stated, I can't eat like this. R51 reported when her meal tray was delivered, Certified Nursing Assistant (CNA) U reported the need for assistance of another staff member to reposition the Resident in bed and then left the room. R51 gestured to the meal tray and stated, I asked her to leave the lid on, now it's going to be cold, like usual. R51's plate was observed to be uncovered and contained a serving of scrambled eggs and bacon. Further observation revealed staff entered R51's room at 8:09 a.m. to reposition the Resident in bed after which, R51 reported her eggs were cold. Confidential Group Meeting During a confidential group meeting held on 3/24/2025 at 10:30 a.m., eight of nine Residents present reported meals were consistently served at unpalatable temperatures with most foods that were supposed to served hot being received cool or cold. Confidential Resident #1 (CR1) reported he liked to eat hot cereals like oatmeal but is no longer requesting hot cereals for breakfast due to the items being cold when the meal tray is delivered. CR #2 (CR2) stated hot foods were on most occasions served at unpalatably cool temperatures, even in the main dining room. CR2 reported the topic of food temperatures and the request for more appetizing meals was a consistent topic during the group meetings. CR2 reported the concerns related to food palatability, including food temperatures, were shared with Dietary Manager (DM) Y at the group meeting on 12/10/2024. Eight of the nine residents present agreed the variety of meals had improved since the meeting with DM Y, but the preferred temperatures of the food remained a problem.

Based on observation, interview, and record review, the facility failed to 1. Perform hand hygiene at appropriate opportunities for hand hygiene related to meal service and medication administration, 2. Appropriately don and doff disposable single use gloves, 3. Ensure contaminated ice was discarded. 4. Rinse and dry respiratory treatment equipment between medication treatments, 5. Maintain a sanitary medication cart, and 6. Ensure Infection Control Polices are update at least annually. Findings include: On 3/23/25 at 12:31 PM, Certified Nurse Aide (CNA) FF was observed in the 100-unit (Oak Lane) lounge preparing to deliver meal trays. After removing a meal tray from the meal cart and placing a can of soda pop on the tray, CNA FF walked toward a table in the lounge and inadvertently bumped into an open ice chest filled with ice. The can of soda pop fell from the meal tray into the open ice chest. CNA FF reached into the open ice chest with an ungloved, unwashed hand and removed the can of soda pop to place back on the meal tray. CNA FF placed the meal tray on a table in the lounge and put on a pair of disposable gloves without first performing hand hygiene. CNA FF exited the lounge with the meal tray and delivered it to a resident in a room across the hall from the lounge. Through the open door of the resident's room across from the lounge, CNA FF was observed placing the meal try on the resident's overbed table before exiting the resident's room back to the lounge. CNA FF did not perform hand hygiene or change the gloves after delivering the meal tray to the resident across the hall from the lounge. CNA FF removed two additional meal trays from the meal cart and delivered them to two additional rooms across the hall from the lounge. CNA FF did not perform hand hygiene or change the disposable gloves during the issuance of meal trays to residents' rooms. On 3/23/25 at 12:41 PM, CNA FF was interviewed after exiting one of the resident's rooms while still wearing the same disposable gloves. CNA FF acknowledged hand hygiene and glove changes were not performed while passing the meal trays. CNA FF was asked if it was common practice to wear gloves in the hallway or go room to room wearing the same pair of gloves without performing hand hygiene and changing gloves. CNA FF replied, I don't usually wear gloves in the hallway or into different rooms. I forgot I had them on. I'll go wash my hands now. At 12:44 PM on 3/23/25, an Activities Aide was observed obtaining ice from the ice chest in which the can of soda pop had fallen and from which CNA FF had reached in with an ungloved, unwashed hand. The facility policy titled Hand Hygiene dated as effective 10/11/23 read, in part: . Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections . Hand hygiene should be performed: Before and after contact with the resident . Resident #88 (R88) R88 was admitted to the facility 3/20/25 with diagnoses including but not limited to acute respiratory failure with hypoxia and pneumonia. Physician's orders for R88 included an order dated 3/22/25 for Ipratropium-Albuterol Solution [a bronchodilator to ease breathing] 0.5-2.5 mg/3 ml: 3 ml inhale orally every 6 hours as needed for SOB [shortness of breath] or wheezing via nebulizer. During medication administration on 3/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) O was observed administering medications to R88. Upon entering the room, the assembled nebulizer cup with attached mouthpiece was observed atop the bedside stand without a barrier beneath it. R88 had just finished eating lunch and had visible chewed up food particles around the mouth and on the teeth. LPN O did not assist R88 with oral care. LPN O did not clean the mouthpiece of the nebulizer that had been sitting atop the bedside stand nor was the mouthpiece replaced. After the medication was administered, LPN O rinsed off the mouthpiece and placed it back on the nebulizer before lying the reassembled nebulizer cup and mouthpiece back atop the bedside stand without a barrier beneath it. LPN O did not disassemble and rinse out the nebulizer. The undated facility procedure Nebulizer therapy, small volume read, in part: . Rinse the nebulizer with sterile or distilled water and allow it to air dry. Disinfect the nebulizer . On 3/25/25 at 7:11 AM, Registered Nurse (RN) A was observed at the medication cart on the 300-unit, Ivy Lane. RN A drank from a mug then placed the mug atop the medication cart next to a thermos without a barrier beneath it. A cellular phone was observed atop the medication cart next to an uncovered, undated plastic container of pudding. During administration of medications, RN A assisted a resident into a wheelchair and to the dining room and administered medications to four residents on Ivy Lane without performing hand hygiene. The policy Medication/Treatment Cart Use dated as effective 8/15/23 read, in part: . Medication/Treatment carts are to be kept clean and sanitary. Each shift is responsible for the cleanliness of the cart, including drawers and top of cart . The Director of Nursing (DON) was interviewed on 3/25/25 at 11:26 AM. The DON said nebulizers and oxygen tubing should be stored in a bag when not in use. When asked regarding nebulizer cleaning and maintenance after use, the DON said nurses are expected to disassemble the nebulizer, rinse the parts in water, and place them on a paper towel to dry before storing them in a bag. The DON said no personal items should not be on the medication carts and nurses should not be drinking and placing drinking vessels atop the med carts. The DON said the pudding on the medication carts was utilized for residents requiring medications to be crushed or placed in a medium for ease of swallowing. The DON said the pudding should have a lid. The DON said the nurses should leave the lid on the pudding container to push back down each time the desired amount of pudding is removed from the container for each resident. When asked about wearing gloves in the hallway, the DON said, No. We don't wear gloves in the hallway because of infection control. The DON confirmed hand hygiene and glove changes are expected when going from one resident to another. The DON was told about the observations on 3/23/25 at 12:31 PM of CNA FF wearing the same pair of gloves, not performing hand hygiene, and removing the can of soda pop from the ice chest with a bare, ungloved hand. The DON did not provide an explanation but said the staff was nervous because they were in survey. The policy Infection Prevention Program Overview dated as effective 10/11/23 read, in part: . The facility must require staff to clean their hands after each direct resident contact using the most appropriate hand hygiene professional practices . 49302 On 3/24/25 at 11:48 AM, the lunch-time meal service was observed in the main dining room. Certified Nursing Assistant (CNA) BB was observed donning single-use gloves and delivering lunch trays to three different residents without changing gloves. CNA BB was observed touching each resident's dishware and cutlery. On 3/24/25 at 11:56 AM, CNA CC was observed passing lunch-time trays to three residents in the dining room without performing hand hygiene between residents. CNA BB assisted all three residents with dishware placement. On 3/26/25 at 8:03 AM, an interview was conducted with Infection Preventionist/Registered Nurse (IP/RN) D regarding hand hygiene expectations during meal service. IP/RN D stated it is expected to perform hand hygiene between trays. IP/RN D continued, It's been a focal point for proper hand hygiene during dining . it will continue to be a point of education. Review of the facility policy titled, Hand Hygiene, revised 10/11/23, read, in part: .hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections . Hand hygiene should be performed: before and after contact with the resident .staff involved in direct resident contact must perform hand hygiene (even if gloves are used) . 45123 Review of infection control policies on 3/24/25 at 1:00 PM, revealed the following policies to be outdated. a.) Infection Control Antibiotic Stewardship & MDROs (Multi-Drug Resistant Organisms), last revised on 10/13/23, b.) Infection Prevention Program Overview, last revised on 10/11/23, c.) Immunizations: Influenza (Flu) Vaccination of Guest/Residents, last revised on 1/11/22. On 3/25/25 at 10:45 AM, an interview was conducted with the Nursing Home Administrator (NHA), who was responsible for providing facility policies. When asked if the policies provided were the most recent and up-to-date policies, the NHA replied, Yes, and corporate is responsible for updating the policies as needed. On 3/25/25 at 12:40 PM, an interview was conducted with Infection Preventionist / Registered Nurse (RN) D who was asked if the policies that were provided were the most updated policies for infection control and replied, Yes, the corporate updates the policies every year.

