Every finding on record at Bay County Medical Care Facility

Based on observation, interview, and record review, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents. Findings include:On 04/27/2026 at 9:50am observed chemical feeder downstream of an atmospheric vacuum breaker (AVB) at the mop sink in the janitor's closet adjacent to the kitchen. On 04/27/2026 at 10:15am observed hose with attached spray nozzle downstream of a hose bib vacuum breaker (HBVB) in the trash compact area. On 04/27/2026 at 10:16am observed chemical feeder downstream of an AVB in the trash compact area. On 04/27/2026 at 1:54pm observed outside spigot with an attached hose without backflow prevention. During this observation, Assistant Director of Plant Operations N stated the backflow preventer is on work order, but they haven't gotten to installing them yet. On 04/27/2026 at 2:08pm observed an inside spigot with an attached hose without backflow prevention in the old garage. During this observation, Assistant Director of Plant Operations N stated that no one has fulfilled the work order yet.According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP) and, follow enhanced barrier precautions (EBP) for residents identified with qualifying wounds, for one resident #65 (R65) of three residents reviewed for infection prevention. This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.Findings include: On 04/27/2026 at 9:27am observed ice machine filter dated 4/30/2020. On 04/27/2026 at 1:28pm observed an unused ozone treatment for the washers located in the laundry chemical room. The ozone tanks are partially capped from the plumbing system leading to the washers, but it remains connected to the water lines leading out towards the hallways. During this observation, Environmental Services Director O was interviewed on how long the ozone tanks haven't been used and she said they haven't been used for at least 10 years. On 04/27/2026 at 1:33pm observed two dead end pipes running from the ceiling located in the laundry personal clothing room. During this observation Environmental Services Director O was interviewed on whether these pipes were used for anything and she stated she's never seen anything hooked to those pipes. On 04/27/2026 at 1:34pm observed what appears to be an unused faucet with the cold and hot water valves removed and the sink was unable to turn on. On 04/27/2026 at 1:37pm observed two uncapped water lines to an old utility sink located in B11 utility closet. On 04/27/2026 at 2:08pm observed inside spigot at the old garage. During this observation, Assistant Director of Plant Operations N was interviewed on whether this spigot is flushed regularly as a legionella control measure, and he stated to his knowledge, it isn't flushed. On 04/27/2026 at 2:16pm observed an inside spigot in the new garage. During this observation, Director of Environmental Services O was interviewed on whether the spigot was flushed, and she stated it's probably not flushed. On 04/27/2026 at 2:18pm observed an outside pavilion with a kitchenette and a bathroom. During this observation, Assistant Director of Plant Operations N stated the water is shut off starting around October and reopens in April, and that the hot water doesn't turn on because the hot water tank doesn't work and the valve is closed off. 04/28/2026 at 9:19am interview with Environmental Services Director O and Assistant Director of Plant Operations N on winterizing and reopening the outside pavilion, and he stated the lines are blown out to close the pavilion and the water is run for a long time when reopening. In addition, Assistant Director of Plant Operations N was interviewed on whether there were a policy and procedure for winterizing and reopening the pavilion, and he stated there wasn't a policy. 04/28/2026 at 9:34am during the interview with Environmental Services Director O she called Senior Maintenance P, and he was asked whether the hot water tank to the outside pavilion was drained before it was shut off, and he stated the hot water tank is drained. 04/28/2026 at 10:29am interview with Assistant Director of Plant Operations N on whether the ice filter dated 4/30/2020 in the main kitchen has been changed out recently, and he stated he wasn't entirely sure. When asked how often the filter should be changed, Assistant Director of Plant Operations N answered it should be changed every 6 months. 04/28/2026 at 11:19am During the interview with Environmental Services Director O on whether the cold and hot water lines are flushed on the empty unit in 2 East, Environmental Services Director O called a staff member who stated they were only flushing the hot water in 2 East. Record review of the flushing logs in Tels, it states on 4/11/2026 ran hot water in all sinks and showers for 3 min each - flushed all toilets on 2- East -preventing legionella bacteria growth and it was marked completed. On 4/4/2026 it states, flushed all toilets - ran hot water in all sinks - ran hot water in all showers and on 3/28/26 it states, flushed all toilets and ran hot water in sink/showers on 2 East, and it was marked as completed. Record review of the facility's water management plan states under control measures procedures, Dead legs have been identified and removed. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. A review of Resident 65 (R65) medical record and Minimum Data Set (MDS) assessment revealed R65 was admitted to the facility on [DATE] with diagnoses: displaced bicondylar fracture of left tibia, unsteadiness on feet, abnormality of gait (walk) diabetes mellitus type 2 (DM), left foot drop, depression, hypertension. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15 and needed assistance with care. During an observation on 04/27/2026 at 9:45 AM an orange Enhanced Barrier Precautions (EBP) sign and red hand stop sign were observed outside R65's room. When Nurse K was asked about the posted signs she identified R65 was on enhanced barrier precautions for a surgical wound on left leg with dehiscence (opening) and infection. Review of the facility's Enhanced Barrier Precautions policy last revised 1/28/26 revealed, Implementation of Enhanced Barrier Precautions.Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). According to a record review of R65's orders revealed: Revision 04/27/2026 Initiate enhanced barrier precautions According to a record review of R65's care plan revealed: Focus: Enhanced Precautions: I have enhanced precautions in place r/t (related to) dehisced left knee incision with Interventions: All staff to wear appropriate PPE (personal protective equipment) when providing direct care. On 04/27/2026 at 10:21AM, During an interview with R65's roommate it was observed that Certified Nurse Assistant (CNA) F performed a bed bath, brief change and assisted in dressing of R65, CNA F wore PPE of gloves only. Upon completion of the bed bath CNA F carried the basin of used bath water through the room past SA and roommate and emptied the basin in the resident's shared restroom donning PPE of gloves only. CNA F did not clean the shared restroom after use and stored the empty wet basin in the resident's closet. On 04/27/2026 at 10:25AM, Observation or R65 laying on bed she was partially dressed and said she was waiting for CNA to return with socks. R65 confirmed she just completed a bed bath, when asked if staff wore gowns with her care and she said sometimes but not when she gets a bath. According to the training record of CNA F completed EBP in nursing homes training dated 06/04/2025; Infection prevention and control for all staff dated 06/04/2025; Personal protection equipment (PPE) donning and doffing dated 06/04/2025. On 04/28/2026 at 1:30 PM, During an interview Wound Care (WC) Nurse E was inquired about EBP residents. WC Nurse E said that high activity care for residents on EBP required gown and gloves at minimum and could require more PPE depending on the activity. On 04/28/2026 at 2:28PM, During an interview Infection Control and Prevention (ICP) Nurse D she was queried how residents in EBP were identified, she said residents in EBP had an orange Centers for Disease Control and Prevention (CDC) EBP sign on their rooms door that identified precautions and PPE needed for activities, a red hand stop sign that directed visitors to the nurse before entering. ICP Nurse D reviewed types of residents that needed EBP and said that staff followed EBP per policy for residents identified with EBP precautions. On 04/28/2026 at 2:53 PM, During a follow up interview with R65 she said she had been to the orthopedic doctor at 10:00 am and had new wound care orders for three times a day and was confirmed she had an infection in the open area on her leg. R65 was queried what PPE staff wore with her care, she said they always wear gloves. R65 was asked if staff wore gowns, she said no they do not. When asked specifically about wearing PPE with wound care she said honestly, no and further said 'they never wear gowns just gloves'. On 04/28/2026 at 3:30 PM, During an interview Nurse G was asked to review PPE for residents in EBP, Nurse G said that residents in EBP required gloves and gowns to be worn with any care provided. Nurse G said PPE is not required to answer a call light, pass a drink or tray. Nurse G was asked if activities of daily living (ADL's) such as personal care, bathing and toileting/brief changing required PPE, she said yes, it does. Review of the facility's policy, Enhanced Barrier Precautions (EBP) last revised 1/28/26, the policies definition of EBP was refer to an infection control prevention designed to reduce transmission of multi-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .1a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions;1b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions;2b. An order for enhanced barrier precautions will be obtained for all residents with any of the following: i. Wounds (e.g., chronic wounds such as. unhealed surgical wounds.); 3a. note: face protection may also be needed if performing activity with risk of splash or spray. 3b. PPE for enhanced barrier precautions is only necessary when performing high contact care activities.; 4High contact care activities include a. Dressing, b. Bathing, d. Providing hygiene, e. changing linens, f. changing briefs.; 7. Enhanced Berry precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: On 04/27/2026 at 9:27 AM, during the initial kitchen tour with Director of Dining Services L, observed the drain line to the ice machine sitting inside the drain. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 04/27/2026 at 9:54am observed the interior walls of the microwave visibly soiled in the one east kitchenette. During this observation, Director of Dining Services L was interviewed on how often the microwave is cleaned, and he stated it's cleaned after every use. On 04/27/2026 at 10:00am observed the interior wall of oven door visibly soiled with grease in the one west kitchenette. During this observation, Director of Dining Services L was interviewed on how often the oven is cleaned, and he said he wasn't sure, but he thinks it's cleaned monthly. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.On 04/27/2026 at 12:04pm during lunch observation in two west kitchenette, observed [NAME] M wash hands and then proceeded to touch the trash can lid with their bare hand to throw paper towel away and continued to prepare food without rewashing hands. According to the FDA 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and .After engaging in other activities that contaminate the hands.On 04/27/2026 at 12:25pm temped shredded lettuce at 49 F, sour cream at 45 F, and shredded cheese at 48 F sitting in cold well, using a thermometer probe. During this observation, Director of Dining Services L was interviewed on what temperature food should be cold holding, and he stated 41 F. In addition, Director of Dining Services L was interviewed whether cold foods are temped before lunch service once it arrives at the kitchenette, and he stated he thought cold foods were temped at the kitchenette, but he could not find the cold holding temperatures in the temperature book at the kitchenette. According to the facility's policy on cold holding, Foods should be held cold for service at a temperature of 41 F or less.According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.