This citation pertains to Intake MI00151063. Based on interview and record review, the facility failed to ensure a safe community discharge for one Resident (#76) of three residents reviewed for transfer and/or discharge. This deficient practice resulted in fear, distress, and feelings of helplessness regarding a safe discharge location. Findings include: Resident #76 (R76) Review of R76's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including a below knee amputation of the right lower extremity and cerebral palsy (a neurological disorder that affects movement, posture, and balance). Review of R76's most recent Minimum Data Set (MDS) assessment, dated 2/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Review of a complaint received by the State Agency (SA) on 3/7/25 read, in part: [R76] has a right leg below the knee amputation and cerebral palsy on his whole left side. He is in a wheelchair . [R76] lives at [Facility Name] . [R76's] insurance is supposed to cover his stay .through October 2025 . [Facility Name] stated [R76] can live on his own . They are having him leave at 5:00 p.m. on 03/07/25. They [facility] arranged transportation, and a hotel stay in [City Name] for two to five days. He [R76] does not have anywhere else to go after the hotel . On 3/24/25 at 11:35 AM, a telephone interview was conducted with the Family Member [(FM) S] for R76, regarding the discharge process. FM S confirmed R76 was discharged to a local hotel on 3/7/25 and did not have a place to reside after the 3-night stay. FM S stated she allowed R76 to stay in her fifth wheel travel trailer, but R76 fell two times trying to ascend the stairs. FM S explained the travel trailer was not large enough to accommodate a wheelchair, so R76 could not access the bathroom. FM S stated R76 eventually moved to a vacant home without electricity, running water, and a leaking roof. FM S said she delivered buckets of water to the vacant home to enable R76 to flush the toilet and bathe. FM S stated she had to purchase a riser as R76 was unable to independently stand up from the low toilet height at the vacant home. On 3/24/25 at 12:21 PM, a telephone interview was conducted with R76 who confirmed he was admitted to the facility following a right below knee amputation. R76 confirmed his stay was complicated by septic shock, cellulitis, and surgical site dehiscence (the re-opening or splitting of a wound). R76 stated the facility paid for a discharge to a local area hotel after they stated he no longer met the criteria for an insured stay. R76 stated, after 3 days the hotel forced him to leave because he could no longer afford the room. R76 confirmed he attempted to live with a family member in a fifth wheel travel trailer but was not able to safely negotiate the steps to enter. R76 stated he fell two times trying to enter the travel trailer, resulting in a bruises and scrapes, and crawled to a sitting area because the trailer would not accommodate his wheelchair. R76 revealed because he could not access the bathroom, he was forced to utilize a urinal and hold a bowel movement for three days. R76 subsequently moved to a vacant home with no electricity or running water. R76 confirmed he was provided buckets of water to bathe and flush the toilets and he utilized a space heater to stay warm. R76 stated he sustained a fall when attempting to use the bathroom at the vacant home resulting in further bruising. R76 stated, They [facility] just wanted me out of there, they didn't care where I went . I had no idea where I was going to live. On 3/24/25 at 1:18 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding R76's discharge process. The NHA confirmed facility petty-cash funds were utilized to pay for a 3-night stay at a nearby hotel for R76. The NHA stated R76 requested funds to cover a 30-day stay at the hotel, but the facility was unable to afford that amount. When the NHA was asked the long-term discharge plan after the hotel stay, he responded, If he [R76] needed longer at the hotel, he was supposed to call me. He never called back. The NHA was unsure where R76 lived after the hotel stay. On 3/25/25 at 12:07 PM, an interview was conducted with Director of Rehabilitation (DOR) T regarding the functional progress of R76. DOR T stated R76's rehabilitation course was affected by rehospitalizations related to post-surgical complications including infections and poor wound healing, as well as R76's pre-existing condition of cerebral palsy which largely affected his non-surgical (left) side. DOR T stated R76 was largely functionally independent at a wheelchair level as he was waiting for fabrication of a right leg prosthetic to continue rehabilitation. DOR T stated R76 resided in the fifth wheel travel trailer prior to undergoing the right below knee amputation but was not able to discharge to that location due to his inability to safely negotiate stairs to enter/exit the home or mobilize within the trailer with a wheelchair due to space limitations. DOR T stated R76 discharged to a hotel but was unaware of his discharge plans following termination at that location. Review of R76's EMR revealed the following physician's wound care order, initiated 1/3/25: Cleanse R [right] BKA [below-knee amputation] wound with Saline or Wound Cleanser and dry gently. Apply moist to dry dressing with [antiseptic] solution .every shift. On 3/25/25 at 2:42 PM, an interview was conducted with Staff X regarding R76's skilled nursing care needs. Staff X verified R76 was receiving wet-to-dry wound dressing with an antiseptic solution on his right residual limb two times per day. Staff X stated no formal wound care training was provided to R76 prior to discharge. When asked the reason for R76's sudden discharge, Staff X responded, Management forced him to leave . I don't know why he got targeted. On 3/25/25 at 2:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) O who verified they were on duty when R76 discharged on 3/7/25. LPN O stated R76 was not discharged from the facility with wound care supplies. On 3/26/25 at 9:41 AM, an interview was conducted with the Director of Nursing (DON) regarding the appropriateness of R76's discharge. The DON verified R76 discharged to a local hotel for three nights at the expense of the facility. When asked the long-term discharge plan, the DON responded, We told him we [the facility] would pay for the hotel stay .after that it was up to him. The DON was unaware if R76 received any formal wound care training or if R76 was discharged with wound care supplies. The DON stated R76 was independent and, could do everything himself. Review of R76's, Post Discharge Plan and Summary, dated 3/7/25, read, in part: Functional Status . Transfer ability upon discharge: 1 person assistance . Toileting ability upon discharge: 1 person assistance . Bathing ability upon discharge: 1 person assist . Skin condition at time of discharge: continue right BKA surgical site care . Review of R76's Occupational Therapy Discharge summary, dated [DATE], read, in part: .discharge recommendations: 24/7 1-person assistance. w/c [wheelchair] . Review of R76's Physical Therapy Discharge summary, dated [DATE], read, in part: .discharge recommendations: 1-person assistance as able, w/c for mobility . Review of the facility policy titled, Transfer and Discharge, revised 3/26/24, read, in part: The transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility . the notice of transfer or discharge required under this section must be made by the facility in writing at least 30 days before the resident is transferred or discharged in a manner they understand . education needed to facilitate a safe discharge and maintenance in the community will be provided and documented by the interdisciplinary team .

Resident #51 (R51) Review of the Minimum Data Set (MDS) assessment, dated 1/17/2025, revealed R51 was admitted to the facility on [DATE] and had diagnoses including coronary artery disease, heart failure and chronic obstructive pulmonary disease (COPD). Review of R51's hospital History and Physical, dated 1/9/2025, revealed the following: [R51] was sent to the emergency room today from the skilled nursing facility after a several day decline in her alertness . Assessment/Plan: septic shock with encephalopathy . acute hypoxic respiratory failure . Review of the census information gleaned from R51's EMR revealed the Resident returned to the facility on 1/10/2025. Review of the facility notice of transfer document titled, Facility-Initiated Transfer for Nursing Homes, dated 1/9/2024, revealed the reason for R51's transfer as Medical needs cannot be met in the nursing home . abnormal [versus] mental status change. The document also contained information related to the resident's right to appeal the transfer and options available related to bed hold. Further review revealed no resident or resident representative signature indicating receipt of the notice of transfer document. During an interview on 3/26/2025 at 8:10 a.m., the DON reported the facility does not provide the written notice of transfer document unless the resident or resident representative involved requests to appeal the transfer. The DON stated staff document conveyance of the reason for the transfer and the right to appeal the transfer in the medical record. Review of the facility policy titled, Transfer and Discharge, last revised 3/26/2025, revealed the following: The notice of transfer or discharge required under this section must be made by the facility in writing at least 30 days before the resident is transferred or discharged and in a manner they understand. Exceptions to the 30-day requirement notice must be made as soon as practicable before transfer or discharge when . The resident's welfare is at risk, and his or her needs cannot be met in the facility (i.e., emergency transfer to an acute care facility) . Procedure: Emergency Transfer to Acute Care . when a resident is transferred on an emergency basis to an acute care facility, notice of the transfer is provided to the resident or the resident representative as soon as practicable. Based on interview and record review, the facility failed to notify the resident and/or resident representative in writing with the reason for a transfer out of the facility for two Residents (#6 and #51) of three residents reviewed for transfer and/or discharge. Findings include: Resident #6 (R6) Review of R6's electronic medical record (EMR) revealed initial admission to the facility on 9/8/22 with diagnoses including vascular dementia and acute kidney failure. Review of the facility census report revealed R6 was hospitalized from [DATE] - 11/26/24. Review of a progress note dated 11/19/24 at 13:13 [1:13 PM]: read, in part: .B/p [blood pressure] now 59/42, On call notified. Will send to ER [emergency room] for evaluation . Review of a facility document titled, Facility-Initiated Transfer for Nursing Homes, dated 11/19/24, did not indicate a date the resident and/or guardian was notified, and the document had no signature. On 3/26/25 at 9:41 AM, an interview was conducted with the Director of Nursing (DON) regarding the transfer notification process. The DON stated the floor nursing staff complete the form and it is then uploaded to the residents' EMR. The DON stated it is not mailed to a resident's representative, rather, the representative is notified by telephone.

Based on observation, interview, and record review, the facility failed to: 1. Maintain a functioning infection control program; 2. Failed to follow facility policy regarding personal protective equipment (PPE) use for quarantined residents related to COVID-19; and 3. Failed to ensure housekeeping staff were aware of the procedure to mix and use the disinfectant chemical for COVID-19 positive or COVID-19 quarantined resident areas to ensure elimination of the COVID-19 pathogen. This deficient practice resulted in the spread of an unidentified Gastrointestinal (GI) organism, the spread of COVID-19 in the Fall of 2021 (resulting in four deaths related to COVID-19 (Residents #501, #503, #504, #505)), the spread of Influenza A (resulting in two hospitalization s of Residents #19 and #21) in [DATE] affecting a total of 59 Residents, with the potential for further outbreaks and death. Findings include: On [DATE] at 11:33 a.m., the infection control (including COVID-19) surveillance, tracking, testing, and immunization data and policies were requested from the Administrator during the Entrance Conference. On [DATE] at 1:42 p.m., the Administrator confirmed that the facility had one staff who had tested positive within the last 14 days and therefore they were finishing up their round of outbreak testing. The Administrator was asked again to provide all the infection control data. The Administrator reported the Infection Preventionist (IP N) had just the previous week partially retired switched to part time (2 days per week) and would be in the building on [DATE]. On [DATE] at 1:50 p.m., an interview was conducted with the Director of Nursing (DON) and Registered Nurse (RN) I. The DON reported IP N had decided to partially retire and would be teaching RN I how to run the Infection Control Program. The DON and RN I were asked again to provide all the infection control data. The DON reported she did not have access to the infection control tracking system and asked if it could be provided on [DATE]. The DON reported no one else had access to the data within the facility except for corporate staff who could access it remotely. The DON and RN I were asked to provide all documentation that was currently available. On [DATE] at approximately 2:00 p.m., RN I provided the COVID-19 policies and the staff COVID-19 line list for January -February 2022 and stated, Here is the January (2022) infection control stuff. Review of the documentation revealed only infection control monthly summaries, maps of outbreaks, and maps for bed availability. There was no resident tracking or line listings and no mapping of infections. A review of the [DATE] Infection summary noted there was an Influenza outbreak during the month but instructed to refer to the outbreak investigation in the IPC binder. RN I reported that IC N would be in the building the following day and could provide more information. On [DATE] at 3:00 p.m., a review of the Infection Control binder revealed no line listing surveillance of the resident illnesses for any month in the previous year. There were summaries for each month stating to See Outbreak Investigations related to the Influenza and Gastrointestinal (GI) outbreaks. The maps contained in the binder only specified which rooms were empty, admitted , Readmission of COVID, Droplet/Contact Isolation, or Contact isolation. There were printed pages where the room numbers were separated by halls with colored squares indicating infections, but it was not on a map and did not show how the rooms and possible infections could be clustered to contain the outbreaks. On [DATE] at 3:10 p.m., a review of a document titled, Timeline for Influenza Symptoms Outbreak (undated) revealed, On [DATE], on Maple Lane, staff noted a few residents with cough and nasal congestion at breakfast time. When 3 residents were identified, the Unit Manager gave the following instructions: identified all residents that had respiratory symptoms. 2. Nursing staff reminded to use extra monitoring .3. Double doors between [NAME] Lane and Oak Lane were closed and the double doors between [NAME] Lane and other departments were closed. 4. All residents were educated and requested that they remain in their rooms . Housekeeping notified of need for extra cleaning of the rooms involved . IDT (Interdisciplinary Team) discussed current details as above at 9am morning report on the 13th. Health department was notified and told (the facility) to monitor the situation and obtain nasal swabs (to test for Influenza) if continues. [DATE], A resident on Oak Lane developed s/s (signs and symptoms) and was tested for Influenza A and was positive. [MEDICATION(S)] (antiviral medication to reduce the length and severity of Influenza) ordered (for that Resident). Based on s/s there was orders for some residents for Guaifenesin (cough medicine). ,d+[DATE] and [DATE]: There were 8 staff members with call offs (called in sick) of various symptoms of sore throats, low grade fever, headaches, muscle aches, cough, congestion, rhinorrhea, and chills. One of the staff had tested positive for Influenza A at Urgent Care . On [DATE], another resident identified w/ (with) s/s on Maple Lane. 6 residents identified on Oak Lane. 5 had nasal swab testing done with 4 identifying as positive (for Influenza A). Another resident was transferred to the hospital w/ other s/s but did test positive for Influenza A and returned the next day. On Ivy Lane there were 3 residents that developed s/s on [DATE] and [DATE]. Guaifenesin DM ordered as appropriate . On [DATE] the local health department was updated. Recommendation was to obtain information from a CDC website. Helpful in the recommendation of prescribing [MEDICATION(S)] for all residents. Facility Nurse Practitioner (NP X) agreed, and orders (were) completed and initiated on [DATE] as Pharmacy delivered the product after midnight that day. Summary of outbreak: Symptoms began on [DATE]. Last reported new case was [DATE] . Investigation did not reveal a source . Review of this timeline did not indicate which residents or staff were affected. The only way to determine who was involved was per a map of the building with highlighted resident names. A review of the document in the Infection Control binder titled, January Summary of Staff Infections and virus signs/symptoms (undated) revealed, .7 staff members called off for nausea, diarrhea, and fever. No correlation as to the unit they worked. 9 staff members called off for s/s influenza. This was spread over (a) 3 week period . There were 4 staff members (undocumented) that had influenza A tests and tested positive . A review of the documented titled, Timeline of GI Symptoms Outbreak (undated) revealed, On [DATE] on Oak Lane, in late evening a resident had (a) large emesis . Small emesis occurred the next morning. As the day progressed, ([DATE]) his roommate had loose stools. A resident 2 doors down developed emesis and 3 loose stools and another resident across the hall had an explosive episode of diarrhea. During the MN (midnight) shift, 5 more residents developed diarrhea and one resident had 2 large emesis . IDT discussed current details as above at 9am (not documented which date) morning report. Health department notified via email . Return email received with forms to fill out on each resident and request to obtain stools specimens from at least 3 residents experiencing the loose stools. Only 2 residents had loose stools at this time . Investigation did not reveal a source . A review of the mapping (unlabeled) for the GI outbreak revealed: 10 residents were documented as part of the GI outbreak. Two of the 10 residents were documented with symptoms but no date of onset. Only three of the residents had dates of symptom resolution. On [DATE] at approximately 3:30 p.m., the DON was informed that the Infection Control Binder that was provided contained no infection mapping to show how the infections could be spreading room to room in the building. The DON reported that there was a way IP N could print the maps from the computer data and would have her do that in the morning on [DATE]. On [DATE] at 10:50 a.m., when asked for the actual maps of the monthly infections, IP N reported she did not know how to go about printing any maps from the computer. When asked how she could extrapolate any possible clusters or trends if she could not visualize where the rooms were, IP N reported she understood what was missing, but that she did not have any map to show location of infected residents. IP N reported she only had the map and no line listing for the influenza outbreak. IP N pointed to a facility map that had names and dates with highlights. IP N reported the dates next to the names were the onset of symptoms, but did not have anything documented as to what the symptoms were or if/when they were tested and or results. IP N confirmed the Residents highlighted were all suspected or confirmed Influenza. IP N also confirmed that no stool samples were sent for testing for the [DATE] outbreak. A review of the unlabeled map of the Influenza A outbreak of [DATE] revealed 34 residents with 12 Residents having onset dates of [DATE] (contradicting the influenza outbreak summary which reported only three Residents with onset on that date.) On [DATE] at 1:21 p.m., IP N provided line listings printed from the Infection computer program. A review of the [DATE] line listing revealed only 2 respiratory infections. IP N confirmed the Residents with Influenza were not tracked in any line listing. The [DATE] line listing was reviewed with IP N. It revealed 2 Residents listed as having other CAI (community acquired infections) with no data as to what the infections were. Three residents were listed as having Urinary Tract Infections (UTIs) yet only one resident had an organism listed. There was no documentation of any symptoms or documentation of any treatments or antibiotics. NP I confirmed she was not tracking the Influenza infections on any log. NP I reported she did retain a copy of the forms she completed per the health department instructions to send to them during the outbreak. These documents were requested for review. NP I reported the staff illnesses were also on the line listings, but review revealed there were no staff members on the line listings. NP I was asked to provide the February Line listing and data, but reported she couldn't because she wasn't finished with it yet. NP I could not explain why she had no data to show despite it being the last day of February. The [DATE] line listing was reviewed and revealed the following infection totals: Respiratory -2, Urinary-3, GI-0, Skin-5, and Other-4. The residents with GI symptoms from the GI outbreak were not tracked on the monthly listing. On [DATE] at 1:32 p.m., an interview was conducted with IP N and RN I which revealed IP N was the only person who had access to the infection control program until the week prior when RN I gained access IP N also revealed she was not tracking the symptoms in her surveillance and that the health department was not notified of the influenza outbreak until [DATE] (5 days after the outbreak began. IP N reported that five Residents had confirmed flu, but all the residents were given [MEDICATION(S)] prophylactically and the health department told them they didn't need to keep testing, but to consider everyone with symptoms of Influenza to be positive. IP N reported the [MEDICATION(S)] was ordered on [DATE] but was not given until a few days later. On [DATE] at 1:49 p.m., IP N brought in a stack of papers she reported were faxed to the health department for residents and staff considered to have Influenza A. Review revealed that some Residents tracked on the Influenza map had no document sent to the health department regarding their status (#507, #508, #509). IP N reported she was not certain about those Residents, or why she hadn't sent forms on them to the health department. When asked when she completed the health department forms, IP N reported it would have been the Monday after the outbreak started ([DATE]) and confirmed no one else was tracking the outbreak on official paper until she started on [DATE]. NP I stated no one had any active infections in February 2022 and provided no data. Regarding the delay in identifying possible outbreaks because they were not tracking the infections in real time. IP N stated, Normally the process is that I go in at the end (of the month) and recap (recapitulate). Generally, we do it (surveillance) in real time when the antibiotics show up. We look in the chart to see what was charted and I put it into (name of computer Infection Control program). IP N was then asked if she was aware of the two Residents who had been complaining of GI symptoms (Nausea and Diarrhea, Residents #2 and #259) the previous day (Sunday [DATE]). IP N stated, No. It was Sunday. A lot of times it is discussed in morning meeting, but we didn't do that today. IP N reported that if staff didn't document the symptoms and communicate with them, she would have no way of knowing. RN I stated, There is a piece that is missing. IP N was asked to provide any further infection documentation and to provide documentation of her communication with the health department. On [DATE] at 3:11 p.m., IP N reported she had more information to provide regarding the Influenza outbreak: they had called the health department for more tests but were not able to get any. IP N reported they had received 10 tests from the hospital but due to turn around time they were not processed correctly and that there was a miscommunication on the draws that were supposed to be done. IP N reported they got some samples back, but that the Nurse Practitioner (NP) X did not want to treat without confirmation, so she called the health department who directed her to look at the CDC guidelines, which directed to treat all residents who may have been exposed to Influenza with [MEDICATION(S)], so that medication was ordered. IP N stated, Within five to seven days we got everything going. IP N was asked during this interview to provide documentation of any conversations or emails she had with the health department. A review of an untitled, undated document regarding the [DATE] GI outbreak provided by IP N revealed, .