Based on observation, interview and record review, the facility failed to ensure that timely care was provided in a dignified manor to 3 of 3 residents reviewed for dignity (Residents R4, R10 and R45).Findings include: A review of R4's medical record revealed an admission into the facility on 2/20/24 and re-admission on [DATE] with diagnoses that included paraplegia, muscle weakness and open wound of scrotum and testes. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 10/15 that indicated moderately impaired cognition and the Resident was dependent on helper for personal hygiene and toileting hygiene and needed substantial/maximal assistance to roll left and right. On 4/29/26 at 9:20 AM, an observation was made of the Resident lying in bed. CNA R had the Resident positioned flat on his back with covers off, gown pulled up, and incontinence brief opened. The CNA was assisting with perineal care. The Resident's bed was elevated to about window height. There was a large window and the Resident's bed was positioned in front of the window with enough space for staff to be on that side of the bed. The CNA was on the other side of the bed while performing peri-care. The Resident's shade was not pulled down to provide privacy. Nurse E came in to perform wound care on the Resident's buttock area and scrotal area. The Resident was turned back and forth in bed to remove the brief and cleanse the resident. The CNA turned the Resident towards her with the Resident's buttock exposed towards the window side and the Nurse performed wound care. During wound care, the Nurse was asked by the surveyor to pull the shade to provide privacy for the Resident. The shade was pulled down over some Resident items on the window area. Outside the window was a paved walk/driveway, grassy area and houses past the grassy area. After wound care and perineal care, the Resident was covered. The CNA was asked about providing privacy during personal care. The CNA reported that usually the Resident's curtain/shade was pulled down because he didn't like the bright light. The CNA reported she did not notice the shade was up and reported it should be down when providing care. A review of the facility policy titled Resident Rights, revealed, . 7. Privacy and confidentiality- You have a right to personal privacy and confidentiality. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care. A review of Resident #10's Face sheet and Minimum Data Set (MDS) assessment indicated R10 was admitted to the facility on [DATE] with diagnoses: spastic hemiplegia affecting right dominant side, dementia, muscle weakness, lack of coordination, contracture of the right hand, unsteadiness on feet, diabetes mellitus type 2 (DM) , [NAME]-[NAME] syndrome (abnormal fusion of neck vertebrae), stage 4 chronic kidney disease (CKD), gastro-esophageal reflux disease (GERD), bipolar disorder, depression and anxiety. The MDS assessment dated [DATE] indicated that the resident had severely impaired cognitive abilities and needed assistance with care. On 04/27/2026 at 3:14PM, An observation of R10 resting in bed with eyes closed lying on right side, bed in low position to the floor, touch call light pad was hung over the top of the head of the bed and out of reach of resident and unable to be triggered by movement of the resident. On 04/27/2026 at 3:17PM, During an interview with CNA I she was asked to observe the location of R10's touch call and light location. CNA I verified the touch call light pad was hanging over the top of the head of the bed said 'it is usually in the middle of his bed so he can reach it' she confirmed that R10 was unable to reach the touch call light pad and then CNA I placed the touch call light pad on R10's bed. Review of R10's care plan revealed, Focus: ADL's: I need assistance with my care including bathing, shaving, and dressing r/t (related to) having impaired mobility, cognitive & communication deficits, contractures in right hand (thumb, 3rd & 4th fingers), muscle spasticity, balance impairments. with Interventions: BATHING: I am mainly dependent upon staff for bathing needs; DRESSING: Staff chooses my clothing. I need max to total assist with dressing; PERSONAL HYGIENE: I am mainly dependent upon staff for personal hygiene. Focus: FALLS/Safety: I am at risk for falls r/t confusion and impulsiveness. with Intervention: Staff to provide resident with the following safety interventions: Floor bed in lowest position when in bed; safety mat along left side of bed when in bed; touch pad call light; keep right side of bed up against wall.According to a record review of R65's daily care plan (kept in residents' room) revealed: Safety . Touch pad call light. During an observation on 04/28/2026 at 9:30AM, R10 was resting in bed on his right side facing the wall, bed in low position to the floor, touch call light pad is laying at the far left side of bed away from the residents reach, light and controller was hung on the head board of the bed away from resident reach. During an interview with R10, he stated he was cold and wanted a blanket and the light turned on, when he was requested to trigger his touch call light pad he said he was un able to reach it, he was not able to trigger the call light as he rolled over in bed it was out of reach of him. R10 reached up toward the light control on the headboard and was unable to reach the controller to turn on his room light. On 04/28/2026 at 9:39AM, CNA H was asked to observe the location of R10's touch call light pad and light controller. CNA H visualized and confirmed that R10 was unable to trigger the touch call light pad either by movement or purposefully and was unable to reach the light controller that was hung on the top of the headboard to use it. CNA H said 'I think it is in his care plan to lay it behind him so if he rolls it will trigger'. CNA H verified that when R10 rolled to reach for the touch call pad that it was out of reach and R10 did not trigger the touch call light pad when he rolled over because it was out of touch range. CNA H moved the touch call pad within reach of the resident. A review of Resident #45's Face sheet and Minimum Data Set (MDS) assessment indicated R45 was admitted to the facility on [DATE] with diagnoses: atherosclerotic heart disease (ASHD), stage 4 chronic kidney disease (CKD), unsteadiness on feet, muscle weakness, gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD) peripheral vascular disease (PVD), orthostatic hypotension ( low blood pressure upon standing), anxiety and depression. The MDS assessment dated [DATE] indicated the resident was cognitively intact. On 04/27/2026 at 12:47PM, During an interview with R45 she said she has had to wait up to an hour for a response to her call light. R45 said she needs assistance to get to the restroom and cannot get there on her own. R45 said she had a kidney disease and that she took medications that increased her urine output, she said that she had refused to take the medication (clarified as Lasix with her) a few times because she had to wait too long and that she had an accident and wet herself because of the long wait, she said that is not right and it is embarrassed her. On 04/29/2026 at 10:16Am, during a follow up interview with resident she said she had not taken her diuretic in a couple days so she wouldn't wet her pants waiting for help to the rest room. When asked if she discussed why she said she had before with the doctor. R45 said not that by not taking the medication worked out better and stated well, I don't have wet pants. Review of R45's progress notes revealed, Date: 04/20/2026. Type: PA plan of care.The patient does request to have her Lasix dose changed to once daily dosing rather than twice daily due to frequent nighttime urination. Review of R45's Falls care plans revealed the following: Focus: FALL/SAFETY RISK. I am at risk for falls due to fatigue and activity intolerance. I have an abnormal gait and tend to shuffle feet; no longer ambulatory. I have decreased ROM that may contribute to my unsteadiness.I am receiving medications with potential for s/e (side effects) . with Interventions: Sit at edge of bed before rising and rise slowly; may sit edge of bed unsupervised. Focus: CONTINENCE: I am both continent and incontinent of bladder and bowel. I have a dx of obstructive uropathy with Interventions: I am able to use my call light for assist to the bathroom; I transfer to commode with SBA (stand by assist) to moderate assist of 1 at grab bar with staff swapping chairs. May have privacy in bathroom with frequent checks; I wear a pull-up at all times for incontinence protection & prefer to wear a pad in my pull-up; I'm requiring max assistance for completion of my toileting hygiene; Offer to take me to toilet every 2 hours, PRN and per request. Review of the facility's Call light system policy revealed that the facility must ensure adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. and the Procedures: 1) 1. All staff will be educated on the proper use of the resident call light system, including how the system works and ensuring residents have access to the call light; 3) Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed for the resident to utilize the call system; 6) All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Review of the facility's Resident Rights policy revealed Procedures: 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. With residents rights listed as 2. Planning and implementing care: iv. The right to receive the services and/or items included in the plan of care; 4. Respect and dignity- You have a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on interview and record review, the facility failed to ensure advance directives were in place and completed appropriately for one resident (Resident #99) of one resident reviewed for advanced directives.Findings include:Review of the medical record revealed Resident #99's (R99) most recently admitted to the facility on [DATE] with diagnoses that included cerebral infarction, heart disease, heart failure, atrial fibrillation and dysphagia.Further review of the medical record revealed R99 was able to make his own informed medical decisions. Review of the Minimum Data Set assessment dated [DATE] revealed R99 was cognitively intact and was able to make his own medical decisions.Review of R99's Resident Code Status and Specific Treatments form dated 4/16/26 revealed that Do not resuscitate (DNR) was selected, however R99 did not sign the form, rather R99's wife had signed the form.Further review of R99's medical record failed to reveal any type of Durable Power of Attorney (DPOA) for Health Care (HC) documentation.On 4/29/26 at 11:49 AM, an interview was conducted with Social Service Assistant (SS) S regarding Resident 99's advance directive/code status. The SS reviewed Resident 99's medical record and reported he was capable and stated, He is his own decision maker. The Resident's code status documents were reviewed and the SS indicated that the DNR was signed by the Resident's spouse. When asked about DPOA-HC documentation, SS S reported they were waiting for the paperwork from the spouse and indicated a care conference today. The SS stated, We don't have healthcare POA yet. SS S stated that the document signed on 4/17/26 was the new status code upon return when the Resident came back to the facility. When asked if the Resident was his own responsible party, why did the spouse sign the new DNR code status form. SS S stated, He should have signed it, I agree with you. She was not the POA. We don't have the paperwork on that, and he is his own person. The SS was asked if the Resident was involved with the DNR status change. The SS reviewed the medical record and reported there was not documentation from the Nurses who signed as witnesses, and the new code status was completed when the Resident had an episode, and he had returned to the facility on 4/16/26. The SS reported that Nurses were to do the code status on admission as part of the admission packet. The SS reported the Nurse should have the Resident sign or make a note if the Resident wanted the wife to sign instead and document in the medical record. The SS was asked if the Resident was aware of the DNR status. The SS reported visiting with the Resident that Monday morning and reported discussing code status at that time and he was a DNR. On 4/29/26 at 1:10 PM, an interview was conducted with Nurse T and Nurse U who had signed as witnesses for the DNR with the spouse on 4/17/26. Nurse T reported that the Resident was fully aware and that the Resident was competent but was non-verbal. The Nurse reported the spouse, and the Resident agreed of the DNR code status. The Nurse reported that the spouse had signed for the Resident. When asked if the Nurse was given the POA documentation at that time, the Nurse reported she was not given the POA paperwork. The Nurse reported she should have had the Resident sign and it was discussed that if the Resident wanted the spouse to sign, documentation should be made on the documents or in the progress notes. A review of the facility policy titled, Advance Directives, revealed Policy: It is the intent of (Facility name) to support and facilitate a resident's right to request, decline and/or discontinue medical or surgical treatment and to formulate an Advance Directive. Procedures: .3. Upon admission, should the resident have an Advance Directive, the documents will be saved in the resident's chart. 4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities.

Based on observation, interview and record review, the facility failed to ensure peripherally inserted central catheter (PICC) dressing changes were completed timely for one resident (R23) of one reviewed for PICC lines. Findings include:R23 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include infection of a superficial incisional surgical site, acute respiratory failure and atherosclerotic heart disease. On 04/27/2026 at 11:08AM, a peripherally inserted central catheter (PICC) line was observed in the right upper arm of R23. The dressing was dated 4/15/26. On 04/27/2026 at 11:11AM, record review revealed a physician's order dated 03/26/2026 that reads: PICC line dressing change one time a day every Wednesday related to infection following a procedure, superficial incisional surgical site subsequent encounter. On 04/27/2026 at 11:13AM, record review of the April 2026 treatment administration record (TAR) revealed that on 04/22/2026 the dressing change was signed out as not completed by Registered Nurse (RN) C and has a corresponding nurses note. The nurses note from RN C, dated 04/22/2026 at 10:45AM revealed that the dressing change was not completed due to the item (dressing change kit) not being available in the backup system. On 04/27/2026 at 11:16AM, an interview was completed with RN B. RN B confirmed the date on the dressing is 4/15/26. RN B was asked how often PICC line dressings should be changed. RN B stated that the dressings should be changed weekly or as needed if they come off or are soiled. RN B stated, I am not sure how they missed it, it should be done weekly. I will check and see who should've taken care of that. RN B stated that the PICC line is due to be removed this week. On 4/28/2026 at 1:23PM, an interview was conducted with the Director of Nursing (DON). The DON was asked who supplies the dressing change kits for PICC lines. The DON stated that Remedi Pharmacy supplies the PICC line dressing change kits and we also have some in our backup system in the building. The DON stated, we don't have a lot in backup, so if multiple residents need a dressing change on that day, we could've run out. On 04/28/2026 at 1:25PM, an interview was conducted with RN C. RN C was asked why the dressing change was not completed on 04/22/2026. RN C stated, I didn't have the supplies available to do it. RN C was asked if they attempted to access the backup system to get a dressing change kit. RN C stated, yes, I tried, but it was out supplies. The pharmacy did not send the supplies either. Review of the facility policy titled, Catheter Insertion and Care, revealed: General Guidelines:4b. Change the TSM dressing on CVAD's and midlines every 5-7 days, when site is rotated, if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled) and/or upon suspected contamination.

Based on interview and record review the facility failed to provide clinical rationale for administration of duplicate/triplicate antidepressant therapy of two (#6 & #55) residents of six reviewed for unnecessary medications.Findings Include:Resident #6On 4/28/2026 at approximately 1:00 PM, a review was completed of Resident #6's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Alzheimer's Disease, Major Depressive Disorder, Insomnia and Generalized Anxiety Disorder. Further review of Resident #6's chart yielded the following:Physician Orders:Escitalopram (Lexapro) Oxalate Oral Tablet 20 MG (milligrams) for Major Depressive Disorder.Trazadone HCI (hydrochloride) Oral Tablet 50 MG for Major Depressive DisorderLexapro and Trazadone are both antidepressants.Care Plan: .admitted with diagnoses of Deprssion, Anxiety, Panic Disorder and insomnia in addition to Dementia. administer medications as prescribed.psychotropic medication management provided by (psychiatric group) . Review was conducted of Resident #6's nursing, physician and psychiatric progress notes were conducted and there was no documentation located regarding Resident #6 usage of dual antidepressant therapy. Resident #55On 4/28/2026 at approximately 1:30 PM, a review was conducted of Resident #55's record and it revealed she admitted to the facility on [DATE] with diagnoses that included, Major Depressive Disorder, Mood Disorder and Anxiety. Further review yielded the following: Physician Orders:Escitalopram (Lexapro) Tab (tablet) 10 mg for Major Depressive DisorderTrazadone Tab 50 MG for Major Depressive DisorderDoxepin HCL Cap (capsule) 10 MG for Major Depressive DisorderLexapro, Doxepin and Trazadone are all antidepressant medications. Care Plan: .I have a dx (diagnosis) of.mood disturbance, insomnia and anxiety. I also have a dx of depression, anxiety, and visual hallucinations.psychotropic medication management provided by (psychiatric group) and the Behavior Wellness Committee to ensure appropriate dosage is given. Review was conducted of Resident #55's nursing, physician and psychiatric progress notes were conducted and there was no documentation located regarding Resident #55's usage of three antidepressants. On 4/28/2026 at 2:00 PM, an interview was conducted with Social Work Director Q who shared Resident #6 is prescribed two antidepressants and Resident #55 is prescribed three antidepressants due to their diagnosis of Major Depressive Disorder. Both residents are currently stable on their current medication regime, and their psychiatric provider is aware of their antidepressant medication orders. Social Worker Q was asked to provide the documentation (regarding the clinical rationale) and upon returning she explained that per their psychiatric practitioner their old charting system would denote the rationale but in the new system it did not. There was no clinical rationale for Resident #6's duplicate medication therapy and Resident #55's triplicate medication therapy. Review was conducted of the facility policy entitled, Psychotropic Medication Use, Revised 4/24/24. The policy did not address duplicate therapy.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed out weekly and nebulizers were stored properly for two residents (R2 and R75) of five residents reviewed for respiratory care. Findings include: Review of the medical record revealed that Resident #2 (R2) was [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure, heart failure and tachycardia. During an observation on 04/27/2026 at 12:39PM, R2's oxygen tubing was dated 4/20/26 and there was a nebulizer in a bag, hanging on the wall next to the bed. The nebulizer equipment was stored together, and moisture was noted in the medication reservoir. During an observation on 04/28/2026 at 1:10PM, R2's nebulizer was found hanging on the wall in a bag, was dated 4/20/26 and the oxygen tubing was dated 4/20/26. During an interview on 04/28/2026 at 1:18PM, Assistant Director of Nursing (ADON) was asked how often the oxygen tubing is changed out. The ADON stated that the oxygen tubing is changed every 7 days. The ADON was asked what the process is for storing and cleaning nebulizers after a treatment. The ADON stated, after each use the nurses take it apart, rinse it and then either goes on a paper towel to dry or they dry it and place it on the wall in a bag. The ADON was made aware of the findings related to dating oxygen tubing and the storage of a nebulizer for R2. Review of the policy titled, Oxygen Administration, revealed: Care and Maintenance: -All tubing will be changed on a weekly basis labeled with the date, time and nurses initials. Review of the policy titled, Nebulizer/Aerosol Treatments, revealed: Procedure: 15. Disassemble equipment: -Discard left over medication. -Rinse cup with sterile saline. -Place equipment in wiki bag. -Wipe Pulmo-Aide machine with a cleaning disinfectant when visibly soiled, upon completion of treatment, and at the end of each shift. A review of R75's medical record revealed an admission into the facility on 4/23/25 and readmission on [DATE] with diagnoses that included heart failure, acute respiratory failure with hypoxia, chronic respiratory failure with hypercapnia and chronic obstructive pulmonary disease. During an interview and observation on 4/27/26 at 11:52 AM, R75 answered questions and engaged in conversation. An observation was made of a nebulizer with a mask on the bedside table. The Resident reported getting breathing treatments a couple times a day and indicated he had one earlier in the morning. The nebulizer was stored on the bedside table, assembled and moisture was observed in the medication chamber. On 4/28/26 at 2:56 PM, an observation was made in R75's room of the nebulizer equipment assembled and laying on the bedside table. An observation was made of moisture in the medication chamber. On 4/28/26 at 3:12 PM, an interview was conducted with the Director of Nursing (DON) regarding storage of nebulizer equipment. An observation was made with the DON of R75's nebulizer assembled and positioned on the bedside table. When asked about facility policy of storage of nebulizers after use, the DON reported the nebulizer equipment should be disassembled, rinse out the cup (medication chamber), let dry or place in a special bag that lets it air dry. A review of R75's medication administration record revealed the Resident was ordered Ipratropium-Albuterol inhalation, 1 dose inhale via nebulizer three times a day related to chronic respiratory failure with hypercapnia, scheduled at 9:00 AM, 2:00 PM, and 8:00 PM. The MAR was documented as received in the morning on 4/27, not administered at 2:00 PM, received the evening dose on 4/27, received the morning dose on 4/28 but not the afternoon dose or evening dose.