[DATE] This was emailed to (local health department nurse): 'On [DATE], 7 residents w/ 3 to 4 loose stools in a 24 hr (hour) period, 1 with emesis and diarrhea, 1 with emesis, and one w/ stomachache. All on Oak Lane. Today [DATE] all resolved except one is still vomiting (2 episodes this AM) and the one w/ emesis only had another one this morning . I was notified last evening of this . I'm thinking this is just a 24 hour bug. Looking back, 3 staff members on that unit had NVD (nausea, vomiting, diarrhea) between ,d+[DATE] and ,d+[DATE] (2021) that they said lasted 24 hours and then they were back to work within 48 hours after s/s were gone .' Received response that if there were at least 3 residents that had loose stools, obtain specimens and call the health department There was only one resident that had loose stools (at that time). All others had resolved . Further review of this document revealed about the [DATE] Influenza outbreak, [DATE] Notified (local health department nurse) of probable Influenza Outbreak and now affecting all 3 units. Had one Influenza test back of resident that was positive and one staff that was positive . Sent a link for Outbreak recommendations by CMS guidelines. Also sent Outbreak Influenza Investigation forms to be filled out on each resident and staff affected. On [DATE] at approximately 2:25 p.m., IP N was asked about the documentation regarding the communication with the health department. IP N revealed that RN I had called the health department on [DATE] and notified them of 3 or 4 cases of probably Influenza. On [DATE] at approximately 3:30 p.m., the DON was interviewed about the [DATE] Influenza outbreak and reported the facility was not concerned with a widespread outbreak. The DON revealed she was not aware whether or not the outbreak and the illness symptoms had been tracked on a line listing. The DON was asked if it was important for the nurses to document residents' signs and symptoms of infection and stated, Yes. I'm not sure why it isn't there. A review of a Health Department form for Certified Nurses Aide (CNA) C revealed she had symptoms of Influenza on [DATE] of muscle aches and cough. There was no documentation if CNA C had been tested for Influenza or the last date/unit she had worked. On [DATE] at 11:30 a.m., and interview with IP N revealed: There was a COVID-19 outbreak in the Fall of 2021 but that it was not being tracked on the monthly line listing; IP N was unable to state when she had started sending the Influenza Resident outbreak sheets to the health department; IP N did not acknowledge CNA C having documented symptoms prior to the outbreak starting on [DATE]; IP N reported it was hard to tell if Resident # 507 was just transitioning or if they were showing signs of the outbreak infection; IP N confirmed that she had identified Residents #507 and #509 as being symptomatic of Influenza A but did not report them to the health department as part of the outbreak and was unable to explain why; IP N reported the delay in starting the [MEDICATION(S)] for the Residents with suspected Influenza A was because the Health Department didn't give her the CDC guidance until the 19th (of [DATE]), and she was not aware she should be checking the CDC guidance during outbreaks; IP N reported she was unaware if the medical director was notified of the outbreak; IP N reported the flu swabs that were housed in the facility were found to be expired when they went to use them. On [DATE] at 12:13 p.m., an interview was conducted with RN O. When asked about the expired flu swab kits, RN O stated, I'm not responsible for ordering them. There is no one person set to monitor that. When we needed the swabs we discovered they were expired. A review of the COVID-19 tracking log (unlabeled) provided by IP N revealed that 13 Residents tested positive between [DATE] and [DATE]. The log revealed only one Resident died related to COVID-19 (#504). This log revealed: Resident #501 tested positive for COVID-19 on [DATE] and was sent to the COVID-19 hub on [DATE]. There was no follow up on what happened to Resident #501 in the facilities documentation. Resident #503 tested positive for COVID-19 on [DATE] and was sent to the COVID-19 Hub that day. Per progress notes Resident #503 returned to the facility and died shortly after related to COVID-19 on [DATE]. Resident #504 tested positive for COVID-19 on [DATE] and died during transport to the COVID-19 hub on [DATE]. Resident #505 tested positive for COVID-19 on [DATE] and was sent to the COVID-19 Hub that same day. There was no follow-up on what happened to Resident #505 in the facility documentation. On [DATE] at 1:15 p.m., an interview was conducted with the Administrator, who was asked about Residents #500, #501, and #505 who were sent to the COVID-19 Hub on [DATE] but had no documentation of their return in their medical records. The Administrator reported that the COVID-19 Hub was in Metro Detroit and that they were considered temporary transfers. When asked what happened to these Residents and their belongings, the Administrator reported he would have to find out. On [DATE] at approximately 1:45 p.m., the COVID-19 staff Health Department Sheets were reviewed with IP N. It revealed: Unit Manager/RN O had symptoms (undocumented) on [DATE], was tested and found to be positive on [DATE] (no time), and under her contacts and last 48-hour work assignment revealed, [DATE]. No close contact with residents or staff longer than ,d+[DATE] minutes. Masks were worn. Administration office. RN S had symptoms (undocumented) on [DATE] and was tested on [DATE], (+) (positive) on [DATE] and last worked [DATE] on the locked unit. IP N was asked why staff were documented as working on the days they tested positive and first reported that staff were supposed to test before they hit the floor, but then stated that sometimes they slip through and forget to test until later (after they start working). On [DATE] at 2:07 p.m., a phone interview was conducted with NP X about the [DATE] Influenza outbreak which revealed: Reported that the first resident she had documentation of symptoms on was Resident #58 on [DATE]; She was unaware there were 12 cases documented as having started [DATE]; The facility had tried to do more testing but the results came back with errors; That she was requesting confirmed results before prescribing the [MEDICATION(S)] and the recommendation to treat everyone prophylactically came later; She had felt during the time that Resident #59 was just transitioning during the outbreak; NP X was not aware Resident #59 was reported to the health department as a probable Influenza case. NP X was also asked about the Fall 2021 COVID-19 outbreak but reported it had only been a few cases and they had been sent to a COVID-19 hub for treatment. On [DATE] at 2:45 p.m., an interview was conducted with the DON. The DON was asked about the issue with getting flu tests for all the Residents with suspected Influenza A since NP X initially would not begin treatment without a positive flu swab. The DON reported that they called about the rejected ones, but that the health department said they didn't need to test anyone else. The DON was asked why IP N had not checked the CDC website regarding the Influenza A outbreak until the Health Department directed her to on [DATE] (7 days after the outbreak began). The DON reported We do look at the CDC, but we go to the local health department first. The DON made no comment on IP Ns lack of knowledge or initiative to check the CDC website if she was unaware what the recommendations were for an Influenza outbreak were. When asked about the lack of accurate and complete infection control monitoring for all illnesses including the Fall 2021 COVID-19 outbreak and the [DATE] Influenza A outbreak, the DON stated, To my knowledge it is complete. When asked if she had reviewed any of the documentation completed by IP N regarding those outbreaks or the GI outbreak in December of 2021, the DON reported that she had not, but that someone from corporate did review it. The DON made no comment about the lack of specific documentation but stated, We can agree that (Name of IP N) missed a few things. On [DATE] at 4:27 p.m., a phone interview was conducted with Nursing Home Administrator (NHA) Y at the COVID-19 Hub where Residents #501 and #505 were sent. When asked what had happened to those Residents, NHA Y stated, (Name of Resident #501) died here. And (Name of Resident #505) was sent to the hospital and she expired there. Correlation of the Influenza map, the documents sent to the health department, and the Influenza test results revealed there were a total of six Residents (#21, #27, #39, #58, #511, and #514) that tested positive for Influenza A in January of 2022 and two Residents were hospitalized related to Influenza A (#19, #21). This correlation also revealed many discrepancies between the Influenza map, the health department forms, and the Infection Control summaries and Outbreak summaries written by IP N. Correlation of the COVID-19 log and the sheets sent to the health department along with interviews and record reviews, revealed 13 Residents tested positive for COVID-19 in the Fall 2021 outbreak, and four Residents expired (#501, #503, #504, #505). Resident #6 Per the documentation provided, Resident #6 was documented as part of the Influenza outbreak on the Influenza map but was never tested for Influenza and documentation was not sent to the health department regarding his infection. Resident #46 Per the documentation provided, Resident #46 was documented on the Influenza Map with symptoms starting on [DATE], but no documentation was sent about him to the health department, and he was not tested for influenza. Resident #52 Per the documentation provided, Resident #52 was not tested for influenza or documented on the Influenza map but documentation was sent regarding Resident #52 exhibiting signs and symptoms of Influenza on [DATE], including fever, cough, and congestion. Resident #59 A review of Resident #59's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #59's Minimum Data Set (MDS) assessment dated [DATE] revealed she scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. A review of Resident #59's progress notes revealed: [DATE] . continues with occasional coughing episodes . temp 100.3 (T) this am, 97.5 (T) this afternoon & currently 99.6 (T) Bilateral & diminished (lung) bases . [DATE] .resting in bed with s/s occasional cough & congestion . [DATE] Resident observed at 0720 no respirations no pulse . A review of Resident #59's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the documentation provided Resident #59 was not tested or treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #507 A review of Resident #507's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [DATE] MDS assessment revealed he scored ,d+[DATE] on the BIMS assessment indicating severely impaired cognition. A review of Resident #507's progress notes revealed the following: [DATE] Pt. (patient) alert. Body aches noted now. [DATE] (Physicians note) . Recently had noted that the patient is steadily declining . [DATE] Daughter notified of new orders per hospice comfort measures r/t (related to) resident transitioning with SOB (shortness of breath) increased R (Respirations) and elevated HR (heart rate). [DATE] .(Resident #507) passed away at 1638 (4:38 p.m.) . Per the documentation provided by the facility, Resident #507 was never tested for Influenza or treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #508 A review of Resident #508's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #508's MDS revealed she was assessed by staff to be severely impaired for cognition. A review of Resident #508's medical record revealed: [DATE] (Physician note) . This patient is nonverbal. Patient is lying in bed awake which is her normal baseline . no other associated signs or symptoms . [DATE] (NP X note) Received (text alert) from staff stating resident has wet lung sounds in bilateral upper lobes upon expiration. (Guaifenesin, cough medicine) every 4 hours was given as needed . oxygen saturation was 93% on room air. Resident does not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] Interested party notified of Tamilfu being prescribed for the Flu that was identified in the building. [DATE] [MEDICATION(S)] Capsule 30 mg. Give one capsule by mouth one time a day for influenza for 5 days. Pwnding (pending) delivery. [DATE] (NP X note) . has had continued decline since recent influenza, will be made comfort measures at this time. [DATE] Resident is (in) bed. No vital signs. Pronounced (deceased ) at 2230 (10:30 pm) . Per the documentation provided, Resident #508 was not tested for Influenza, but was logged on the Influenza mapping and reported to the health department with symptoms starting on [DATE]. Resident #511 A review of the Influenza tests that were provided by the facility revealed that Resident #511 tested positive for Influenza A on [DATE]. This resident was not tracked on a sheet provided to the health department, and was also not tracked on the facility Influenza mapping. A review of the facility policy titled, Infection Prevention Program Overview revised ,d+[DATE] revealed, .The facility establishes a program under which it: Investigates, identifies, prevents, reports, and controls infections and communicable diseases for all residents, staff, and volunteers, visitors and other individuals . Decides what procedures such as isolation, should be applied to an individual resident, and Maintains a record of incidents and corrective actions related to infections . This is accomplished by maintaining effective methods for investigating the incidence of infection, controlling transmission and preventing infections . There is on-going monitoring for infections among residents and personnel and subsequent documentation of infections that occur . Systems are in place to facilitate recognition oof increases in infections as well as cluster and outbreaks . The administrator is ultimately responsible for the infection prevention program. The infection preventionist (IP), formerly Infection Control Professional (IP) . serves as coordinator of an Infection Control Program . Responsibilities may include: Collecting, analyzing, and providing infection data and trends to nursing staff and healthcare practitioners. Consulting on infection risk assessment, prevention, and control strategies. Providing education and training. Implementing evidence based infection control practices including those mandated by regulatory and licensing agencies . The IP completes the line listing of infections and the monthly report forms . A review of the facility policy titled, Infection Prevention Surveillance revised ,d+[DATE] revealed, . The Infection Preventionist does surveillance of healthcare-associated infections by: A. Review of culture reports and other pertinent lab data . C. Chart review. D. Review of the 24-hour report, or morning stand-up meeting and walking rounds throughout the facility ll. Surveillance Symptoms Considerations. 1. All symptoms must be new or acutely worse . Reporting of infections to the Health Department is done as required by law. A review of the facility policy titled, Outbreak Investigation last revised on [DATE] revealed, An outbreak (epidemic) is defined as healthcare associated infections greater than would otherwise be expected in a particular time or place . Any personnel recognizing a possible outbreak will immediately report this to the Infection Preventionist through with the facility management and medical director will be notified Outbreaks can cause significant morbidity and in some cases mortality, making expedient identification and prevention strategies a primary goal . Routine surveillance and trending of infection types and sites provides a benchmark that can be used to measure possible significant increases in new cases of a given infection . Develop a line listing of cases. Include name, common factors with other infected guests/residents (place, time). G. Develop a map to identify clusters or trends of signs and symptoms of potential infection and confirmed cases of infection in guests/residents or staff. H. Evaluate the data gathered to try to identify the source and connection between cases. This may help determine control measures to focus on . XV. Analyze Data and Plan for the Future. 1. Compile data gathered during the outbreak and analyze for possible improvement opportunities in i[TRUNCATED]

Based on observation, interview, and record review, the facility failed to prevent sexual exploitation (behaviors) involving five Residents (#15, #19, #32, #50, #56) of 19 residents reviewed for abuse, with the potential to affect all residents on the memoryd care unit. This deficient practice resulted in the likelihood of sexual abuse and serious psychosocial harm. The Immediate Jeopardy (IJ) began on 11/06/20 at 4:30 p.m., when the Survey team discovered there were multiple attempted sexual encounters by Resident #56 towards four vulnerable cognitively impaired female Residents (#15, #19, #32, and #50 ). There were no adequate interventions put in place to increase the supervision of Resident #56 to protect the facility residents from the potential for sexual abuse and psychosocial harm. The IJ was removed on 11/06/20 at 6:14 p.m., when an acceptable abatement plan was received to ensure additional supervision of Resident #56. The deficient practice continued at a potential for more than minimal harm at a pattern level until confirmation of the plan of correction was completed. Findings include: During an interview on 11/05/20 at 5:25 p.m., Activity aide/ Staff E, was asked about a female resident on the memory care unit observed exiting a male resident's room. Staff E responded, We have (Resident #32) who wanders, and (Resident #19) and (Resident #15); we have to watch them as they wander into boys rooms as the boys (male residents on the memory care unit) are sexual. Staff E stated only Resident #56 acted out sexually. Staff E stated, There was an incident with (Resident #19) the other day; (Resident #19) was on her back. (Resident #56) was on top of her. I told the nurse and they got (Resident #19) off her back (Resident #19) was crying from the pressure of (Resident #56) being on top of her, and the door was closed. They were both clothed . Staff E confirmed Resident #19 had been found lying on her back on Resident #56's bed with the door to the room closed. During an interview on 11/05/20 at 5:45 p.m., Registered Nurse (RN) C, the memory care unit nurse, was asked about the incident involving Resident #19 and Resident #56. RN C confirmed the incident had occurred between Resident #19 and Resident #56 when she was working on the memory care unit on 11/03/20, and stated the incident was noted in her nursing progress notes. Review of Resident #19's progress note, dated 11/03/20 at 18:36 (6:36 p.m.), by RN C revealed, (Staff E) reports when she responded to a call light, she saw (Resident #19) lying with her clothes on in a male resident's bed. (Resident #56) was on top of her. (RN C) went to (Resident #56's) room and upon approach, (Resident #19) was lying sideways on the bed with her clothes on, (her) face was flushed and (Resident #56) was sitting upright with his clothes on next to her . Review of Resident #56's Minimum Data Set (MDS) assessment, reference date 10/16/20, revealed an [AGE] year old male resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #56 was independent with bed mobility, transfers, toileting (including adjusting clothes), and walking in his room and on the unit (facility halls). The Brief Interview for Mental Status (BIMS) assessment revealed a score of 3/15, indicating severe cognitive impairment. The behavior assessment showed no behavioral symptoms, including sexual acts. Further review of Resident #56's progress notes revealed three additional resident to resident incidents involving acts of sexual exploitation behaviors towards four female Residents (#15, #19, #32, and #50). These additional incidents occurred on 9/09/20 with Resident #50, and on 9/05/20 with Resident #19 and Resident #32. Review of Resident #15's progress revealed another incident occurred on 10/18/20. Review of Resident #19's MDS assessment, reference date 8/20/2020, revealed a [AGE] year old female resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #19 required one-person assistance for bed mobility, transfers, walking, and toileting. The BIMS cognitive assessment was unable to be completed, and showed severely impaired daily decision making. Review of Resident #15's MDS assessment, reference date 8/18/2020, revealed a [AGE] year old female resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#15 was independent with bed mobility and transfers, and required one-person assistance for walking and toileting. The BIMS assessment revealed a score of 3/15, indicating severe cognitive impairment. Review of Resident #50's MDS assessment, reference date 7/15/2020, revealed a [AGE] year old female resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #50 required one-person assistance for bed mobility, transfers, walking, and toileting. The BIMS assessment was unable to be completed, and showed severely impaired daily decision making and communication (non-verbal). Review of Resident #32's MDS assessment, reference date 6/09/20, revealed a [AGE] year old female resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #32 required two-person assistance with bed mobility and transfers, and required one-person assistance for walking, and toileting. The BIMS assessment was unable to be completed, and showed severely impaired daily decision making. During an interview on 11/05/20 at 5:52 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were asked about the 11/03/20 incident involving Resident #56 and Resident #19. The NHA and DON acknowledged being aware of this incident, and provided copies of two progress notes per request for Resident #56 and Resident #19, dated 11/03/20. The DON and the NHA confirmed the incident was not reported to the State Agency (S.A), and they did not provide a requested investigation report or witness statement at that time. Review of surveyor emails received from the NHA on 11/06/20 confirmed the additional resident to resident incidents on 10/18/20, 9/09/20 and 9/05/20 were not reported to the S.A., and were not investigated by the facility. Review of a facility investigation report, dated 11/04/20, received by this Surveyor from the NHA via email on 11/06/20, showed an internal facility investigation regarding the resident to resident incident between Resident #56 and Resident #19, which occurred on 11/03/20. This facility, Incident and Accident Investigation Form, dated 11/04/20, revealed, (Staff E) responded to a call light in room [ROOM NUMBER] (Resident #56's room). (Staff E) knocked on the door and entered the room. (Staff E) observed (Resident #19) lying crosswise in the bed, and (Resident #56) rolling off (Resident #19) and sitting up on the side of the bed. Both residents were fully clothed with no inappropriate behaviors noted . Review of the Electronic Medical Record (EMR) for Residents #15, #19, #32, #50, and #56, including nursing progress notes, social services notes, and physician notes, revealed no psychosocial services referral or physician follow up related to Resident #56's sexual behaviors. The EMR was absent of any psychosocial assessment for the potential for psychosocial harm after each resident to resident incident, for any of the involved vulnerable female residents. Review of the current Care Plans for Residents #15, #19, #32, #50, and #56 did not reference any sexual behaviors or interventions for Resident #56, and no protections or interventions for Residents #15, #19, #32, and #50 related to these incidents. During a phone interview on 11/06/20 at 9:50 a.m., CNA I, a regular day shift CNA on the memory care unit, was asked about resident to resident incidents involving Resident #56. CNA I confirmed the 11/03/20 resident to resident incident involving Resident #19 and #56 occurred when she was working on the memory care unit. CNA I stated, I came at the end (of the incident) .I saw the nurse (RN C) and the activity aide (Staff E) were taking (Resident #19) out of his (Resident #56's) room .I was told that the activity aide (Staff E) said (Resident #19) was laying in the bed and (Resident #56) was on top of her .We (the nursing staff) would try to keep an eye on him as he does have a record of approaching women in a sexual manner . CNA I was asked about any other resident to resident incidents involving Resident #56. CNA I stated, I heard he had his hand down another resident's shirt .I can't remember who. He has been seeking out female residents. He wasn't on 15 or 30 minutes checks (visual supervision) this week to my knowledge. I guess he attempted with (Resident #15) .I was told she was in a room and he was standing in front of her with his pants down . Review of Resident #56's Electronic Medical Record (EMR) revealed no evidence of 1:1 supervision, 15 minute or 30 minute checks for the months of October and November, 2020. Resident #56's Care Plan revealed no evidence of current checks on his visual location on the memory care unit. During a phone interview on 11/06/20 at 10:15 a.m., RN C, the regular day shift nurse on the memory care unit, was asked about the incident on 11/03/20 between Resident #56 and Resident #19, and whether she reported the incident to management. RN C responded, I called the Director of Nursing (DON) after I got (Resident #19) back to her room and checked her over. And I spent some time with the activity aide (Staff E) who was really upset . RN C stated she believed she told the DON Resident #56 was on top of Resident #19. RN C stated when she arrived to the scene, (Resident #56) was sitting at the head of the bed, and (Resident #19) was laying midway in the bed, and they both had their clothing on . RN C reported Resident #56 was not on a 1:1 supervision or 15 minute or other designated checks at the time of this incident. When asked about any other resident to resident incidents involving Resident #56, RN C stated, I was there (at work) when one happened. An elderly lady was in his (Resident #56's) room and she (CNA D) happened to walk in on them, (Resident #32), and the aide was (CNA D) . RN C confirmed this incident occurred on 9/05/20 after reviewing her progress notes. RN C reported CNA D stated, 'I need to report something to you. I caught (Resident #32) in (Resident #56's room), and (Resident #56) was standing in front of her face' .Then he walked to another resident's room (Resident #19). We (staff) were able to redirect from that situation as well. I called the ADON that day, RN M, and that's when we initiated 15 minutes checks . The EMR showed Resident #56's 15 minute visual location checks (verifications) were discontinued on 9/23/20, which was confirmed by RN C. During an interview on 11/06/20 at 10:40 a.m., CNA D, another regular CNA working on the memory care unit, was asked if she observed the incident on 9/05/20 involving Resident #56 and Resident #32. CNA D stated, Correct. It was (between) (Resident #56) and (Resident #32). I knocked on (Resident #56's) door, and walked in .