This citation pertains to Intake Numbers 2716028, 2716054 and 2723179.Based on observation, interview and record review, the facility failed to ensure that staff followed 2 resident's (Resident #101 and Resident #104) plans of care for safe transfers of 5 residents reviewed, resulting in falls with a fracture, and a head injury, with hospitalization.Findings Include: Resident #101:Review of the Face Sheet, physician orders and care plans dated 9/2018 through current, revealed Resident #101 was 88 years-old, admitted to the facility on [DATE], had cognitive impairment, required assistance with all Activities of daily Living/ADL's and was a two person assist for all transfers. The residents diagnosis included, Vascular Dementia with behaviors, Stroke with Hemiplegia and weakness of the right side, and Heart Disease. Review of the facility Accident/Incident report dated 12/27/25, revealed on on 12/27/25 at 5:15 a.m., Nursing Assistant/CNA I was assisting the resident to bed by her self. CNA I lifted the resident up from the wheelchair, and she started screaming, CNA I immediately sat her on the bed. The nurse assessed the resident and no pertinent signs of injury were noted. At the next shift, she was assessed again due to complaints of right knee pain, with bruising and slight swelling noted; the resident was transferred to the hospital for evaluation. The resident returned to the facility with a non-displaced fracture of the right Fibula. CNA I was interviewed and said she had not followed the residents plan of care, she lifted her herself. CNA I was terminated by the facility and all staff were re-educated on the importance of following resident's plan of care.Review of the facility care plan dated 12/18/25, revealed Resident #101 was a transfer: 2 assist. CNA I revealed in the facility investigation, that she transferred the resident by her self on 12/27/25, when she started screaming and said her right knee hurt. CNA I was not at the facility during the investigation; this survey was unable to contact the CNA for an interview per phone.Review of the x-ray dated 12/27/25, revealed a non-displaced fractured of the right Fibula.Review of the facility Employment Termination Notice dated 12/29/25, revealed CNA I had been sent home on [DATE], pending investigation and terminated on 12/29/25, due to not following the residents care plan-neglect.Observation and interview was done on 1/22/26 at 3:15 p.m., the resident was in bed with Family member E sitting next to her. When asked about pain, the resident denied having any pain. The resident was unable to tell what happened on 12/27/25, she did not recall the incident. During an interview with family member E, he revealed he loved the facility, and did not want the resident to go anywhere else; he said he was not up-set with the facility, things happen.Review of the facility Accident/Incident report dated 12/27/25, revealed the residents leg brace got caught on her wheelchair and she was unable to turn, resulting in a fracture. Nursing Assistant I was terminated, staff were educated on following resident's plan of care and the incident was reviewed by the facility Improvement Committee.Resident #104:Review of the face Sheet, Incident/Accident Report dated 12/25/25, and care plans up-dated 12/25, revealed Resident #104 was 75 years-old, admitted to the facility on [DATE], required total assist with all ADL's, was non-ambulatory, bed bound, and required a mechanical lift for all transfers. The residents diagnosis included, Alzheimer's Disease, weakness, contractures of elbows, knees and left hand, Dementia with severe mood disturbance, Anxiety and failure to thrive. The resident received Hospice services prior and post incident (on 12/25/25).Review of the residents care plan dated 12/25, revealed she was a mechanical lift with 2 person assist.Review of the manufactured guidelines for the mechanical lift used with the resident of concern stated There are circumstances, such as combativeness, obesity, contracture (the resident had contractures) of the individual that may dictate the need for a two-person transfer (2 staff used with the transfer using the lift).Review of the facility Incident/Accident report dated 12/25/25, revealed on 12/2525, CNA A put the resident from the wheelchair to her bed using the lift. CNA A transferred the resident with one assist only, put her to bed, left the room to take the lift out and returned to find the resident on the floor, with a laceration above her left eyebrow. CNA A then lifted the resident up and put her to bed; then informed the nurse of her fall.During an interview done on 1/22/26 at 1:34 p.m., Nurse, LPN C stated He (CNA A) stated he needed me in the room ASAP. She was bleeding on her head, she was in her bed. There was blood on the floor. He did not look at the care plan (x2 assist for transfers). I called the other nurse, we called 911, put ice on her head, did a sugar test, she was in the same state as before (prior to fall); she was sent to the hospital.During an interview done on 1/22/26 at 9:00 a.m., the Administrator and Director of Nursing said CNA A did not follow the residents care plan, he was terminated.During an interview done on 1/22/26 at approximately 12:10 p.m., Human Recourses/HR stated yes, he was terminated (CNA A) for neglect. During a phone interview done on 1/22/26 at 3:32 p.m., CNA A stated When I took her (Resident #104) off the lift, she was on the bed, more towards the side, towards you. I took the lift out of the room, came back and she was on the floor. Her head was bleeding; I panicked and I put her on the bed, I couldn't stand to see her on the floor. I got the nurse and she looked at her. I should of had another CNA with me for the transfer, we all transfer like that. She does not move, her body shifts, that's probably how she feel off. I did not look at her care plan that day; yes, I did get terminated.Review of the facility Employee Counseling Form dated 12/26/25, revealed CNA A was terminated due to neglect of a resident and not following procedures procedures (2 person assist with mechanical lift for all transfers).Review of the residents Hospital records dated 12/25/25, stated No intraventricular hemorrhage, subdural hemorrhage. The hospital records revealed there was not a significant brain bleed.Review of the Hospital chest and pelvic X-ray dated 12/25/25, revealed no active findings.During an interview done on 1/22/26 at 3:00 p.m., Medical Director, MD F stated The bleed (brain bleed) was not significant, I don't think the bleed would have caused her (Resident #104) death.Review of Resident #104's Medical Certificate of Death dated 12/29/25, listed the cause of the residents death as Alzheimer's Disease and the manner of death was natural.