(Resident #56) was standing in front of (Resident #32) with his pants unzipped; (Resident #32) had her head off to the side .All I said was, '(Resident #56), move away,' and I got (Resident #32) out of the room. (Resident #32) was right in front of him .She was sitting on a chair. He had his pants unzipped and his hand on the side of her. The way her head was he was trying to get a blow job (oral sex) from her, and she didn't want to do it. She was starting to fiddle with something on the table with her dementia. She wasn't engaging in it. His pants were open and they were down. There was no underwear on. She could see his penis . CNA D was asked if Resident #56 had sought out other residents for sexual reasons. CNA D stated, I think it's mostly (Resident #32), (Resident #19), and (Resident #50). For (Resident #15), it's consensual. Somebody (staff) walked in on them, and they came to me and said, 'You need to go in that room and see what's going on.' I went in the room and (Resident #15) was laying beside (Resident #56) in his bed .(Resident #15) didn't have any underwear or clothes on and I went to try to get (Resident #15) up (out of the bed). (Resident #56) was sitting up, and you could see the wrinkles in his pants .I tried to get (Resident #15) out as quickly as I could. Her long pants were underneath the bed .Both residents are not care planned for this. He was just sitting up, pulling his pants up over his knees. It's been (happened) in the last two months. I don't' know if they had sexual relations .(Resident #15) looked at me and she said, 'I'm sorry.' Review of Resident #15's nursing progress note, by Licensed Practical Nurse (LPN) P, dated 10/18/20 at 23:00 (11:00 p.m.), related to the resident to resident incident involving Resident #56 and Resident #15, showed, Observed (Resident #15) lying unclothed in (Resident #56's) bed. No s/s (signs/symptoms) of distress. (Resident #56) standing beside bed facing resident; (Resident #56) was fully clothed. This nurse heard (Resident #15) exclaim, 'Oh[***] upon entering (Resident #56's) room. Attempted re-direction with gesture that it was time to leave the room. However (Resident #15) stayed in (Resident #56's) room. Staff member able to re-direct (Resident #15) out of room without difficulty. Cont. (continued) with no s/s of distress. Review of Resident #15's and Resident #56's EMR including Care Plans, assessments, consents, and all documents revealed no reference to consensual sexual relations for these two residents. During a phone interview on 11/06/20 at 10:40 a.m., CNA D revealed she was working on the memory care unit when another resident to resident incident occurred, on the same day (9/05/20) a few minutes later after the resident to resident incident involving Resident #56 and Resident #32. CNA D stated, (Resident #19) was in her room and she was sitting in the rocking chair. It was the same day. I found (Resident #56) standing in front of (Resident #19). (Resident #56's) pants were up. I think I caught it before anything (a sexual interaction) happened; I'm not positive . Review of Resident #56's progress note, dated 9/05/20 at 14:22 (2:22 p.m.) by RN C revealed, CNA (D) reports she observed a female resident (Resident #32) in (Resident #56's) room sitting in a chair, with (Resident #56) standing directly in-front of female resident's (Resident #32) face with his zipper down, (sic) no actual physical contact made and female resident (Resident #32) was immediately redirected out of the room .Within minutes, (Resident #56) was observed in another female residents room (Resident #19) and as the female resident (Resident #19) was sitting down in her chair, (Resident #56) had his legs straddled over the resident's legs and was manipulating his pants .no actual physical contact was made, they (Resident #56 and Resident #19) were immediately separated and as female resident (Resident #19) was walking away, (Resident #56) began rubbing her back .Notified (RN J), Clinical Manager on call of these behaviors, she then notified ADON (Assistant Director of Nursing) (RN M) of above concerns of behaviors as observed by CNA (D) . RN C and CNA D confirmed the first female resident referenced was Resident #32, and the second female resident was Resident #19. Review of Resident #56's progress note, dated 9/06/20 at 9:10 (a.m.) by RN C revealed, .Upon waking (Resident #56) was observed making attempts to lead a female resident into his room . RN C confirmed the female resident was Resident #19. Review of Resident #32's and Resident #19's nursing progress notes revealed no entries related to the above sexual exploitation incidents for either resident on 9/05/20 or 9/06/20. Review of Resident #19's current Care Plan revealed, (Resident #19) exhibits delusions that are very stressful to her. Most of her delusions are sexual in nature. She makes statements that she was raped .Interventions: Reassure (Resident #19) that she is safe . During a phone interview on 11/06/20 at 10:40 a.m., CNA D continued, Yes, I was working when the other incident happened (on 9/09/20) with (Resident #56). (Resident #56) was walking down the hallway and he went up to (Resident #50) and was trying to go underneath her shirt to get at her breast. (Resident #50) was stunned. (Resident #50) did not want this to happen. Again, I took (Resident #50) away from (Resident #56). I told (Resident #56) it was inappropriate for him to do (this) .(Resident #56) was underneath her shirt . CNA D reported she told the nurses, including LPN G. Review of Resident #56's progress note, dated 9/09/20 at 23:00 (11:00 p.m.) by LPN G revealed, Resident (#56) was observed ambulating in the hallway by another female resident (Resident #50). Both residents were observed standing together at the (memory care unit) front doors. When this nurse approached, (Resident #56) had his pants unzipped stating to the female resident, 'Come on, just come in my room with me, see this.' .Then approx. (approximately) one hour later, both residents were back up ambulating in the hallway .(Resident #56) was reaching towards female resident (Resident #50) then female resident grasped a hold of both of (Resident #56's) hands in a friendly manner with no words spoken . Review of Resident #50's typed progress note, dated 9/09/20 at 6:41 (a.m.) by LPN G revealed, Inaccurate documentation with the entry struck out with one black line. This progress note read as follows: Resident (#50) was emotionally upset when (Resident #56) attempted to keep her in the corner and was showing her his penis then attempting to get her to go in his room. (Resident #50) was again upset when he attempted to touch her breasts however this nurse was able to intervene . During an interview on 11/06/20 at 1:28 p.m., LPN G was asked about the 9/09/20 incident and her nursing progress notes, including the 'inaccurate documentation' progress note struck out regarding this incident. LPN G confirmed she recalled the incident, and stated, It (sic) wasn't any touching or anything like that. I had to rewrite that note. I should have taken more time and sat down and got my thoughts more clear when I wrote it. That's why it's crossed out. They (Resident #56 and #50) were just in the same area, and (Resident #50) was by the (memory unit entry/exit) door and he (Resident #56) was by the (same) door and it was late at night .I came down (the hall to the memory unit main door) and she (Resident #50) grabbed my hand and we went to her room. (Resident #56) went to his room. It is not unusual for (Resident #50) to grab a hand when you come by her. Surveyor asked LPN G if Resident #56 initiated any sexual contact or attempted to touch Resident #19 inappropriately, per earlier CNA interview and the progress notes, including the inaccurate documentation entry. LPN G responded, Everyone has their own interpretation of things. It is hectic in the middle of the night. LPN G denied awareness of any other resident to resident incidents related to Resident #56. During an observation on 11/09/20 beginning at 11:45 a.m., Resident #56 was observed seated in a standard chair in the memory unit day room, fully dressed and well groomed. He was holding his cane on his lap, and his pants were clearly fully zipped. He was seated well beyond 6' away from other facility residents. Resident #56 was being supervised by activity staff, Staff F, and RN C was also providing supervision on the unit. There was a 15 minute visual verification check log on a clipboard for Resident #56, which was completed to the current time. The facility initiated 15 minute checks for Resident #56 per the abatement plan after the Immediate Jeopardy was called on 11/06/20. During an interview on 11/09/20 at 12:43 p.m., RN C was asked about the resident to resident incidents on 9/05/20 involving Resident #56. RN C responded, (Resident #56) was being sexually inappropriate. (Resident #56) tried to make a connection/contact with (Resident #32) but did not succeed as her face was turned away, and she did not connect with what was going on. The first event (incident with Resident #32) was in (Resident #56's) room .The second incident was in (Resident #19's) room. (CNA D) walked in. (Resident #19) had her clothes on. I looked in. (Resident #19) was sitting in her chair and (Resident #56) was standing over her with his legs straddled and he was maneuvering his pants down, and I did not see his penis out. I think he was after getting some sexual needs met; he was being sexually inappropriate. I can't remember anything (Resident #56's behavior) being inappropriate before that (the two incidents that occurred on 9/05/20) . RN C was asked to review her nursing progress notes on 9/06/20 (which conveyed Resident #56 was demonstrating behaviors of making attempts of leading female elders (residents) into his room.) RN C reviewed her progress notes, then stated, It was (Resident #19) who he was trying to lure into his room, not by the hand, (Resident #56) was talking to her and gesturing for her to come into his room .I told (RN J) and the ADON, RN M was notified .I asked them to take him to another unit (in the facility) into consideration (off the memory care unit). RN C confirmed Resident #56 remained on the memory care unit. Resident #56 was observed to reside on the memory care unit in room [ROOM NUMBER] during this survey. During an interview on 11/09/20 at 2:37 p.m., Staff E was asked to clarify Resident #19's body position when she was discovered with Resident #56 on top of her in his bed. Staff E stated, (Resident #19) was laying across the foot of the bed, across so her neck didn't have any support. (Resident #19) was laying straight on her in the same position. (Resident #19) was on her back; his (Resident #56's) chest was on her chest. They were chest-to-chest. (Resident #56) rolled off of her, and I couldn't get her to sit up .(Resident #19), .her face was red and her eyes were watering .Staff E confirmed Resident #56's door was closed initially when this occurred. Staff E stated, I have seen him (Resident #56) stand at his door and get the wanderers (female residents who demonstrate wandering behavior) to come into his room. He (Resident #56) puts his hand on their back and is trying to guide them in there . During an interview on 11/09/20 at 3:26 p.m., the Social Worker (SW) H was asked about Resident #56's behaviors, and any psychosocial assessments or interventions. SW H stated, I have made a referral to (Psychiatric Services Company Name) (on 11/09/20, after the IJ was called by the S.A.). (Name of staff physician assistant) at (Psychiatric Services Company Name) reviewed (Resident #56's) medications to decrease his libido (sexual drive/desire). It will be a recommendation, not an order. They were recommending [MEDICATION NAME] 10 mg; (facility Nurse Practitioner, NP N) will touch base and may be starting (Resident #56) on [MEDICATION NAME] (an antidepressant known to possibly reduce libido). I know our corporate office is asking for alternative placement, and family does not want that. I'm waiting to hear; it's between family and corporate. If they still say he cannot be here, I will look for an all-male AL (Assisted Living) or a foster care home. It has been recommended from our corporate office . Surveyor asked about not seeing any social services notes addressing psychosocial follow up specifically related to the five resident to resident incidents involving Resident #56 and the sexual exploitation of vulnerable female Residents (#15, #19, #32, and #50). SW H reviewed the incident nursing progress notes, and stated, It's not like we witnessed any sexual acts; we haven't witnessed anything. To be honest I did not even catch a pattern going on. They nursing would fill out an incident report; nursing follows up on that .There is nothing he had done that should have reportable. It's more people wandering into him room. I didn't get the feeling he was preying on other women. They (the nursing staff) never brought anything to my attention that I would need to assess or get other interventions in place. I remember that one note being read in morning meeting (manager/department head staff meeting), and it was all interpretation, just that she (Resident #15) was laying in his (Resident #56's) bed fully clothed, and it did not need to be reported, it was all interpretation from the nurse . When asked if incidents like this should have had psychosocial follow up, SW H responded, I do think we should have followed up and contacted the family on what they (staff) observed, and making sure they were ok with things. The only one (incident) I'm aware of is with (Resident #15). I'm not familiar with the (Resident #32) and (Resident #19) one (incident). (Resident #50), yes, I'm aware of that one (incident). SW H acknowledged if nursing did not follow up, then social services should have followed up with the residents regarding any psychosocial outcome. Regarding the incident with Resident #50 and Resident #56, SW H stated, .It was in a common area, and it wasn't like he had her cornered. It (the progress note) did state he (Resident #56) was trying to get her (Resident #50) back in the (his) room with him .They both have dementia and they are not in their right frame of mind to be aware of what they are doing .I can see how (since) it's happening with different residents it seems he is preying on people . On 11/09/20 at 4:00 p.m., when notified of the Immediate Jeopardy, the NHA and DON were offered an opportunity to comment or participate in an interview regarding the five resident to resident incidents involving Resident #56. Both declined to comment. During a phone interview on 11/10/20 at 8:18 a.m. and 11:31 a.m., the memory care unit manager, LPN K, was asked about the incident between Resident #56 and Resident #19 on 11/03/20. LPN K stated, The event occurred at 4:00 p.m .on the day shift .I was notified the next day. I read it in the nurses notes. I handled it from a nursing perspective. I asked (Staff E) some questions and I talked to (LPN C) about it. I wanted facts, not impressions, and any unusual touching behaviors. (Resident #19) likes to find a bed when she's tired. We were monitoring the situation (with Resident #56) with women (on the unit). Because there was no inappropriate contact, no, I didn't notify the doctor. There was no redness or bruising from him (Resident #56) rolling off of her (Resident #19). No, I didn't see it as abuse or sexual exploitation from what they have told me. I didn't think of it as sexual at that point. No, I didn't notify the social worker. We read these notes in morning report (the morning department/manager staff meetings.) LPN K acknowledged the DON was present at the morning meetings and would therefore know about this incident. When asked about the other four resident to resident incidents involving Resident #56 and the four female residents on the memory care unit. LPN K responded, I couldn't tell you which occurrence happened when. Just whatever was in the nurses notes is what I would have responded to (Resident #50), I didn't see anything concerning, she (Resident #50) wasn't fearful of me touching her.). I did talk to (Resident #15's family member), (Resident #50's family member), and (Resident #32's family member) to give them a heads up. They (the female residents involved) were seeking out (Resident #56), and (Resident #56's) response .we were monitoring the situation closely. The physician was not notified. The social worker would have been notified in morning report . LPN K was asked if she would do anything different in terms of reporting and investigating going forward. LPN K stated, I think we should have talked more about it (these incidents). The social worker specifically, then we would go from there and talk to the physician. It is a dementia (memory care) unit and we have to be objective at how we look at those behaviors. We notice if things aren't quite right with them (the residents). During a phone interview on 11/10/20 at 11:47 a.m., RN J, the nurse manager who was on call on 9/05/20, was asked about the incidents on 9/05/20. RN J stated, I refer to upper management. This is not something I do anything further with. I indicated for her (RN C) to contact him, the Assistant Director of Nursing (ADON). The DON was on vacation at the time. I would not have notified the physician or social worker. During a phone interview on 11/10/20 at approximately 12:30 p.m., the ADON, RN M, was asked about the resident to resident incidents on 9/05/20 involving Resident #56, and Residents #32 and #19. RN M responded, When (RN C) called me, I verified the issue. In my conversation with (RN C) I did not deem anything had happened as there was no abuse found . RN M was asked if the physician or social worker were contacted. RN M responded, No, I did not deem anything was necessary at that time. We have stand up meetings. We read all the notes and they (the nursing managers) were made aware. (Resident #56) has had his pants unzipped, (this is) nothing new. I did not find that concerning. (Resident #56) might forget to pull his pants up. I was not aware of the straddling part .I did not believe there was any sexual intent . During a phone interview on 11/10/20 at 11:56 a.m., the facility nurse practitioner, NP N, was asked if they (the Nurse Practitioner and physician team) were aware of these incidents when they occurred, and if they made any recommendations related to these incidents involving Resident #15, #19, #32, #50, and #56. NP N stated, . I knew briefly about it toward the end of last week. They (the facility) put a 15 minute check on him (Resident #56). We did start him on [MEDICATION NAME] (antidepressant medication), 10 mg .to try to control his libido . NP N reported reviewing the nursing progress notes on the dates of each of the resident to resident incidents (on 11/03/20, 10/18/20, 9/09/20, and 9/05/20), and their physician notes after these occurrences. NP N acknowledged they (the physician team) were not aware of any of these incidents; they were confident if they were aware, the behaviors and medications would have been addressed, and added, I couldn't do anything about it as I didn't know about it (the incidents) .To me, it sounds unacceptable. NP N was asked if they should have been notified of Resident #56's sexual behaviors and made a referral for psychiatric services. NP N confirmed they should have been notified and given the opportunity to make a referral for a psychiatric consult, and to address Resident #56's behaviors. The Medical Director (Resident #56's physician) was unavailable for an interview on the last date of this survey, 11/10/20, per NP N. Review of Resident #32's recent progress notes revealed no note regarding the 9/05/20 sexual exploitation incident with Resident #56 as the perpetrator. Family notification on 9/09/20 revealed Resident #32's family member was notified Resident #32 had sexual behaviors towards a male resident, which appeared to first occur on 9/09/20, after the 9/05/20 incident. The family member was not notified of the incident on 9/05/20, however was notified Resident #32 was seeking out a male resident (unspecified). Review of Resident #50's recent progress notes revealed only the note with the entry struck out, dated 9/09/20 (earlier referenced), regarding the sexual exploitation incident with Resident #56 as the perpetrator. There was no replacement progress note for this date and incident. Family notification on 9/10/20 revealed Resident #50's family member was notified a male resident (unspecified) was inviting Resident #50 into his room. The family member was not notified of the i (TRUNCATED)

Based on observation, interview, and record review, the facility failed to identify, evaluate, and implement interventions to prevent an avoidable accident when a Certified Nurse Aide (CNA J) failed to safely transport a food cart to the dining room, for one resident (#77) of three residents reviewed for avoidable accidents/safety, from a total sample of 26 residents. This deficient practice resulted in Resident #77 being struck from behind by a food cart and falling forward on her face, which caused severe bodily injury including increased pain, hospitalization and multiple facial fractures. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #77 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 77 scored 5/15 on the Brief Interview for Mental Status (BIMS) examination; indicative of severe cognitive impairment. The above MDS assessment indicated Resident #77 required supervision for ambulation on the unit and was considered not steady on her feet but able to stabilize her balance independently. The facility document titled: Incident and Accident Report dated 9/20/17, revealed: Resident (#77) was walking in hallway across from dining room .near kitchen and CNA (J) was pushing food cart and did not see (Resident #77) and hit her. Resident (#77) fell forward (face) first to the floor .unconscious 1 - 2 minutes. A review of the hospital emergency department report dated 9/20/17, revealed: .Apparently she (Resident #77) was standing in the hallway when she was struck by a food cart, causing her to fall over onto the floor directly onto her face. She did have loss of consciousness. She does complain of pain to her face as well as her left shoulder and left hand which she rates 6 out of 10 .She does have significant swelling to her face and nose .CT (CAT (computerized axial tomography) scan) of patient's facial bones .shows a significantly displaced, impacted bilateral nasal bone fracture with nondisplaced [MEDICAL CONDITION] superior margin of the maxilla (large bone that forms the sinus cavity bilaterally and parts of the palate of the mouth) near the midline involving the base of the anterior nasal spine. There is mildly displaces and buckled fracture involving the nasal septum .given that the patient did have loss of consciousness with her fall and the extent of her injuries, it is recommended that she be admitted for further care for observation and her family members are agreeable. Review of the Medication Administration Record [REDACTED] 9/22/17 at 4:55 p.m. for pain level of 5 and 8:58 p.m for pain level of 4. 9/23/17 at 1:00 a.m. for pain level of 5, 5:20 a.m. for pain level of 5 and 9:05 a.m. for pain level of 8. 9/24/17 at 8:44 a.m. for pain level of 1 and 9:00 p.m for pain level of 5. 9/25/17 at 6:58 a.m. for pain level of 3 and 10:00 p.m . for pain level of 5. No other documentation could be found of pain medication administered to Resident #77 prior to 9/22/17, the date of her injury. The following interviews with staff and observation were conducted regarding the incident on 9/20/17 with Resident #77: 01/26/18 01:47 PM CNA J: The food carts that we used to have were like five feet tall and I was bringing it back the one night . I was going down the hall near the dining room. On the right side of hall, I noticed residents coming out of the dining room so I veered the cart over. I hit something, felt a bump, and when I looked around the cart I saw (Resident #77) lying on the floor. She was on her face with her arms to her sides. I went around and I was checking her and she wasn't responding, I sent someone for help. One of the nurses came .they said she probably went unconscious .She was sent to the hospital .We got all new food carts. The next day they made us have two people on the carts until the new ones came. 01/26/18 02:05 PM Registered Nurse (RN) M: (Resident #77) walks slowly with the walker. She likes that side of the wall. At that time our kitchen carts were tall. The aide came through, didn't see (Resident #77) and hit her. There was a lot of blood . There was enough reason (injuries) to send her (to the emergency department) right away, I think her nose was broken, there was a laceration . 01/26/18 01:17 PM Dietary Staff P and Dietary Staff Q: We used to have tall ones (food carts) and we went to two-person when pushing (the carts) until we got the new ones. We couldn't see over the others and these (new carts) you can (see over). An observation was made by this Surveyor, at this time, of 6-8 plate lids stacked on the new cart, a potential obstruction of view. 01/30/18 09:18 AM RN K: I did not witness it .I was called to the site where she was on the floor already. (CNA J ) explained to me she was on the opposite wall because people were coming out of the dining room (around dinnertime). She was pushing the cart and then she felt (she hit) something and found (Resident #77) on the floor. 911 had already been called. 01/30/18 09:32 AM RN L: .Someone came running and said they needed a nurse. I went over and (Resident #77) was laying prone on the floor, up against the wall on the opposite side (of the hall from dining room). I touched her back, asked her if she could hear me and she moaned. I asked her if she hurt and she told me her left shoulder, knee, and her face. I remember that she had a lip puncture. There was blood coming out of her nares and there was some swelling already starting .(Resident #77's) arms had been at her side on the floor and her walker was under her. I made the decision to send her in (to the hospital) . I was worried about a head injury. 01/30/18 10:04 AM DON: I received a phone call what had occurred. The next morning, I came in and did a re-enactment. (CNA J) reported she had stopped and was talking to a resident by the dining room door. When she began to move (the cart) again she said she heard a bump. (Resident #77) was walking along with her walker, she always walks along that side, and was in the blind spot of the cart (and was hit) . 01/30/18 10:37 AM Nursing Home Administrator (NHA): .at that time it was felt we would provide two staff with every cart and then made the decision to order new carts. Effective immediately all food carts were to have two staff. New food carts were ordered on [DATE] and they arrived in (November). Review of the electronic Progress Notes dated 9/22/17 at 11:58 a.m. regarding Resident #77 showed: .on 9/20/17 at 18:45 (6:45 p.m.) was ambulating in the hallway outside of the main dining room wither (sic) walker. Reenactment was done, revealed that (Resident #77) exited the west door of the main dining room and crossed the hall to the other side along the hand rail, which is her normal pattern when walking back to her room after supper. This occurred at the same time that (CNA J) looked and spoke with two other residents exiting out the east entrance of the main dining room. When (CNA J) looked ahead around the food court (cart) as she was watching for other staff and residents to come out of the west entrance, did not see (Resident #77) along the opposite side of the hallway. As a result, (Resident #77) was bumped with the food cart, causing her to fall forward 01/30/18 01:33 PM Director of Nursing: When asked by this Surveyor about education for CNA J and other staff the DON replied: A widespread memo (dated 9/21/17) went out to all departments to instruct staff on use of two staff when pushing the food carts, effective immediately . The DON indicated there was no standard training, orientation, or policy and procedure for pushing food carts and indicated food carts had not been previously identified as a hazard. A review of the personnel record for CNA J found no documentation of education or discipline regarding safe transport of food carts.