This Citation Pertains to Intake 2660956.Based on interview and record review, the facility failed to protect the one (#701) resident's right to be free from sexual abuse by another resident of three residents reviewed resulting in a non-verbal, severely cognitively impaired resident (#701) having their genital area touched by Resident #702, and staff not immediately separating the residents. Findings include:Review of Facility Reported Incident (FRI) documentation revealed on 10/12/25 at approximately 11:37 AM, the Administrator was informed of allegation of sexual abuse involving Resident #701 and Resident #702. Per the FRI, Resident #702 is Resident #701's father and was witnessed by staff with their placed on (Resident #701's) groin region. An interview was conducted with the Director of Nursing (DON) on 1218/25 at 10:00 AM. During the interview the DON verbalized the facility switched Electronic Medical Record (EMR) system from Matrix to Point Click Care (PCC) on 10/1/25. Review of facility provided investigation documentation related to the FRI included the following: - Five Day Investigative Summary of Incident which included a recapitulation of resident information, staff statements, resident interviews, and actions taken by the facility including implementation of a 1:1 staff member for Resident #702, Resident #701 moving rooms to a different unit of the facility and follow up review/monitoring by the facilities Quality Assurance and Performance Improvement (QAPI) Committee. - Memo to Nursing Staff re: All Staff dated 10/13/25. The Memo was entitled, Immediate Action Required for Inappropriate Resident Contact and specified, If any staff member observes a resident attempting to inappropriately touch another resident, it is critical that the following steps are taken immediately: 1. Intervene and separate the residents without delay. 2. Ensure the safety and dignity of both individuals. 3. Stay with the resident(s) involved until a supervisor or appropriate clinical team member can assess the situation and determine next steps. 4. Document the incident thoroughly and report it according to facility protocol. - Copy of email documentation from the DON to facility staff dated 10/13/25 at 2:02 PM which detailed, (Resident #702) IS NOW a 1:1 INDEFINATELY. I want the 1:1 to stay far pay and just make sure he is not going into other rooms or touching any other residents inappropriately. (Resident #701) did move rooms. WE DO NOT want (Resident #702) brought up to see (Resident #701). If (Resident #702) wants to see (Resident #702) then she will have to come to. dining room and not his room and the 1:1 stays the whole time. - Documentation of staff education/training with signed Staff In-Service/Meeting sign-in sheets and Sign-In Sheets pertaining to the memo, email communication, and facility protocol for abuse were included. - Interview forms with other residents on the unit with the questions, Do you feel safe here? and Have you ever had an interaction with another resident that made you feel unsafe? - Written, signed statement from Certified Nursing Assistant (CNA) A dated 10/12/25. The statement detailed, I (CNA A) saw (Resident #702) rubbing his daughter (Resident #701's) private area. Once I was seen coming, he removed his hand. I reported to the nurse who then went to approach him and was seen with his hands on (Resident #701's) private area and quickly moved his hand. - Written, signed statement from Registered Nurse (RN) C dated 10/12/25. The statement specified, At approximately 11:30, I was made known by (CNA A) that (Resident #702) was inappropriately touching his daughter (Resident #701) in the groin area. As (Resident #702) saw me coming closer, he pulled his left hand back. I then confronted him asking if he was just touching (Resident #701) to which he responded, 'That's my daughter.' (Resident #702) then self-propelled to the back of the dining room to look out the window. (Resident #701) was then transported to her room for a skin assessment. On 12/18/25 at 12:00 PM, Resident #701 was observed in the dining/central room area of the unit. The Resident was reclined in a Broda chair (specialized, highly adjustable wheeled chair with solid leg rests and increased upper body support for positioning). Resident #701 did not respond verbally when spoke to and did not make eye contact. An interview was completed with Licensed Practical Nurse (LPN) B on 12/18/25 at 12:02 PM. When queried regarding communication with Resident #701, LPN B stated, Never heard (Resident #701) talk. When asked if the Resident responds non-verbally to communication, LPN B responded the Resident has made eye contact when I feed them. LPN B was then asked if Resident #702 comes to the unit to see Resident #701 and revealed they had not seen Resident #702 come to see Resident #701. LPN B continued, It was requested that we would take (Resident #701) down there (unit where Resident #702 resides) to visit for the first week or so. When queried, LPN B revealed they were aware of the incident that occurred involving Resident #'s 701 and 702 but did not observe anything themselves. Record review revealed Resident #701 was originally admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury (TBI), polyneuropathy (condition affecting nerves causing weakness and pain), intellectual disabilities, left leg contractures, mood disorder, and generalized anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and dependent upon staff for all Activities of Daily Living (ADLs). Review of Resident #701's Electronic Medical Record (EMR) revealed the following: - 8/4/25 at 2:31 PM: Social services quarterly assessment. non-verbal and is unable to communicate her needs. is unable to make herself understood and is unable to understand others. alert to self only. (Resident #701's dad (Resident #702) is also a resident at the facility and does visit with her. There is some risk for resident incidents in public areas. If another resident were to approach her, she would be able to defend herself if needed though she may or may not do so. Not proceeding to care plan to address risk though will continue to monitor. - 10/12/25 at 12:00 PM: Nurses Note Late Entry. Res was observed at 11:30 by CNA in the dining room to have been touched near the groin over her clothing by (Resident #702). Res was immediately taken to her room where a skin assessment was completed. No abnormal findings were discovered. Res with no outward signs of fear or agitation at this time. - 10/12/25 at 12:50 PM: Nurses Note Late Entry. has been removed from her room at this time and is being placed in (different room on different floor of facility). - 10/13/25 at 2:53 PM: Health Care Provider (HCP) Consult Notes. Late Entry. Reason for Encounter/Chief Complaint: Acute visit for an event that occurred between the resident and another resident in the dining area. (Resident #701) is a long term care resident with chronic conditions including but not limited to intellectual disability who was noted by a CNA to be touched near the groin over her clothing by another resident while sitting in the dining area. resident was noted to not have any signs of fear or agitation. Resident was subsequently moved to a room on a different floor. On 12/18/25 at 11:50 AM, Resident #702 was not present in their room. The Resident had a private room. At 11:55 AM on 12/18/25, Resident #702 was observed in the dining room, sitting in a wheelchair. An interview was completed at this time. Resident #702 was very hard of hearing and indicated they could not hear all questions asked. Review of Resident #702's medical record revealed the Resident was originally admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, heart disease, dementia with mood disturbance, agitation, anxiety, and psychotic disturbance. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired, displayed verbal behaviors towards others one to three days, and required substantial/maximum assistance with bathing, transfers and hygiene, and supervision/touching assistance with ambulation up to 50 feet. Review of Resident #702's EMR revealed the Resident had a history of inappropriate sexual behaviors towards other residents and staff. A care plan was present in the prior EMR (Matrix) entitled, Mood/Behavior: I have diagnoses of major depressive disorder. generalized anxiety. Dementia. with psychotic disturbance. mood disturbance. I lack insight & impulse control due to my dementia. I have made inappropriate sexual comments towards staff & also attempt to inappropriately touch staff/other residents.I have also occasionally wandered into other resident rooms uninvited. I also exhibit delusional thinking. I am at risk for resident incidents due to my behaviors; my lack of insight and impulse control. (Start Date: 2/11/21). The care plan was carried over into PCC on 9/25/25 with minor changes.The care plan included the interventions:- Do not place me near female residents (Start Date: 9/14/22; Created in PCC: 9/25/25)- Encourage structured activity that is supervised to minimize the time that I am alone with others (Start Date: 12/1/21; Created in PCC: 9/25/25)- Observe me closely when I am in resident occupied areas (Start Date: 12/1/21; Created in PCC: 9/25/25)- Remove me from the area if become inappropriate (Start Date: 12/1/21; Created in PCC: 9/25/25)- Let me know that my behavior is affecting others or that I am being inappropriate (Created in PCC: 9/25/25)- Do not leave me unsupervised in public areas (Start Date: 12/1/21; Not carried over to PCC) The care plan was modified in PCC on 10/13/25 and I am currently under 1:1 supervision while awake was added. Review of documentation in Resident #702's EMRs revealed the following: - 6/22/25 at 10:53 AM: Nursing. Resident in dining room stating to staff that he is looking for a piece of ass. Prior to that staff mentioned that he was propelling up and down the hallway looking into residents' rooms. Staff asked him what he was doing, he stated that he is looking for a piece of ass. - 6/22/25 at 10:56 AM: Nursing. Resident was heard in hallway making sexual comments and requesting sexual favors from housekeeper. Housekeeper redirected resident. Resident is visiting in dining room with other residents - 08/25/25 at 8:01 AM: Social services quarterly assessment. alert and oriented to self, family, and location of room. will occasionally hallucinate; see's people going in and out of other's rooms when there is no one there. does not have a mental health diagnosis. can be pleasant and cooperative with staff though at times he does become angry and will yell. does have a hx (history) of occasionally making sexually inappropriate comments, has at times been overly friendly towards females, and wander into other resident's rooms. Close supervision is provided. while he is up as a precautionary measure. can be seen propelling his wheelchair through the halls and visiting with other residents and staff. assessed to be at moderate risk for a resident-to-resident incident at this time. can become aggressive or combative. does have delusional thinking or hallucinations. has wandered into other resident's rooms and could be at an increased risk of a resident-to-resident incident. - 10/12/25 at 1:25 PM: Nurses Note Late Entry. nurse called resident's daughter (Durable Power of Attorney- DPOA) at this time to made aware of incident. (DPOA) voiced understanding of the situation. - 10/15/25 at 5:33 PM: Nurses Note. Late Entry: Resident has attempted to go in and out of other resident rooms this shift. - 10/18/25 at 11:36 AM: Nurses Note. remains with 1:1 supervision. He did make one attempt to wander into another resident room . - 10/21/25 at 2:23 PM: Social Services. On 10/12/25 at approximately 11:30am (Registered Nurse [RN] C) was made aware by Certified Nursing Assistant (CNA) A that (Resident #702) was inappropriately touching his daughter (Resident #701) in the groin. As (Resident #702) saw RN coming close he pulled his left hand back. RN confronted (Resident #702) asking him if he was just touching (Resident #701) to which he responded, 'That's my daughter'. (Resident #702) then self-propelled to the back of the dining room to look out the window. (Resident #701) was then transported back to her room for a skin assessment. SS spoke with (Resident #702) about accusations which he responded with 'I wouldn't do that; that's my daughter'. (Resident #702) immediately had a 1:1 staff put with him while up. (Resident #701) had a room change to a different unit within the facility. Record review further revealed Resident #701 and Resident #702 had the same person, family member D as their designated legal decision maker. On 12/18/25 at 3:00 PM an interview was completed with the DON. When queried regarding Resident #702's history of inappropriate sexual behaviors, the DON stated, History of saying things but never acted on it. When queried regarding Resident #702's care plan interventions, including not being placed near female residents, the DON indicated the intervention was a precaution. When asked what occurred, the DON revealed CNA A saw Resident #702's touching Resident #701's groin area and immediately went to get RN C. The Residents were separated, Resident #701 was assessed, and Resident #702 was placed on a 1:1 staff member. When queried regarding Resident #701, the DON stated they were always impaired and does not talk. The DON stated they were informed by a staff member that Resident #701's arm went up when Resident #702 touched them like stop. When asked if there was a history of Resident #702 sexually abusing Resident #702, the DON stated, (Family Member D) denied a history of abuse. The DON continued, We think it is something that happened for a long time at home. No way to know. When asked why Resident #701 was moved rooms/units and not Resident #702, the DON revealed Family Member D thought that would be best as they were both Resident's legal decision maker. When asked to clarify if Resident #701 and Resident #702 were not immediately separated by CNA A when they first observed the inappropriate behavior, the DON confirmed and verbalized that was part of the education provided. At 4:00 PM on 12/18/25, an interview was completed with Social Worker (SW) E. When queried regarding Resident #702's behavior, SW E stated, He likes to hang out by the nurses' station, he is social. When queried regarding wandering in and out of other resident rooms, SW E replied, Never seen going in and out of other rooms. When queried regarding sexual behaviors, SW E responded that Resident #702's sexual behaviors were verbal comments. With further inquiry regarding who Resident #702 made sexual comments to, SW E replied, Not to other residents that I know of. Social Services quarterly assessment documentation they wrote which specified Resident #702 had been overly friendly towards females and wander into other resident's rooms was reviewed with SW E at this time. When asked why they said Resident #702 did not wander into other resident rooms when they documented the Resident did, SW E responded they were told by facility staff but had not witnessed it themselves. When queried if they spoke to and assessed Resident #'s 701 and 702 following the incident, SW E verbalized Resident #701 is nonverbal and stated, I followed up. SW E then stated, I talked to (Resident #701) about it. SW E was queried regarding Resident #702's response and responded that Resident #702 got very agitated. SW E verbalized Resident #702 said they would never do anything like that and that Resident #701 is their daughter. When queried if Resident #702 was aware they were observed inappropriately touching Resident #701 by facility staff, SW E did not provide further explanation. An interview was conducted with CNA F on 12/18/25 at 4:10 PM. When queried regarding Resident #702, CNA F stated, He is very particular but did not provide further explanation. CNA F was asked about Resident #702 spending time with Resident #701 and stated, He would go visit his daughter. When asked if they had observed any inappropriate or strange behaviors from Resident #702 towards Resident #701, CNA F responded that Resident #702 would occasionally call Resident #701 by a different name. CNA F was asked if they ever observed Resident #702 touching Resident #701 and replied, He would tap (Resident #701) and hold her hand. CNA F verbalized Resident #702 would say, Come on honey, lets go to bed to Resident #701. When queried regarding Resident #702's inappropriate sexual behaviors, CNA F stated, He would say stuff (sexual) but never seen him act out. An interview was completed with RN C on 12/18/25 at 4:33 PM. When queried if they recalled an incident on 10/12/25 involving Resident #701 and Resident #702, RN C verbalized they did. When asked what happened, RN C stated, It was (CNA A) who saw it, and I went over. RN C was asked what happened when they went over and replied, (Resident #702) was quick to pull his hand back and went back to the dining room like he was Mr. innocent. When asked where Resident #702 was touching Resident #701, RN C revealed he was touching her in the groin area, above her clothes. When queried if they thought Resident #702 knew what they were doing, RN C stated, I did, yeah. RN C elaborated that Resident #702 pulled his hand away from Resident #701's private area quickly and then hurriedly wheeled themselves to the dining room. When queried if they asked Resident #702 what they were doing, RN C responded they did and stated Resident #702 said That's my daughter, I would never do that in a defensive tone. When asked, RN C revealed the Residents were seated in the dining/common room area of the unit. When queried if Resident #702 displayed sexually inappropriate behaviors prior to this incident, RN C verbalized they had. When asked what behaviors they had observed, RN C revealed it was primarily sexual requests and verbalizations. When queried if they had observed Resident #702 displaying sexually inappropriate behaviors, RN C verbalized they had and revealed the Resident had said things to them such as Get into bed with me in a sexual way. RN C was asked if they observed Resident #702 touching Resident #701 inappropriately prior to this incident and indicated they had not. When asked if Resident #702 was often alone with Resident #701, RN C replied, (Resident #701) would lay down between meals and (Resident #702) would peak in their room. When queried regarding Resident #701's reaction to Resident #702 touching them, RN C stated, Didn't seem to know what was happening. On 12/19/25 at 9:25 AM, an interview was completed with CNA A. When queried regarding the incident involving Resident #'s 701 and 702 on 10/12/25, CNA A stated, They were sitting in the dining room and (Resident #702) had his hand on (Resident #701's) leg and was rubbing it. CNA A stated Resident #701 was looking around and acting suspicious and then moved his hand down. CNA A was asked where on Resident #701's leg Resident #702 was rubbing and replied, Thigh. CNA A elaborated that Resident #701's leg is contracted and bent up. CNA A continued, The (Resident #702) moved his hand to (Resident #701's) crotch area and patted it. He felt it. When asked what patted it meant, CNA A stated, Like rubbed and caressed it. When asked what they did, CNA A stated, I went and got the nurse. CNA A was asked if Resident #702 was still looking around and acting suspicious when they were touching Resident #701's crotch area and replied, Yeah. When queried why they went to get the nurse instead of immediately separating the residents, CNA A indicated Resident #702 would move his hand back if they got close. When queried where Resident #701 and Resident #702 were, CNA A revealed they were sitting in the dining room. When asked where the nurse was, CNA A responded, At the nurses' station. CNA A was asked what they told the nurse and stated, I said (Resident #702) is rubbing down (Resident #701's) leg to her privates. When asked what the nurse did, CNA A revealed RN C went right to where the Residents were sitting. CNA A indicated they went with RN C and stated, (Resident #702) was still doing it and then pulled his hand away. CNA A continued, (Resident #702) said that's my daughter and I'm not doing anything in a very defensive tone. When asked if Resident #702 used that tone when they said they were not doing anything, CNA A replied, Yeah. When asked if Resident #702 had sat with Resident #701 and acted in a suspicious manner before, CNA A replied, Yeah I was with him 1:1 before and got to know him. When asked why Resident #702 had a 1:1 staff member before, CNA A stated, For the same thing, he touched his daughter (Resident #701). CNA A was asked when that happened and replied, Probably last year. CNA A revealed they were informed Resident #702 had their hand inside of (Resident #701's) brief that time. When queried if they had observed Resident #702 act in the same suspicious manner prior to the incident on 10/12/25, CNA A replied, Yes, when he gets in those moods and will act that way towards staff as well. CNA A was asked what they meant and stated, (Resident #702) gets that way and will say let's go to my room and ask for sex. When queried if they were saying Resident #702 would act suspicious prior to making sexual comments/requests, CNA A replied, Yeah. CNA A was asked if they thought Resident #702 was aware of his actions when he was touching Resident #702's private area and stated, He knew. An interview was conducted with the facility Administrator and DON on 12/19/25 at 10:30 AM. When queried if there was a prior sexual abuse incident involving Resident #701 and Resident #702, the DON stated, Not that I am aware of. The Administrator and DON were informed CNA A stated Resident #702 had previously been a 1:1 with staff due to inappropriately touching Resident #701 in sexual manner previously. The DON stated, I did not know anything about that. The Administrator then stated, At one point we had incidence where someone thought they saw something. When asked what they saw, the Administrator revealed a staff member had made an allegation that they observed Resident #702 in Resident #701's room with their hand under their blanket and touching Resident #701's genital area. The Administrator stated, We did and investigation and assessments. We were not able to verify that anything occurred and Resident #702 was on a 1:1 at that time. When asked if the allegation of sexual abuse was reported to the State Agency, the Administrator replied, No because we could not verify it. An Incident and Accident (I and A) report related to the abuse allegation as well as any other allegations were requested. The DON reviewed the EMR and stated, There are no events (I and A) reports. Further review of Resident #702's EMR revealed a Social Services note dated 12/9/24 at 12:00 PM which detailed, On 12/4/24 at approximately 3:15 PM, (RN G) came to Social Services office to inform them (Resident #702) had been seen in (Resident #701's) room by (Staff H). (Staff H) let (RN G) know that while. walking by witnessed (Resident #702) next to the bed of (Resident #701) with the covers lifted and (Resident #702) hand possibly down (Resident #701's) pants or brief. When (Staff H) and (Resident #702) made eye contact, (Resident #702) was like a deer in headlights and immediately stopped and removed hands. 12/4/24 at 4:15 PM Social Services and Administrator interviewed (Staff H). When asked specifically what saw, (Staff H) states 'it was so quick, but when walking by (Resident #701) room I saw (Resident #702) by bed with covers lifted and (Resident #702) had his hand down (Resident #701's) pants or brief. (Resident #702) moved hand right away when he saw me'. 12/4/24 4:30 PM Social Services and Administrator interviewed (Resident #702) Asked the resident if we could talk to him privately in his room to which he agreed. While walking with (Resident #702) down the hall to his room, (Resident #702) made comments to Social Services 'why is he accusing me of touching her like that? She's, my daughter. That's just crazy'. Social Services asked who 'he' was to which (Resident #702) did not answer. Once in (Resident #702's) room he continued to state, 'I wouldn't do something like that'. (Resident #702) continued to say, I came from a family of 12, I was married to a beautiful wife. Social Services asked why he was in (Resident #701's) room to which he responded with 'I was just checking on her for the day to see how she was doing. Resident #702 was asked if he was holding her hand which he responded with 'yes, if I was going to do anything like that, I would at least close the door'. 12/4/24 4:50 PM Social Services and Administrator interviewed (RN G). (RN G) was asked if they had mentioned anything to (Resident #702) about what was witnessed to which (RN G) responded 'no'. (RN G) stated 'was informed by (Staff H that she witnessed (Resident #702) with his hand under the covers of (Resident #701) and possibly seeing (Resident #702) hand down (Resident #701) pants. I locked the cart and went to assess. By the time I arrived in room - (Resident #702) was sitting beside the bed with his hands in his lap. The bed covers of (Resident #701) did not appear in disarray. Spoke with (Resident #702) and asked him to come out to nurses' station which he did with no resistance'. Social Services and Administrator interviewed (CNA I). (CNA I) was not assigned to (Resident #702) today but mentioned that 'on Monday 12/2/24 was going to see (Resident #701) when noticed (Resident #702) in her room and was about to close the door'. She removed (Resident #702) from the room. did not mention this on Monday due to (Resident #702) is the father of (Resident #701) and he often visits her in her room. Social Services and Administrator interviewed (CNA A) . states that 'after incident I was getting (Resident #701) up for dinner and go to dining room. The covers were undisturbed. was wearing a t-shirt and brief. brief was intact/undisturbed'. Skin assessment completed on (Resident #701) . No signs of any apparent trauma or penetration. No noted scratches or markings. (Resident #702) was placed on monitoring for fear and any increase in behaviors. Staff re-education provided regarding resident-to-resident incidents. A follow up interview was conducted with the Social Worker E, DON, and Administrator on 12/19/25 at 11:10 AM. When queried, the DON revealed the allegation occurred on 12/4/25 and verbalized they found a soft file on the incident but did not report because it was unsubstantiated. When queried if the incident had been investigated by the State Agency at any time, the staff indicated it had not and had occurred prior to the facilities' last annual survey. When asked if it should have been reported, due to being an allegation of sexual abuse, an explanation was not provided. The DON stated, We couldn't substantiate anything. The sheets were not disturbed and (Resident #702's) brief was intact. The Administrator added that the staff member who made the allegation was not clinical and indicated they were unable to say what they saw with certainty. The DON revealed the facility increased monitoring of Resident #702 and placed him on a 1:1 for over a month but the 1:1 staff was discontinued when no other concerns were identified. With further inquiry regarding Resident #702's history of inappropriate sexual behavior including the non-reported allegation in December 2024, the staff confirmed Resident #702 had a history of and was monitored for inappropriate sexual behaviors but did not provide further explanation. Review of facility provided policy/procedure entitled, Abuse, Neglect, and Exploitation: (Reviewed: 4/23/25) revealed, It is the policy. to provide protection for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse. All allegations of suspected abuse. must be immediately reported to: -Administrator. - State Survey and Certification agency. Prevention of abuse. I. Assess, monitor, and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included Resident #702 being placed with a 1:1 staff member indefinitely for supervision, Resident #701 being moved to a different unit/area of the facility, staff education/training, ongoing monitoring of Resident #701 and Resident #702, and review/monitoring in facility QAPI committee. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to 1) Prevent and implement preventive measures to avoid pressure ulcers for 2 residents (Resident #39 and Resident #62) of 3 residents reviewed for pressure ulcers and 2) Follow through with the intervention of an air mattress for 1 resident (Resident #39), resulting in Resident #62 having a facility-acquired, preventable, Stage IV pressure ulcer and, for both residents, an increased likelihood for infection, cross contamination, antibiotic usage with side effects, pain, and discomfort. Findings Include: Resident #39: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 7/24, and physician orders dated 4/13/25 through 4/17/25, and nurses' progress notes dated 4/13/25 through 4/17/25, revealed Resident #39 was [AGE] years old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, had a trach (artificial breathing stoma) and dependent on staff for Activities of Daily Living/ADL. The resident's diagnoses included, respiratory failure, chronic lung disease, muscle weakness, Dysphagia (deficit swallowing), heart disease, diabetes, Spinal stenosis, anxiety, and oxygen dependence. At the time of the survey, the resident had no diagnosis of pressure ulcers. The first observation documented was when this surveyor did an observation on 04/15/25. During an interview on 4/15/25 at 10:29 a.m., the resident stated I got something on my bottom, it hurts; they (staff) saw it yesterday and put something on it. It started hurting yesterday (4/15/25) and I told them, but now it's bad (increased pain). An observation of Resident #39's wound (coccyx pressure ulcers) done on 4/15/25 at 10:37 a.m., revealed on the left and right side there were 3 open areas on the lower buttocks. The resident was verbalizing pain when Nursing Assistant/CNA L turned her over to observe the coccyx area; the resident said it burnt and hurt. There was a layer of white cream that staff had put on her. At this time, the resident did not have a air mattress on her bed, but she had a pressure reduction mattress. Review of the resident's physician's orders and an interview done on 4/16/24 at approximately 10:40 AM, revealed, at this time no assessment or orders were found regarding the pressure ulcers or for any treatment. During an interview done on 4/16/25 at 10:53 AM., Wound Nurse, RN C stated I saw it today (on 4/16/25), it's a Stage 2 (Pressure Ulcer), there are 2 of them (there were 3 open areas documented by Nurse C); they (staff) probably put silicone on it. They should have ordered something. They wait for me to do it. On 4/15/25 at 10:50 AM, a review was done of Resident #39's facility nursing progress notes, dated 4/12/25 at 1:52 PM, through 4/13/25 at 2:17 PM, (at the time of this review, there were no nursing notes at all for 4/14/25, or for 4/15/25) revealed no documentation of any pressure ulcers or any reddened areas on the resident. On 4/15/25 at 10:55 , review was done of Resident #39's facility weekly skin assessments dated 3/29/25, 4/4/25 and 4/11/25, revealed no documentation of any pressure ulcers, damaged skin integrity nor reddened areas. At the time of the review, no documentation was done on 4/15/25 at all. Review of the resident's facility progress note dated 4/15/25 at 11:40 a.m. (this was after the observation was done of 3 pressure ulcers was made by the surveyor) stated This nurse was asked to assess resident's bottom at this time as she was c/o (the resident was complaining) pain. Upon assessment there was found to be three superficial open areas to left inner buttock. Measurements are as follows; superior wound measuring 1.0 cm x .7 cm, middle wound measuring .8 cm x .3 cm, and inferior wound measures .1 cm x .2 cm. Areas cleansed w/NS (with normal saline), patted dry, Hydrogel was then applied. Area covered w/ 4 x 4 boarded foam patch. Orders placed; Triad cream applied to rest of buttocks as ordered. Res. (resident) stated that feels a little better already. Review of the facility physician order dated 4/15/25, stated Cleanse three superficial openings to left inner lower buttock w/NS, pat dry. Apply Hydrogel, then cover w/ 4 x 4 bordered foam patch for protection. During an interview On 4/17/25 at 9:15 AM, Wound Nurse, RN C stated She (the resident) refused to get up for us to put the air mattress on. Observation and interview with Resident #39 was done on 04/17/25 at 9:40 AM. No air mattress was on her bed. Resident stated, No one asked me if I could get up for the air mattress to be put on, I was up yesterday, no one asked me to get up to put it (air mattress) on; I did not refuse to get up. During an interview on 04/17/25 10:40 AM Maintenance A stated Yes, it was put in TELL's yesterday (on 4/16/25) at 12:36 PM, but it didn't get put on. It was put in as critical; that's an excessive amount of time (for not being put on the resident's bed). During an interview on 4/16/25 at 12: 50 PM, Maintenance B stated They (staff) had just put her back in bed and they said she would not get up again. It did not get put on yet. During an interview on 4/17/25 at 9:23 AM, Wound Nurse, RN C stated I usually initiate an air mattress, I put it in TELL's (facility maintenance communication program) and I put it on critical (meaning to get the requested task done that day). Wound Nurse C said she put the request for an air mattress to be put on the resident's bed on 4/16/25. Wound Nurse C said there was no policy for requests put through the maintenance TELL's. 22927 Resident #62: In an observation and interview on 04/15/25 at 01:59 PM, Resident #62 was noted to be laying in bed getting ready for a nap and laying on her back. Resident #62 denied any concerns. Record review of Resident #62's progress note, dated 3/5/2025 at 9:35 PM, resident weekly skin assessment completed: Resident buttocks is cleared and intact . Record review of Resident #62's progress note dated 3/12/2025 at 9:41 PM, resident weekly skin assessment completed: Resident inner buttocks is pink area cleansed and dried and facility barrier cream applied as ordered. Record review of Resident #62's progress note, dated 3/13/2025 at 2:28 PM, resident did get up in her wheelchair for a few hours and tolerated it well. Buttocks near rectum with macerated area noted measuring approximately 5 cm x 2.5 cm. Resident is incontinent of bowel & bladder and refuses care at times. Area cleansed and triad cream applied. Wound nurse notified. Record review of Resident #62's progress note, dated 3/19/2025 at 05:29 AM, resident has an area on inner buttocks that appears to be open with some slough noted . Triad cream in place at this time. Message sent to wound nurse for possible treatment. Observation on 04/16/25 at 08:25 AM with Certified Nurse Assistant's R and S revealed that both CNA's applied enhanced barrier precautions of personal Protective equipment (PPE) CNA R walked into the room and pulled the bed away from wall, air mattress was not placed on hold or stopped. Resident rolled side to side by staff. Bowel-soiled Brief changed, and dressing covered in stool. The state surveyor observed a Stage 4, open wound at the rectal/coccyx area, that was red beef bottom with white tissue noted, deep wound bed noted, no barrier cream was noted. Area cleansed and no dressing applied at this time. Record review of Resident #62's 'Daily Care Plan' located in the resident's wardrobe within the resident's room revealed Skin: Encourage to turn side to side while in bed, Head of Bed less than 30 degrees except when eating, Air mattress. There were no documented air mattress settings or when to increase or decrease the firmness of the mattress. Observations and interviews were conducted on 04/16/25 at 08:40 AM with Registered Nurse J and Certified Nurse Assistant (CNA) R. RN J had opened wound dressing packets at the treatment cart in hallway and squirted solutions into the packets. Both Registered Nurse J and Certified Nurse Assistant (CNA) R. applied enhanced barrier personal protection equipment (PPE) and CNA R pulled the bed away from the wall so she could be on side of bed, walked past the air mattress control and did not place on hold or stop the air flow. Settings observed on 5 dots out of 10 dots (soft to firm) during dressing change to coccyx area. RN J applied a pair of gloves, assisted in turning the resident to her left side, removed the soiled brief and performed wound measurements of 2 cm x 1 cm and stated there was no tunneling. Red sanguineous drainage noted and bleeding noted with cleaning. Three 4 x 4 gauzes were noted. RN J used the right hand to change only left-hand glove, applied collagen powder, sprayed into the wound, skin prep, and placed exoderm treatment dressing to wound to seal the wound bed. RN J then placed a pillow placed to her upper back area. The state surveyor asked why he was only changing one glove. RN J stated that he only changed left hand glove because he was holding Resident #62 with his right hand, and it did not touch anything else. Nurse was observed using the right hand to remove the left glove and re-apply new left-hand glove (cross contamination noted). Nurse did not use hand sanitizer or wash hands between cleaning of stool and applying wound dressing. Possible Cross contamination with dressing change. In an interview and record review on 04/16/25 at 12:46 PM, Registered Nurse C, who is wound care certified, acknowledged that Resident #62's Stage 4 pressure injury developed in-house on 3/20/25, as Moisture Associated Skin Damage (MASD) and was treated with Triad cream, but the wound was an open wound, measuring 6 x 4 cm with no depth at that point. RN C stated the wound was covered with slough and that she did write the measurements in the progress notes. RN C stated that she does write a note weekly for wounds. Record review of the 3/26/25 progress note documented an open wound with drainage. On 04/03/25 the wound had developed into a Stage 4 wound with depth. A progress note on 4/12/25 noted a Stage 4 pressure wound. The state surveyor asked about updating the care plan. RN C stated I thought that I did. I added an air mattress to the care plan. I am used to Point Click Care, the matrix program has been a struggle for me. In an interview and record review on 04/16/25 01:59 PM, Registered Nurse C, who is wound care certified, revealed that Resident #62's pressure ulcer did develop at the facility and the wound started on 3/19/2025 as slough. Resident #62 went out to hospital on 3/24/2025 and came back. Resident #62's pressure ulcer area on 4/3/2025 was open and measured 4 cm x 2.3 cm and a depth of 1 cm with drainage. Observation was made on 04/17/25 at 08:12 AM of Resident #62 laying on her right hip area with pillows behind her upper back area. Resident #62 was awake, but she was chilled and has on extra blankets. Observation of air mattress setting was made- still on static with a half firm setting. Resident #62 stated its just stays hard on her butt all the time. In an interview on 04/17/25 at 09:23 AM, Registered Nurse C was asked about the facility air mattress usage and if the actual pressure ulcer is a criteria for an air mattress. RN C replied, It just depends on how bad the wound is. I will initiate an air mattress with open wound. I put it in the tells maintenance (computer program) to let them know about the need for the mattress. Usually, it takes just a couple of hours or a day. An interview and observation on 04/17/25 at 09:43 AM with Registered Nurse C, revealed there is no policy or procedure for the use air mattress on resident beds. The owner's manual maintenance is look for it. Setting of air mattress, some have cycled air. The Patriot brand of air mattress has a setting of 10 dots from soft to firm and facility sets it on between 3 to 5 and go down from there. Static setting- I don't know what that is. Alternating setting is used. I'd have to look at the bed. Registered Nurse C and the state surveyor went to room [ROOM NUMBER] to observe the resident's Patriot bed air mattress, which was set on static with 6 dots. Registered Nurse C, stated I don't understand the air mattress settings. I don't know the difference between the static and alternate settings. That would be a Licensed Practical Nurse (LPN) M restorative nurse question. I just don't know. I came from the hospital setting and not long-term care. In an observation observation and interview on 04/17/25 at 10:28 AM, Licensed Practical Nurse (LPN) M (restorative nurse) came into the resident's room, room [ROOM NUMBER], and stated that the Patriot air mattress is the older model and the comfort level with a pressure wound should be between 5 and 7 dots on the control setting. During resident care, the staff are to firm up the mattress to 10 dots and then back down to the settings on the care plans. We use the static setting, and we do not use the alternate setting. The wound care nurse sets the settings and does the care plans. Record review of the resident's in-room 'Care Guide', located in the room wardrobe, revealed no settings were stated on the care guide for air mattress use. In an observation and record review on 04/17/25 at 10:00 AM, Licensed Practical Nurse (LPN) M and the State surveyor Went to the second-floor [NAME] unit to room [ROOM NUMBER]. Resident #62 has a Patriot air mattress in place with settings at 5 dots, a static setting. Record review of the in-room care guide, dated 4/9/2025 and located inside the wardrobe closet door, revealed under the heading of ski: Air mattress (no settings were documented). Record review of Resident #62's nurse notes, dated 3/19/2025 at 8:48 AM, noted that the Head of Bed (HOB) is not to be over 30 degrees. Resident was observed with 4 pillows placed behind her upper back areas raising the resident further up on her coccyx.

Based on observation, interview and record review, the facility failed to ensure clean, reusable medical equipment for one resident (Resident #12) and hand hygiene for one resident (Resident #62), resulting in cross-contamination and the likelihood of further cross-contamination. Findings include. On 4/16/25, at 1:48 PM, an observation of Nurse P at Resident #12's doorway was conducted. Nurse P asked Nurse Q if they had scissors. Nurse Q entered their left pocket, pulled out a pair of scissors and handed them to Nurse P. Nurse P entered Resident #12's room and closed the door. Upon opening Resident #12's door, an observation was made of Nurse P cleaning the scissors with an alcohol pad with their gloved hands. Nurse P was asked if they were using an alcohol pad and Nurse P offered, Yes, its an alcohol pad. On 4/16/25, at 1:55 PM, Nurse Q was asked if the scissors were shared scissors and Nurse Q offered, the scissors were shared. Nurse Q was asked what their normal disinfection process was for reusable scissors between resident use and Nurse Q offered, we use alcohol. On 4/16/25, 3:30 PM, a record review of Resident #12's electronic medical record revealed an admission on 1/2/2024 with diagnoses that included Stroke, Diabetes and seizure disorder. Resident #12 had intact cognition and required extensive assistance with all activities of daily living. Resident #12 required enhanced barrier precautions due to their urinary catheter and had an order for a dressing change to their coccyx. Resident #12 had a recent history of a wound infection. On 4/17/25, at 11:38 AM, an interview along with Infection Control Nurse (IC) Nurse N was conducted. IC Nurse N was asked to clarify the Standard Precautions policy to ensure proper disinfection of reusable medical equipment. IC Nurse N stated, we would use the EPA disinfectant. 22927 Resident #62: An observation on 04/16/25 at 08:25 AM with Certified Nurse Assistant's R and S revealed that both CNA's applied enhanced barrier precautions of Personal Protective equipment (PPE). CNA R walked into the room and pulled the bed away from wall. The air mattress was not placed on hold or stopped. The resident rolled side to side by staff. Bowel-soiled brief was changed, and the dressing was covered in stool. The state surveyor observed a Stage 4, open wound at the rectal/coccyx area, that had a red beef bottom with white tissue noted. A deep wound bed was also noted. No barrier cream was noted. The area cleansed and no dressing was applied at this time. Record review of Resident #62's 'Daily Care Plan', located in the resident's wardrobe within the resident's room, revealed Skin: Encourage to turn side to side while in bed, Head of Bed less than 30 degrees except when eating, Air mattress. There were no documented air mattress settings or when to increase or decrease the firmness of the mattress. Record review of a 'Enhanced Precautions' form located on the same clip board with the 'Daily Care Plan', undated, noted Resident #62 with rectal wound, staff to wear gloves and gown when providing care to resident and change gloves if contact with infective material. Hand hygiene after resident contact, contact with resident surroundings, or when removing gloves. An observation and interview was conducted on 04/16/25 at 08:40 AM with Registered Nurse J and Certified Nurse Assistant (CNA) R. RN J had opened wound dressing packets at the treatment cart in hallway and squirted solutions into the packets. Both Registered Nurse J and Certified Nurse Assistant (CNA) R applied enhanced barrier personal protection equipment (PPE). CNA R pulled the bed away from the wall so she (CNA R) could be on side of bed. CNA R walked past the air mattress control and did not put on hold or stop the air flow. Settings observed at 5 dots out of 10 dots (soft to firm) during dressing change to the coccyx area. RN J applied a pair of gloves, assisted in turning the resident to her left side, removed the soiled brief, and performed wound measurements of 2 cm x 1 cm and stated that there was no tunneling. A red sanguineous drainage and bleeding were noted with cleaning. Three 4 x 4 gauzes were also noted, RN J used the right hand to change only the left-hand glove, applied collagen powder by spray it into the wound, skin prep, and placed the exoderm treatment dressing to the wound and held it to seal wound bed. RN J then placed a pillow placed to her upper back area. The state surveyor asked why RN J only changed one glove. RN J stated that he only changed the left-hand glove because he was holding Resident #62 with his right hand, and it did not touch anything else. The nurse was observed using the right hand to remove the left glove and re-apply a new left-hand glove (Cross contamination noted) RN J did not use hand sanitizer or wash hands between cleaning of the stool and applying the wound dressing. There is a possible cross contamination with the dressing change. In an interview on 04/17/25 at 01:45 PM with Registered Nurse/Infection Preventionist N, the state surveyor inquired about hand washing with dressing changes. RN N stated that the nurse needs to wash before and during the dressing change. After a dirty dressing change, remove gloves and wash hands. Both gloves should be changed and hands washed before proceeding with the dressing change. The state surveyor asked about cross contamination. RN N stated that that is the cause for cross contamination and should be done- pre-wash. use gloves, remove soiled dressing, remove dirty gloves, wash hands, reapply clean gloves, set-up a barrier, perform the treatment and place the dressing. Then remove the gloves and wash hands again.