This citation pertains to MI# 812 Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being (did not assess a resident prior to moving him off the ground following a fall), in 1 (#101) of 4 sampled residents, from a total of 4 sampled residents, resulting in a delay in treatment and an increase in pain due to a [MEDICAL CONDITION]. Findings include: Record review of facility 'Fall' policy dated 5/2010 revealed that a fall refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of overwhelming external force. Record review of facility/corporate 'Basic Head to Toe Assessment' dated 6/2012 revealed the purpose of the policy was to assess resident baseline status, identify abnormalities and address as needed, identify deviations from baseline and provides a systematic approach to assessing residents. The policy included that a lower extremities inspection included: If client is in bed and lying on back, assess length and position of each leg. Lower extremities palpation included: [MEDICAL CONDITION], joints hips, knees, ankles and feet. The policy noted that the head to toe assessment could be done quickly and to ask another nurse to help if unsure how to assess a particular area. Record review of facility 'Pain Management' policy dated 5/1/10 revealed fundamental information included a comprehensive evaluation of pain includes characteristics of pain and physical assessment. Procedure #4.) In residents who have dementia and cannot verbalize that they are feeling pain, symptoms of pain can be manifested by particular behaviors such as calling out for help, pained facial expressions, refusing to eat, striking out when moved or touched, increased confusion. Record review of facility reported incident summary revealed that on 7/8/13 at 5:20 AM, Resident #101 was found by staff on the floor at the foot of his bed with his brief down around his ankles. The investigation summary noted that the resident had a [DIAGNOSES REDACTED]. A Certified Nursing Assistant (CNA) had provided care 15 minutes prior to being observed on the floor. The investigation summary noted that the resident was sitting on the edge of the bed with his walker in front of him when the CNA left the room. The investigation summary revealed that later in the morning the resident was having increased difficulty transferring and complained of pain. Record review of Resident #101's 'Fall' care plan revised dated 5/17/13 revealed that the resident was at risk for falls. On 6/15/13 the facility not noncompliance with following safety measures, alarms and restraints not appropriate. Record review of Resident #101's 'Accident/Incident' report dated 7/8/13 revealed that the resident was observed on the floor (un-witnessed fall) and that the registered nurse notified the physician via fax at 5:40 AM of the fall. There was no noted assessment of the lower extremities or range of motion noted. Record review of Resident #101's nurse notes dated 7/8/13 at 5:50 AM revealed that the resident was found on the floor and required assist of three people to get up onto the bed. The nurse noted no injury was apparent at that time. In an interview on 8/7/13 at 11:34 AM, Certified Nurse Assistant (CNA) #6 stated that Resident #101 was very confused and would ask to go upstairs. CNA #6 stated that at 4:50 AM she went to clean Resident #101 up and change his brief on 7/8/13. CNA #6 stated that she stood Resident #101 at the side of the bed while he held onto his walker and she changed his brief. The CNA stated that Resident #101 was watching TV and that it was 5:05 AM when she left him. CNA #6 stated that in the past Resident #101 would get out of bed, get his walker and come down the hall with his brief around his ankles. CNA #6 stated that Resident #101 had a history of [REDACTED].#101's alarms. CNA #6 stated that after the nurse found the resident on the floor they picked the resident up, put him in a wheelchair, and then into bed. CNA #6 stated that the resident didn't complain of pain until they put him into the bed. CNA #6 stated that Resident #101 complained of pain to the right leg when it took three of them to put him into bed, and that he could not stand very well. In an interview on 8/7/13 at 12:57 PM, Registered Nurse (RN) #4 revealed that it was at the end of her shift on 7/8/13, when she went to Resident #101's room to do blood sugar check and upon entering the room she saw Resident #101 sitting on the floor on his buttocks with his legs out in front of him. RN #4 stated that the resident wasn't calling out and that he did not have an alarm, but was just sitting on the floor with his brief down around his ankles. RN #4 stated that the resident wanted up, so she called Certified Nursing Assistants (CNA's) to come and assist her. RN #4 stated that Resident #101 was a big guy and that it took three of them to get him up and that he did not stand very well and kept saying "get me up, get me up". RN #4 stated that Resident #101 was confused and kept saying he wanted to go down stairs (single story building). RN #4 stated that the resident had been confused all night prior to the fall. RN #4 stated that they got the resident into a wheelchair and then into the bed. RN #4 stated that she did an accident/incident report and gave report to the next shift nurse. In an interview on 8/8/13 at 5:40 AM, Certified Nurse Assistant (CNA) #9 who worked during the time of the fall on 7/8/13, revealed that Resident #101 was very confused and had fallen on the floor and that it took three people to get him up and after they started to move him he complained of pain to one hip. CNA #9 stated that Resident #101 had been very confused that night. CNA #9 stated that every time they tried to move him he complained of pain to his hip. CNA #9 stated that when she left her shift Resident #101 was lying in bed on his back. In an interview on 8/8/13 at 9:45 AM, Certified Nurse Assistant (CNA) #7 revealed that he started his shift at 6:00 AM (on 7/8/13) and that Resident #101 was in bed. CNA #7 stated that the resident complained of pain when he and another CNA slid him up in bed between 6:00 -6:30 AM. CNA #7 stated that he told the nurse when she was done with report that Resident #101's right leg hurt. CNA #7 stated that the resident did not get up during his shift and stayed in bed. CNA #7 stated that the resident ate lunch in bed around 11:30 AM because he sat beside him and that he didn't eat much. CNA #7 stated that Resident #101 was pretty uncomfortable. In an interview on 8/8/13 at 10:13 AM, Certified Nurse Assistant (CNA) #8 revealed that she assisted CNA #7 with sliding Resident #101 up in bed (on 7/8/13) and before they even touched him he yelled out. CNA #8 stated that Resident #101 had put his hand down on the bed to move and he yelled out. CNA #8 stated that she and CNA #7 used a pad that was under him and when they grabbed a hold of the pad he yelled out again. CNA #8 stated that they stopped and did not move the resident, and that she went down and told Licensed Practical Nurse (LPN) #5. CNA #8 stated that LPN #5 was in the dining room passing medications and told her that she would call (doctor) when she was done. CNA #8 stated that when she walked into the room to assist CNA #7 that morning, Resident #101 looked uncomfortable and told her that he fell on the floor going to the bathroom. CNA #8 stated that Resident #101 did not get up during the shift and was not moved until the EMS (emergency medical services) came to transfer him at 1:45 PM at the end of her shift which ended at 2:00 PM. In an interview on 8/8/13 at 8:25 AM, Licensed Practical Nurse (LPN) #5 revealed she came into work at 6:00 AM and the midnight nurse reported that Resident #101 had sat on the floor just before she had gotten there and that midnight nurse did the investigation. LPN #5 stated that the resident did not want to get up for breakfast and that she went down to his room to evaluate him and that he complained of pain with movement at 7:30 AM. LPN #5 stated that the resident did not get out of bed during her shift. Record review of Resident #101's 'Medication Administration Record' for the month of July 2013 revealed that the resident received one tablet of [MEDICATION NAME] (pain medication) at 10:00 AM on 7/8/13. There were no other pain medications given to Resident #101 for the rest of the day shift. Further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Licensed Practical Nurse (LPN) #5 nurse notes dated 7/8/13 at 9:30 AM revealed that the physician was notified of right hip pain and that an x-ray was ordered. There was no documented physical assessment of Resident #101's lower extremities or range of motion noted. Record review of Resident #101's SBAR (Situation Background Assessment Recommendation) form dated 7/8/13 at 1:00 PM and completed by Licensed Practical Nurse (LPN) #5, revealed that Resident #101 complained of pain to his right hip at a 8/10 during care. There was no physical assessment of the residents lower extremities noted. Record review of Resident #101's radiology report dated 7/8/13 at 12:32 PM revealed 'Acute intertrochanteric femoral fracture with mild displacement with varus angulation. In an interview on 8/8/13 at 12:50 PM, Licensed Practical Nurse (LPN) #10 revealed that on 7/8/13 she was working as a float nurse and that she filled out the transfer form for Resident #101 to be sent out to the hospital and that it was at the end of her shift around 1:45 PM. LPN #10 stated that she did not see the resident, look at his legs or do an assessment, that she only did the paperwork for LPN #5 because she was so busy and was unfamiliar with the transfer form because she worked contingent. In a second interview with Registered Nurse (RN) #4 on 8/8/13 at 6:30 AM, she revealed that Resident #101 was found on the floor at the foot of the bed and that he was facing the doorway. RN #4 stated that Resident #101's brief was down around his ankles. RN #4 stated Resident #101 didn't say anything until he seen her come through the door and then he wanted up off the floor. RN #4 stated that she asked Resident #101 what he was doing and he told her going down stairs (single story building) and that he denied it was his room and was confused. RN #4 stated that it took three staff members to get the resident up to his wheelchair, pushed over to the bed and still needed three people to assist him into bed because the resident didn't help or bear weight. RN #4 stated that the resident had on white non-skid socks that were slipping during transfer and that they did not grip very well. Record review of Resident #101's 'Accident/Incident' reports for the previous 6 months, prior to the fall on 7/8/13, revealed that the resident had a total of 7 reported falls. Record review of facility 'Standard of Nursing Practice' policy, dated 3/2013, revealed that the nursing process ensures appropriate care and services for each resident and that the delivery of nursing care in the facility is based on a thorough assessment of the resident to identify his or her care needs. Record review of Resident #101's hospital records dated 7/8/13 revealed right leg shortened and externally rotated. #