Based on observation, interview, and record review, the facility failed to update and/or revise individualized, person-centered care plans to reflect changing needs for 4 residents (#6, #39, #52, #62) of 18 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings include: Record review of facility 'Comprehensive Care Plan' dated 11/27/2024 revealed it is the policy of this facility to develop and implement a comprehensive person-center care plan for each resident, consistent with the rights, that includes measures objectives and time frames to meet a resident's medical and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #62: Observation on 04/16/25 at 08:25 AM with Certified Nurse Assistant's R and S revealed that both CNA's applied enhanced barrier precautions of personal Protective equipment (PPE). CNA R walked into the room and pulled the bed away from wall, air mattress was not placed on hold or stopped. Resident rolled side to side by staff. Bowel soiled brief changed, and dressing covered in stool. The state surveyor observed a Stage 4, opened wound at the rectal/coccyx area, that was red beet bottom with white tissue noted, deep wound bed noted. No barrier cream was noted. Area cleansed and no dressing applied at this time. Record review of Resident #62's 'Daily Care Plan' located in the resident's wardrobe within the resident's room revealed Skin: Encourage to turn side to side while in bed, Head of Bed less than 30 degrees except when eating, Air mattress. There were no documented air mattress settings or when to increase or decrease the firmness of the mattress. Observations and interviews were conducted on 04/16/25 at 08:40 AM with Registered Nurse (RN) J and Certified Nurse Assistant (CNA) R. RN J had opened wound dressing packets at the treatment cart in hallway and squirted solutions into the packets. Both Registered Nurse J and Certified Nurse Assistant (CNA) R applied enhanced barrier personal protection equipment (PPE) and CNA R Bed pulled away from the wall so she could be on side of bed, walked past the air mattress control and did not place on hold or stop the air flow. Settings observed of 5 dots out of 10 dots (soft to firm) during dressing change to coccyx area. RN J applied a pair of gloves and assisted in turning the resident to her left side and removed the soiled brief and performed wound measurements of 2 cm x 1 cm and stated no tunneling, red sanguineous drainage noted, bleeding with cleaning. Three 4 x 4 gauzes were noted. RN J used the right hand to change only left-hand glove, applied collagen powder sprayed into the wound and skin prep, and placed exoderm treatment dressing to wound (held to seal wound bed). RN Jthen placed a pillow placed to her upper back area. The state surveyor asked why only changing with one glove? RN J stated that he only changed left hand glove because he was holding Resident #62 with his right hand, and it did not touch anything else. Nurse was observed using the right hand to remove the left glove and re-apply a new left-hand glove (Cross contamination noted). Nurse did not use hand sanitizer or wash hands between cleaning of stool and applying wound dressing, thereby causing a possible cross contamination with the dressing change. In an interview and record review on 04/16/25 at 12:46 PM, Registered Nurse C, who was wound care certified, acknowledged that Resident #62's Stage IV pressure injury developed in house on 03/20/25 as Moisture Associated Skin Damage (MASD) and was treated with Triad cream, but the wound was an open wound, measuring 6 x 4 cm with no depth at that point. RN C stated the wound was covered with slough and that she did write the measurements in the progress notes. RN C stated that she does write a note weekly for wounds. Record review of the 3/26/25 progress note documented wound open with drainage. Then on 4/3/25 the wound developed into a Stage 4 with depth, and a progress note on 4/12/25 noted a Stage 4 pressure wound. The state surveyor asked if the the care plan was updated. RN C stated I thought that I did. I added an air mattress to the care plan. I am used to Point Click Care, the matrix program has been a struggle for me. Record review of Resident #62's care plans, pages 1- 20, revealed on page 7 under Skin management: I have skin interventions in place; pressure relieving mattress on my bed; waffle cushion in my wheelchair; A&D to bilateral feet with AM & HS care . There were no documented settings for the air mattress in use on the resident's bed or when to increase or decrease the mattress air pressure. 22347 Resident #39: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 7/24, and physician's orders dated 4/13/25 through 4/17/25, and nurses' progress notes dated 4/13/25 through 4/17/25, revealed that Resident #39 was [AGE] years old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, had a trach (artificial breathing stoma) and dependent on staff for Activities of Daily Living (ADL). The resident's diagnoses included, respiratory failure, chronic lung disease, muscle weakness, Dysphagia (deficit swallowing), heart disease, diabetes, Spinal stenosis, anxiety, and oxygen dependence. Observation of the residents skin was done accompanied by Nursing Assistant/CNA L on 4/15/25 at 10:37 a.m., revealed 3 small pressure ulcers. Review done on 4/15/25, of the resident's facility Daily Care Plan dated 1/29/25 (in the resident's room) and the Skin Management care plan dated 2/24/25, revealed no documentation of any open areas on the resident at all. The Skin Management care plan stated My skin will remain intact through next review (no open areas were documented). The resident's care plan was not up-dated timely to reflect the actual skin condition (x 3 pressure ulcers). Resident #52: Review of the Face Sheet, physician orders and nursing progress notes, dated 3/1/25 through 5/15/25, and MDS Assessment Summary dated 1/28/25, revealed Resident #52 was [AGE] years old, alert with mild cognitive impairment, admitted to the facility on [DATE], dependent on renal dialysis, and dependent on staff for ADL's. The resident's diagnoses included, end stage renal disease, sepsis, hemiplegia and hemiparesis following a stroke, dialysis dependent, Epilepsy, depression, Acquired absence of kidney, mild cognitive impairment, and mood disorder. Review was done on 4/16/25 at 11: 55 a.m., of Resident #52's facility pain care plan dated 2/3/25. It revealed only one intervention; give meds per physician orders. No documentation was found regarding interventions related to non-pharmacological pain reduction interventions. During an interview done on 4/15/25 at approximately 11:10 a.m., Resident #52 said he was in a lot of pain. The resident denied staff implemented any non-pharmacological measures when given examples. During an interview done on 4/16/25 at 10:00 a.m., MDS Nurse, RN H stated We typically have non-pharmacological approaches in pain care plans. We (MDS) are the ones that up-date the goals/care plans; the nurses notify us of wound care. The care plans should be done the day they find it (the wound). During an interview done on 4/16/25 at 10:15 a.m., Wound Nurse, RN C stated Care plans can only be changed by MDS and wound (wound care nurse). Wound Nurse C said the nurses were not allowed to do or up-date resident care plans. Interview done on 4/16/25 at 10:20 a.m., with the DON, who stated, I feel like more interventions should be in place. Review of the facility Pain Management policy, dated 12/23/24, stated Non-pharmacological pain management interventions include but not limited to: Adjusting room temperature, massage, turning and repositioned to a comfort position, loosen any constrictive bandage or device, applying splinting, physical modalities (cold compress, warm compress), exercises to address stiffness and present contractures as well as restorative nursing programs to maintain joint mobility, cognitive/behavioral interventions (music, diversions). Review of the facility Baseline Care Plan policy, dated 9/25/24, stated (The facility) will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Interventions will be initiated that address the resident's current needs including: Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. Any special needs such as for IV therapy, dialysis, or wound care. Once established, goals and interventions will be documented in the designated format. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident. 37771 Resident #6: A review of Resident #6's medical record revealed an admission into the facility on [DATE] and re-admission on 3/12/25 with diagnoses that included mood disorder, major depressive disorder, mild intellectual disabilities, Alzheimer's disease, dementia with mood disturbance, malnutrition, pressure ulcer of right ankle, right heel and left heel at Stage 4, pressure ulcers of other sites at Stage 2 and unstageable and osteomyelitis. Resident #6's care plan for risk for skin breakdown pressure/injury, revealed an APPROACH: (Resident's name) has an air mattress on my bed. (Resident name) has a ROHO cushion in her w/c (wheelchair), dated 2/11/2025. Resident #6's care for Mood: (Resident's name) has a diagnosis of ., with a GOAL: I will be free from significant side effects of psychotropic medication through next review, with a listed APPROACH: Nursing administers my medications as ordered by provider. Labs as ordered by provider, and The potential side effects of my medications are monitored as listed in the Nursing Drug Handbook, did not have individualized Resident information on behaviors, medications or the potential side effects to monitor. On 4/16/25 at 2:35 PM, an interview was conducted with the Wound Care Nurse (WCN) C regarding Resident #6's multiple pressure wounds. The WCN was asked what kind of air mattress was on the Resident's bed and what were the settings for the air mattress? The WCN reported that the care plan would have the information, and that the Patriot air mattress was to be set between 5 and 7 dots and set on static. The WCN stated, They put it on the care plan. It's set up to the comfort level at that time (when applied). When asked how staff assess for her comfort level, the WCN reported the Resident was non-verbal and that assessing her comfort level would be difficult. The WCN was asked how would staff know what to set the air mattress machine to. The WCN stated, Usually it is on the care plan. A review of the care plan revealed the approach for an air mattress on my bed, but did not give resident specific settings for the air mattress. On 4/16/25 at 3:07 PM, an observation was made with Wound Care Nurse C of Resident #6 lying in bed. The resident did not respond to verbal stimuli or engage in conversation. The air mattress was on and functioning. The air mattress was set at 6 of 10 dots (the soft to firm setting) and set on static air. The WCN reported that CNA's may firm up the mattress while providing care by changing the settings. A review of the care guide that was in the resident's room revealed no direction for staff on the settings for the air mattress. On 4/17/25 at 12:39 PM, an interview was conducted with the MDS Coordinator, Nurse H regarding Resident #6's lack of individualized care plan. The MDS Nurse reported that the Social Services would complete the interventions for the psych medications. A review of the interventions for the goal for psychotropic medications was reviewed. The Nurse reported a lack of behaviors and stated, Needs to be more resident specific, and asked if the care plans needed to be individualized for the Resident, the Nurse stated, yes.

Based on observation, interview and record review, the facility failed to ensure dignity for 2 residents (Resident's #39 and Resident #51) of 3 residents reviewed for dignity (call light response time) and residents from the confidential Resident Council group meeting (held on 4/16/25), regarding call light response times. Findings Include: Resident #51: Review of the Face Sheet, MDS dated ,d+[DATE], nurse's progress notes dated 2/1/24 through 4/15/25, revealed Resident #39 was [AGE] years old, mild cognitive impairment, admitted to the facility on [DATE], and dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included, high blood pressure, heart failure, lymphedema, unsteadiness, lack of coordination, chronic kidney disease, anxiety disorder, cardiac pacemaker with a history of right breast cancer. During an interview done on 4/15/25 at 10:09 a.m., Resident #51 stated If they (staff) are busy, I do wet my pants sometimes. If its real bad, we go in the hall and yell help. Night is fast (call light response times), its more or less before lunch (delayed light response times). They can't get to all of us, so we wait. Resident #51 said she feels embarrassed when she wets her pants. The resident stated One time I thought I was having a heart attack; I couldn't breathe, and I was scared. I think they were short (short staffed), it took them about 45 minutes to get here. I used to be a nursing assistant, I know. Resident #39: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 7/24, and physician orders dated 4/13/25 through 4/17/25, and nurses progress notes dated 4/13/25 through 4/17/25, revealed Resident #39 was [AGE] years old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, had a trach (artificial breathing stoma) and dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included, respiratory failure, chronic lung disease, muscle weakness, Dysphagia (deficit swallowing), heart disease, diabetes, Spinal stenosis, anxiety, and oxygen dependence. During an interview done on 4/15/25 at 10:09 a.m., If there are busy, I do wet my pants sometimes. If it's real bad we go in the hall and yell help. Night is fast, its before lunch. They can't get to all of us, so we wait. Review of the facility Resident Council Notes dated 10/30/24, 12/31/24, 1/28/25, and 2/26/25, revealed complaints regarding call light response times being too long. Review of Council notes dated 10/30/24 and 12/31/24, stated Some of the residents voice concern about the length of time their call lights are on. Review of Council notes dated 1/28/25 and 2/26/25, stated There was a discussion about call lights and residents stated that this has been the same as the previous month (continued delayed response times). Review of the facility resident's Rights policy dated 3/26/25, stated You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely (including timely response to call lights). 37771 Resident Group Meeting: On 4/16/25 at 10:30 AM, an interview was conducted with 13 Confidential Residents in a group meeting. The Residents were asked about any concerns they had regarding the care they received at the facility. A couple Residents reported long call light wait times. A Resident stated, The CNAs (Certified Nursing Assistants) are too busy, and the CNAs are busy working with someone else. One Resident complained of having to wait up to 45 minutes at times and another reported 30 minutes. One Resident reported having to use the bathroom and stated, I have been incontinent of stool because of waiting, and another Resident stated, You have to sit and pray that someone will answer the call light and get you to the bathroom in time. Three Residents out of the group reported incontinence while waiting for the call light to be answered. A Resident reported that Nurses don't help with answering call lights, while another Resident voiced that some Nurses do answer, but most will not answer, call lights. When the group was asked who felt the Nurses could help with answering the call lights more, most of the census of the group raised their hands.

Based on observation, interview and record review, the facility failed to inform/educate 13 of 13 residents who attended the confidential group meeting about the location of the survey results and failed to ensure that the recent State Survey and Plan of Correction were readily accessible, affecting all Residents in the facility of a census of 89, resulting in Residents, Resident Representatives, visitors and staff being unable to review the survey results and plan of correction. Findings include: On 4/16/25 at 10:30 AM, an interview was conducted with 13 Confidential Residents in a group meeting. The Residents in the group meeting were asked Without having to ask, are the results of the State inspection available to read? No Resident of the group acknowledged they knew of survey results being available. 13 of 13 Residents reported they did not know what survey results were, that the results were to be available without having to ask for them, or where they would find the results. The majority of the Residents were in wheelchairs. On 4/16/25 at 11:50 AM, an observation was conducted in the hallway near the front entrance and the Administrator's (NHA) office. There was a bulletin board on the wall that had multiple papers attached to the board. On one end of the board were printed survey results with pages clipped together and hung on a push pin. The copy of the results was too high to be accessible from wheelchair height and were in small print impeding reading to acknowledge what the documents were from wheelchair height. The document 2567 of survey results were posted on the bulletin board for 3/7/23 but did not have the plan of correction printed on the documents. There was no survey for 2024 posted on the bulletin board. On 4/16/25 at 12:18 PM, an interview was conducted with the Administrator (NHA) regarding the lack of readily accessible results of the most recent survey of the facility. The NHA reported that there should be the survey up there, that it probably was at one time and that he will copy it off and put it up there. On 4/16/25 at 12:18 PM, an interview was conducted with the NHA regarding the lack of plan of correction with the surveys that was posted on the bulletin board for 2023 and 2021. The NHA reported that the survey that he will post will have the plan of correction with the survey results. A review of the facility policy titled, Resident Rights, reviewed 3/26/25, revealed, . 6. Information and communication . k. You have a right to: i. Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility .

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary condition, and 2) Ensure that all partly used, opened foods had a use-by date. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred. During the initial kitchen tour done on 3/11/25 at 7:35 AM, accompanied by Dietary [NAME] C, the following observations were made: -At 7:36 a.m., The silver cart used for food storage was found to have dried food splattered on the inside door and on the top shelf. -At 7:37 a.m., a half loaf of bread was found open, with no use-by date on it. -At 7:39 a.m., the large can opener was found to have chipped silver paint on the blade. -At 7:40 a.m., a plastic container with sunflower seeds had a use-by date of 1/12/25. -At 7:42 a.m., three large silver pans of slices of peanut butter pie were found with no dates at all on them. -At 7:43 a.m., in the clean and ready for use covered counter Robot Coupe was found a piece of hair stuck under the blade. -At 7:45 a.m., in the backer's drawer was found a sticky substance on the bottom along side clean utensils. 1 East Kitchenette: -On 3/11/25 at 7:48 a.m., the East Kitchenette was observed accompanied by Dietary Aide A, the following concerns were noted: -At 7:49 a.m., the inside glass plate of the microwave was found to have dried on food. -At 7:50 a.m., in the cooler was found a container of lettuce with a use-by date of 3/10/25. -At 7:52 a.m., the inside door of the freezer had an excessive number of crumbs on the top seal of the door. During an interview done on 3/11/25 at Dietary Manager Dsaid he agreed with the above items found and verbalized staff should have dated everything with a use-by date. During an interview done on 3/11/25 at 12:21 p.m., Dietary Consultant F stated I do a test ray weekly; we usually don't get any complaints. Dietary Consultant F agreed food items opened and partly used required a use-by date. Review of the facility Food and Supply Storage policy dated 1/25, revealed the dietary department dates foods with a use-by date when opened and stated Discard food past the use-by or expiration date.

Based on observation, interview and record review, the facility failed to adequately supervise and prevent injuries/falls for three residents (Resident #7, Resident #18, Resident #279), resulting in multiple injuries of residents and prolonged illness and hospitalization s. Findings included: Record review of the facility 'Compliance with Reporting Allegations of Abuse/Neglect/Exploitation' policy dated 3/30/2023 revealed it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies. Injuries of unknown source: Includes circumstances when both the following conditions are met. (i.) The source of the injury was not observed by any person or could not be explained by the resident. (ii.) The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Resident #279: Injury of Unknown origin: Record review of Resident #279's Minimum Data Set (MDS) dated [DATE] revealed an elderly resident. Section C: Cognitive patterns revealed moderately impaired cognitively with decisions poor, cues/supervision required, inattention-behavior present fluctuations (comes and goes) changes in severity. Disorganized thinking functional. Section GG: Functional abilities revealed total dependence on staff for: bathing, upper/lower body dressing, mobility of rolling left and right, sit to lying, lying to sitting, sit to stand, and chair to bed. Section I: Active diagnoses revealed coronary artery disease, heart failure, orthostatic hypertension, gastroesophageal reflux disease, diabetes, Alzheimer's disease, dementia, malnutrition, and anxiety were noted. There was no mention of osteoporosis (weakening of the bones). Record review of Resident #279's electronic medical record, Continuity of Care' document revealed there was no osteoporosis diagnosis. Record review of the facility incident report (FRI) noted that on 8/26/2023 at approximately 10:00 AM Resident #279 was noted to have left leg shortening and rotation of the leg. Record review of the facility Resident #279 investigation file of injury of unknown origin revealed that a commuted intertrochanteric acute Fractured of the left hip. Record review of the FRI documents. In an interview and record reveal on 03/13/24 at 09:56 AM with the Director of Nursing (DON) revealed that the incident for Resident #279's Injury of unknown origin identified on 8/26/2023, was investigated by DON and Nursing Home Administrator (NHA). The DON stated that the investigation looked back to 8/23/2023 and went forward from that date. The DON stated that the investigation. Summary was that there was no wrongdoing, and that the medical director did state that the fracture may have happened as a spontaneous fracture. The DON reviewed the medical record with the state survey and acknowledged that there was no medical diagnosis for osteoporosis for the resident. Record review of Resident #279's hospital Computed Tomography (CT) scan report dated 8/26/2023 revealed a comminuted intertrochanteric acute fracture of left hip with mild-to-moderate fragment separation. Findings: Again, seen is a comminuted and moderately displaced intertrochanteric fracture of the proximal left femur. Fracture appears be superimposed on marked bone demineralization. No clear lytic or blastic bone lesion is this region to definitively indicate a pathological fracture . 37668 Resident #58: On 3/11/24 at 11:43 AM, Resident #58 was not in their room. An observation of their room was completed at this time. Anti-slip strips were observed on the floor next the Resident's bed. Record review revealed Resident #58 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia, weakness, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and was dependent/required maximum assistance for transferring, hygiene, and mobility. Review of Resident #58's Electronic Medical Record (EMR) revealed a Safety Events-Falls report, dated 2/22/24, which detailed Resident #58 had a witnessed fall in their room. The Event Summary specified, Probable/Possible cause of fall: Care plan not followed. Resident leaned too far forward while sitting at the edge of the bed. Was the Care Plan followed: No . Aide did not follow care plan which stated Resident is to be transferred as a two assist with gait belt and walker for support . The event indicated Certified Nursing Assistant (CNA) W was the only witness to the incident. Review of progress note documentation in Resident #58's EMR revealed the following: - 2/22/24 at 4:20 PM: This nurse entered room after being told that Resident was lowered to the floor. Upon entering resident's room, resident was laying alongside bed with bilateral arms in lap and legs extended out. Prior to being lowered, resident's aide changed brief and put on pants after providing care to get resident up for dinner. Aide sat resident up at the edge of the bed to place gait belt as resident began to lean forward . lowered resident to the floor . - 2/23/24 at 9:21 AM: On 2/22/24 During an attempt to transfer resident from bed into wheelchair the CNA sat the resident up on the edge of bed and was attempting to apply gait belt when the resident began to lean forward sliding out of the bed. The CNA was unable to support the resident's weight to place back into bed, and slowly guided to a lying position on the floor along the right side of bed. The CNA then utilized the staff emergency call light to alert the nurse . licensed staff was called to resident's room regarding a fall. Upon entering residents' room, observed (Resident #58) lying on the floor along the right side of bed. Resident was positioned with head towards the head of bed with bilateral legs extended straight out towards the foot of bed. Resident's walker was positioned along the right side of them . No pain or injury noted . At time of incident the CNA stated . had sat resident up at the side of her bed in an attempt to apply gait belt for a 1 assist transfer when the resident began to lean forward causing (Resident #58) to begin sliding out bed. CNA was unable to support resident's weight to reposition back into bed, so then guided (Resident #58) to a safe position on the floor and alerted the nurse. Resident is care planned for 2-assist with walker for support for all transfers. CNA was counseled . PT (Physical Therapy) referral sent . Resident placed on 3-day monitoring r/t fall and self-transfers. Review of Resident #58's Electronic Medical Record (EMR) revealed a care plan entitled, Mobility: I am unsteady and have generalized weakness, so I need assist with transferring and walking. I have c/o (complaints of) vertigo (dizziness) with noted orthostatic hypotension episodes (decrease in blood pressure with change in position). I have had falls at this facility & history of falls at home . I have impaired cognition and may not always ask for assistance (Start: 9/18/20; Reviewed/Revised: 3/1/24). The care plan included the interventions: - I transfer to/from the bed & w/c (wheelchair) with max assist of 2 with walker (Start Date: 10/11/22) - I require assistance for turning and repositioning in bed (Start Date: 9/18/20) An interview was completed with the facility Administrator on 3/12/24 at 11:48 AM. When queried regarding Resident #58's fall, the Administrator revealed CNA W attempted to transfer Resident #58 with one assist, was unable, and lowered the Resident to the floor. When asked, the Administrator stated, (CNA W) will be here at 3:00 PM for work. An interview was completed with CNA W on 3/12/24 at 3:47 PM. When queried if they were assigned to care for Resident #58's on 2/22/24, CNA W confirmed they were. When queried if they were transferring the Resident by themselves and had to lower the Resident to the floor, CNA W confirmed. CNA W was asked what had occurred and stated, I never get help. I put my staff call light on (to request assistance with the transfer) and revealed no one responded. When asked how long they waited, CNA W replied, Maybe five to ten minutes. CNA W revealed the Resident was sitting up, ready to be transferred, and was becoming antsy waiting for another staff member to respond. CNA W revealed they proceeded to attempt to transfer the Resident by themselves and had to lower them to the floor. CNA W stated, I own it. (Resident #58) was a two assist and I should have waited. A demonstration of the transfer and how the Resident was lowered to the floor was completed at this time. When asked what happened after the Resident was on the floor, CNA W indicated the staff assistance call light was still on and no one had responded so they made sure the Resident was okay and exited the room to look for assistance. When queried how long it took to locate another staff member for assistance, CNA W stated, The nurse was at the cart, not even 20 feet away from the room. CNA W then stated, My assist light was still on and reiterated no staff had responded. An interview was conducted with the Director of Nursing (DON) on 3/12/24 at 4:10 PM. When queried if all staff are responsible/expected to respond to staff assistance call lights, the DON verbalized they were. When queried regarding Resident #58 being lowered to the floor on 2/22/24, the DON revealed CNA W had attempted to transfer the Resident with one assist when the Resident was care planned for two-assist. The DON was then queried regarding CNA W stating no one had responded to their staff assist light and the nurse being outside of the room, the DON indicated they were unaware and would address. 49944 Resident #7: On 03/11/24 record review revealed that resident #7 was [AGE] years old and admitted to the facility on [DATE] and still resides in the facility. Resident #7 has a brief interview for mental status (BIMS) score of 5 indicating severe impairment of their mentation. Resident #7 has diagnoses of Alzheimer, dementia, muscle weakness, unsteadiness on feet, abnormalities of gait, history of falling and anxiety. On 03/11/24, record review of a Facility Reported Incident (FRI) investigation provided by the facility revealed that Resident #7 fell and sustained a fracture on 02/29/24 and currently is on 1:1 monitoring for safety at this time. On 03/12/24, record review of the summary of the FRI investigation from 02/29/24, revealed that resident #7 was in her wheelchair at the nurse's cart at approximately 07:32 PM on 02/29/24 with the nurse present and sustained a fall at 07:35 PM. On 03/12/24, record review of the FRI investigation timeline revealed that on 02/29/24 at 7:10 PM CNA 'A' transferred resident #7 from her bed to her wheelchair because they noted resident #7 to be attempting to self transfer out of bed. CNA 'A' then took the resident to the nurse's med cart so they could go to break. At 7:32 PM on 02/29/24 LPN 'A' and activity aide (AA) 'A' assisted Resident #7 back to a seated position in her wheelchair, LPN 'A' then took resident #7 back to the nurses med cart where another nurse was present and preparing medications for medication pass. At 7:35 PM resident #7 was observed on the floor in the hallway of the second floor. On 03/12/24 at 12:30 PM an interview was conducted with the Director of Nursing (DON), the DON was asked if Resident #7 had someone with them at the time of the fall and if they were being supervised since it seemed the resident was anxious and was attempting to self transfer from bed prior to the fall. The DON stated that LPN 'B' was present with resident #7 at his medication cart and was preparing medications for other residents The DON then stated that LPN 'B' then went into another residents room to administer medications, at this time resident #7 self-propelled in her wheelchair off the hallway as she usually does and out of sight of staff and sustained a fall. The DON was asked again if the resident was being supervised at the time of the fall and they said no. The DON was asked if the resident should've been supervised since her BIMS was 5 and she said yes. On 03/12/24 at 12:45 PM an interview was conducted with the restorative nurse, the restorative nurse was asked if resident #7 had any prior falls in the facility, they stated that resident #7 had a fall on 01/23/24 and that was the first time they knew the resident to stand up from her wheelchair prior to the fall on 02/29/24. The restorative nurse was asked if the resident should be supervised when out of bed based on her BIMS of 5, they replied they didn't believe the resident needed to be supervised at all times. Restorative nurse stated the resident usually got around the facility on their own in their wheelchair. On 03/12/24 at 12:51 PM an attempt was made to contact LPN 'B', LPN 'B' did not answer the phone and never called back to complete the interview. On 03/12/24 at 03:38 PM, an interview was conducted with AA 'A' about Resident #7's recent fall with fracture. AA 'A' was asked what their involvement was in the lead up to the fall. AA 'A' stated that they were leaving an activity in the 2nd floor recreation room, AA 'A' said they were taking another resident back to their room from the activity when they noticed resident #7 looking worked up in the hallway by 2 west. AA 'A' said resident #7 gets worked up at night time and can become anxious. After AA 'A returned the resident from the activity to their room and as they were heading back to the recreation room to get another resident, AA 'A' noted resident #7 to be standing in an alcove area between the east and west hall. AA 'A' stated that the resident was by herself when she discovered her standing. AA 'A' assisted the resident to sit down in her chair and AA 'A' stated LPN 'A' was there to help as well. AA 'A' stated at that point LPN 'A' was with the resident and she went back to work. On 03/13/24 at 02:17 PM an interview was conducted with LPN 'A', LPN 'A' was asked about her involvement in resident #7's fall with fracture. LPN 'A' stated that they transported resident #7 down towards her room on the west hall after assisting AA 'A' to get resident #7 seated in her wheelchair and placed her at the medication cart with LPN 'B'. LPN 'A' stated that LPN 'B' was present at the medication cart at the time resident #7 was placed there.

Based on observation, interview, and record review, the facility failed to properly wash food contact surfaces, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 3/11/24 at 10:40 AM, during an inspection of the kitchen, Dietary Aide P was observed to be cleaning a meat slicer. At this time, Dietary Aide P was queried on their cleaning process and stated that they use a detergent wiping cloth first, followed by multiple applications of sanitizer wiping cloths. Dietary Aide did not describe using water rinse to clear the detergent before applying sanitizer. According to the 2017 FDA Food Code Section 4-603.16 Rinsing Procedures. Washed UTENSILS and EQUIPMENT shall be rinsed so that abrasives are removed and cleaning chemicals are removed or diluted through the use of water or a detergent-sanitizer solution by using one of the following procedures: (A) Use of a distinct, separate water rinse after washing and before SANITIZING if using: (1) A 3-compartment sink, (2) Alternative manual WAREWASHING EQUIPMENT equivalent to a 3-compartment sink as specified in 4-301.12(C), or (3) A 3-step washing, rinsing, and SANITIZING procedure in a WAREWASHING system for CIP EQUIPMENT; . On 3/11/24 at 12:33 PM, during an observation of lunch service, Dietary Aide Q stated that they needed the blender base (blades) but another staff member stated that they were dirty in the sink. At this time, Dietary Aide Q was observed to wash the blender base with detergent and a sponge, rinse off the detergent, then place the blender base on the drying rack. Dietary Aide Q then proceeded to use the blender base to puree food without using a sanitizing kill step to ensure the destruction of foodborne pathogens. According to the 2017 FDA Food Code Section 4-701.10 Food-Contact Surfaces and Utensils. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. During an interview on 3/13/24 at 1:46 PM, Dietary Manager R was queried on training for staff regarding cleaning equipment and stated that they have yearly trainings that are mandatory.

Based on observation, interview and record review, the facility failed to follow policies and procedures for medication labeling and storage in 3 of 3 Medication carts reviewed, 1 of 2 Medication rooms reviewed and narcotic reconciliation, resulting in opened and undated multi-dose medications, and the disposal of expired medications and altered medication efficiency with the likelihood of misappropriation going unnoticed. Findings include: Record review of the facility 'Administration of Medications' policy dated 10/25/2023 revealed the facility ensures medications are administered by licensed nurses as ordered by the physicians and in accordance with professional standards, in a manner to prevent contamination or infection. Record review of the Center of Disease Control (CDC) https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Observation and interview on 03/12/24 at 03:35 PM with Licensed Practical Nurse (LPN) B of the 1 East south unit medication cart teens cart. Observation of the 1 East south medication cart revealed Resident #63's Flonase nasal spray 50mcg open and not dated. Resident #12's Flonase 50mcg spray opened and not dated. also, Albuterol sulfate inhaler 90mcg not dated open 198 puffs noted on dial. Observation and interview on 03/12/24 at 03:48 PM with Licensed Practical Nurse (LPN) C of the 1 East north unit medication cart revealed Resident #27's multi-dose bottle of Ferrous Sulfate liquid bottle came with 473 milliliters (ml), currently has 300ML, no open date noted on bottle. LPN C looked on all side of the bottle with no open date found. Observation of Resident #68's budesonide 0.5mg/2ML. nebulizer treatment ampules noted two foil packets opened and not dated, one loose vial was found in the brown zip lock bag not in a dispensing package and unlabeled. Observation of Resident #17's Atropine 1% eye drop for secretions the bottle was opened and not dated. Observation of Resident #62's Haldol 5mg/ML injectable 3 vials and one without the green sealed cap found in a clear plastic bag lying at the back of the medication cart in the top drawer. Observation and interview on 03/13/24 at 08:31 AM of the 1East Medication room with Registered Nurse (RN) A of the medication room refrigerator revealed a single Aplisol 1ml (10 test per bottle) injectable with top opened with no open date documented on bottle or plastic bag. RN A stated that it should have been dated when first used and threw out the bottle. 37668 On 3/12/24 at 3:55 PM, a tour of the Two East Medication Cart was completed with Registered Nurse (RN) X. The following items were present in the cart: - Evencare Blood Glucose Test Strips, Opened and Undated. When asked how long blood glucose testing strips are able to be used for after opened, RN X stated, 60 days. - Ipratropium Bromide 0.5 milligrams (mg) and Albuterol Sulfate 3 mg/3 milliliter (mL) inhalation solution (Douneb treatment) vials for Resident #16. The foil container was open and undated and there were two loose vials in the bottom of the box. - Ipratropium Bromide 0.5mg and Albuterol Sulfate 3 mg/3 milliliter (mL) inhalation solution vials for Resident #32. The foil container was open and undated and there was two loose vials in a separate box. When asked how long Ipratropium Bromide 0.5 mg and Albuterol Sulfate Inhalation 3 mg/3 milliliter (mL) inhalation solution is good for after being opened, RN X revealed they did not know. When queried if the medication information insert in the box contained the information, RN X reviewed the document and stated, One week once foil (package) opened. - Fluticasone Furoate/Vilanterol Ellipta 200 mcg (microgram)/ 25 mcg inhaler for Resident #32, opened and undated. When asked how long the medication is able to be used for after opened, RN X reviewed the medication information insert and stated, 6 weeks. - Albuterol Sulfate 0.63mg/3mL inhalation solution for Resident #51, foil package open and undated. - 10-inch winged infusion set (Huber needle) with 22-gauge (g) X 0.75 inch needed; Expired: 12/31/23. When queried, RN X revealed a Resident was currently using the needles for infusion treatments. - Novolin R Insulin 100 U (units) vial for Resident #24. The vial was dated as opened on 2/19/24 and expired on 4/1/24. When queried how long Novolin insulin is able to be used for after opened, RN X indicated they thought it was 30 days. When queried regarding the expiration date of 4/1/24, RN X was unable to provide an explanation. - Carboxymethylcellulose sodium 0.5% eye drops for Resident #14, open and undated. - Olopatadine 0.1% eye drop vial for Resident #28, Opened and undated. - Carboxymethylcellulose sodium 0.5% eye drops for Resident #51, open and undated. - Olopatadine 0.1% eye drop vial for Resident #51, Dated as opened on 1/30/24 and expired on 2/27/24. When asked, RN X confirmed Resident #51 was currently receiving the medication. - Atropine 1% drops for Resident #14, Opened and undated - Alphagan P 0.1% eye drops, 5 mL vial for Resident #24. Open and undated. An interview and documentation review was completed with the Director of Nursing (DON) on 3/12/24 at 5:08 PM. When queried regarding open, undated, and expired medications and medical supplies in the Two East Medication Cart, the DON verbalized medications should be dated when opened and disposed appropriately. The DON indicated they would address the concerns. 39059 On 3/12/24, at 9:00 AM, During medication administration task, a record review of the Sign In and Out Sheet for Narcotics with Nurse L revealed only 4 columns. There was a column for Date Time Outgoing Nurse Incoming Nurse. Nurse L was asked what the signatures on the sheet meant and Nurse L explained that the incoming nurse looks at the actual narcotics and the outgoing nurse looks at the orange sheets and then both nurses sign that they match. Nurse L was asked how they keep track of newly delivered narcotic cartridges and Nurse L stated, we just match what's in the drawer to the orange sheets. On 3/13/24, at 11:40 AM, the Director of Nursing (DON) was interviewed regarding the Narcotic reconciliation process in the facility. The DON explained when the Narcotics are delivered from the pharmacy each cartridge of narcotics are wrapped in an orange narcotic sheet. The narcotic gets placed into the locked drawer in the medication cart and the orange sheet gets placed in the narcotic binder on top of the cart. Once the narcotic is destroyed or completed, the orange sheets get placed in a mailbox and then stored in medical records. The DON offered that two nurses destroy narcotics and place them in the drug buster. The DON explained they do not have a part of it and stated the Quality Nurse M managed the process. On 3/13/24, at 11:50 AM, the Quality Nurse (QN) M was interviewed regarding the facility process on narcotic reconciliation. QN M offered that the narcotics get delivered and two nurses sign them in to the appropriate cart. QN M explained the nurses reconcile at shift change with the orange narcotic sheets to ensure the quantities match. QN M offered that they are never present when narcotics are delivered as they are delivered at night time. QN M stated, we used to audit but had been compliant for quite some time so we stopped but then began auditing two to three months ago. QN M was asked how they would recognize if a narcotic cartridge and the orange sheet for that cartridge went missing how would they know. QN M offered that was why they began the auditing again. QN M was asked if there was discrepancies and QN M stated, there was discrepancies on the count; it was either the medication was given and not charted or the other way around. QN M further offered that they had discussed with a new employee/nurse that they may change the narcotic reconciliation process to add the total number of cartridges to the count sheets rather than just the two nurse signatures. On 3/12/24, at 1:30 PM, a record review of the facility provided policy Controlled Substance & Narcotic Count Revised: 9/27/23 revealed . Medication Administration and Accountability by Nurses a. The nurse administering a controlled substance will immediately sign out each dose of medication after it is removed from the locked drawer in the proof of use sheets and administered. NOTE: The medication is also signed out on the residents EMAR. b. After completion, Proof of Use Sheets are restored in the facility for a period of at least 2 years. c. All controlled substances locked in the double lock cavinet or drawers, or any refrigerated substance [NAME] be accounted for at the beginning and the end of each shit, jointly by the nurse coming on and going off duty. i. These counts will be verified by the signature of both nurses on the shift inventory sheets . d. A count of number of pills will be completed with each count and noted on the Controlled Substances Shift Inventory Sheet. i. Nurses will add number of new cards containing controlled substances with each deliver. ii. All nurses will subtract completed cards removed . The facility did not provide the Controlled Substances Shift Inventory Sheet nor was this document located in the binder atop the medication carts.

Deficient Practice Statement (DPS) One: Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing effective outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure appropriate Personal Protective Equipment (PPE) utilization and staff knowledge for transmission-based isolation precautions resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness to all 71 facility residents. Findings include: On 3/11/24 at 11:46 AM, an isolation cart was observed outside of Resident #45 and Resident #19's room. A sign was present above the cart, directly next to the door with a red hand signaling to stop. There was no signage visible indicating the reason for the red hand sign and/or the type of isolation precautions. An observation of the cart revealed it contained gowns, goggles, and procedural masks. There was no hand sanitizer available in the hallway. The room door was open, and Resident #45 was visible from the hallway. At 11:48 AM on 3/11/24, Housekeeper AA was observed in the hall near Resident #45 and Resident #19's room. When queried regarding the reason for the red hand sign outside of the door and the PPE cart, Housekeeper AA stated, (Resident #45's) spouse tested positive. Housekeeper AA was asked what they tested positive for and replied, Covid. When queried if both residents were in transmission-based isolation precautions, Housekeeper AA indicated only Resident #45. When asked what type of precautions were in place and what Personal Protective Equipment (PPE) is required, Housekeeper AA stated, Have to wear a gown, gloves, N-95 (respirator mask that filters very small microbes), all of it. When queried where they obtain an N-95, Housekeeper AA indicated they should be in the drawers of the PPE cart. On 3/11/23 at 12:00 PM, a PPE cart with a red hand stop sign was observed outside of Resident #25 and Resident #40's room door. At 8:50 AM on 3/12/24, Licensed Practical Nurse (LPN) B was observed in Resident #48 and Resident #17's room wearing PPE from the hallway. There was no PPE cart and/or sign outside of the room door. On 3/12/24 at 8:58 AM, Resident #25 and Resident #40's room door was open. From the hallway, a staff member was observed providing care to Resident #25 while wearing a gown and gloves. LPN B was observed exiting the room and walking to Resident #45 and Resident #19's room. LPN B proceeded to don a gown and goggles without performing hand hygiene and then entered the room. An interview was completed with LPN B on 3/12/24 at 9:05 AM., When queried regarding observation of them wearing a gown in Resident #48 and Resident #17's room, LPN B confirmed they were. When asked why they were wearing a gown, LPN B replied, (Resident #48) has an ileostomy (surgically created opening in the abdomen to the intestine to allow for the passage and collection of fecal matter). When queried if Resident #48 was on transmission-based isolation precautions, LPN B indicated they were. When asked why there was no signage present indicating the Resident was on precautions and/or PPE available outside of their room, LPN B replied they did not know. When queried regarding the stop sign and PPE cart outside of Resident #45 and Resident #19's room, LPN B revealed the precautions are in place for Resident #45. When asked why the Resident was in transmission-based isolation precautions, LPN B stated, Covid. When queried what PPE is required for residents on precautions for Covid, LPN B replied, Wear googles, gown, gloves, and an N-95. LPN B was then asked why they did not wear an N-95 into the room, LPN B replied, I wasn't? When informed this Surveyor observed them don a gown and goggles, without performing hand hygiene, changing their mask, and/or donning an N-95, LPN B stated, I don't know. LPN B then revealed there were no N-95 masks in the PPE cart and they would get some. When queried if Resident #19 is also on transmission-based isolation precautions, LPN B replied they were not. When asked how individuals know which Resident has precautions in place, LPN B replied, You know which resident by looking at the care plan inside the room. When asked to clarify if they were saying you have to enter the room to look at the care plan handing on the wall to know which Resident has precautions in place, LPN B confirmed that was correct. When asked why there were no gloves in the PPE carts outside of the rooms, LPN B indicated gloves are inside of the rooms. LPN B was then asked what PPE is required to be worn for each type of precautions including contact, droplet, and airborne. LPN B was unable to accurately state the PPE required per Centers for Disease Control guidelines. On 3/13/24 at 9:02 AM, an observation of Certified Nursing Assistant (CNA) BB exiting Resident #25 and Resident #40's room and entering the hallway with PPE on. CNA BB proceeded to begin removing their PPE in the hallway of the facility. Upon approaching the room, Resident #40 was seen sitting in a wheelchair in their room. CNA BB stepped back into the room and disposed of their gown. When asked if they has provided care to Resident #40, CNA BB confirmed they had. When queried regarding observation of them exiting the room and being to remove their PPE, CNA BB did not provide an explanation. An interview was conducted with the Director of Nursing (DON) on 3/13/24 at 9:17 AM. When queried what is the first step, prior to donning PPE, to enter a resident room with transmission-based isolation precautions in place, the DON replied, Hand Hygiene. A tour of the hallway was completed with the DON at this time. When asked how staff are supposed to perform hand hygiene prior to donning PPE and entering a room, the DON confirmed there was no hand sanitizer available outside of the rooms and indicated they would address the concern with Infection Control staff. An interview and review of facility infection control data was completed with Infection Control (IC) Registered Nurse (RN) Y, Licensed Practical Nurse (LPN) I, and LPN Z on 3/13/24 at 10:54 AM. When queried, RN Y explained LPN I was retiring, and they were taking over as the IC nurse. RN Y was asked how long they had been working at the facility and indicated approximately six months. When queried how many Residents were on transmission-based isolation precautions, RN Y stated, 11. When asked if there were 11 residents in transmission-based isolation precautions on the survey start date, RN Y indicated there were. When queried why that number did not match the number identified on the CMS-802 form, RN Y revealed residents who have enhanced precautions in place are not included on the CMS-802 form as transmission-based isolation precautions. When asked, RN Y stated the facility follows CDC guidelines for transmission-based isolation precautions. RN Y was then asked how staff and visitors know what PPE is required to enter a room when the only visible signage is a red stop sign and revealed the precaution signage is under the red hand stop sign. When queried how that clearly identified the type of precautions and specific PPE to used in a visible place, RN Y revealed it does not but they were unaware the type of precautions could be listed. When queried what PPE is required for droplet precautions, RN Y stated, Mask, gown, and googles. When queried what PPE is required for contact, RN Y stated, Gown and gloves. RN Y was then asked what PPE is required for Covid-19 and provided a sign which stated Respiratory Transmission Precautions which indicated an N-95, gown, gloves, and eye protection should be worn. When queried what type of precautions Resident #45 is supposed to have in place, RN Y stated, (Resident #45) was just exposed (to Covid) and their spouse tested positive. RN Y revealed the Resident's wife had visited with the Resident in their room the day before becoming ill and testing positive. RN Y was then asked if the Resident was in precautions due to close exposure and suspected infection and confirmed they were. When asked what type of PPE is required for Residents suspected of Covid - 19 infection, RN Y replied droplet. When asked why the Resident was not on airborne precautions, with N-95 use, due to exposure and suspected Covid-19 infection, RN Y indicated their understanding of CDC recommendations was that an N-95 mask was not necessary as the Resident had not tested positive. When queried regarding mitigation of potential spread through use of best options for PPE, further explanation was not provided. When queried regarding Resident #45's roommate, RN Y replied they were not on precautions. RN Y was then informed of staff statements regarding appropriate PPE and indicated staff had been educated. When queried regarding process surveillance of transmission-based isolation precautions and appropriate PPE utilization, RN Y indicated they would need to increase rounding. When queried what is the first step in donning PPE, none of the staff responded. When asked if hand hygiene should be performed prior to donning PPE, all staff verified if should. When queried how staff are able to perform hand hygiene prior to donning PPE for residents in transmission-based isolation precautions when there is no hand sanitizer available outside of the rooms/in the hallway, LPN I indicated there was hand sanitizer available right inside the resident rooms. When asked if PPE should be donned prior to entering the room, RN Y verbalized understanding and indicated they would address the concern with the DON. A review of facility provided Infection Control Surveillance Form documentation revealed a handwritten form containing the headers: Date, Room Number, Name, Antibiotic, S (Susceptible)/R (Resistant), Diagnostic Test, Comments, Type of infection, Urinary continence, and Type of Precautions. A list of residents receiving antibiotics for each month was also included. The form did not indicate what type of criteria was utilized, admitted , symptoms, etc. The facility infection control data for January 2024 was reviewed with RN Y and LPN Z at this time. When queried what the Date section indicated on the Infection Control Surveillance Form, RN Y replied that was the date that the infection began. When asked what criteria the facility utilized, RN Y replied, McGeers. RN Y was asked where they track whether an infection meets McGeer criteria and stated, All meet criteria. Unsampled Resident#1 was reviewed at this time. The Resident was listed as having been diagnosed with Bronchitis. Per the line list, the Resident was treated with two separate antibiotics but the start and stop dates of the medications were unclear as the dates listed were 1/10, 1/15, and 1/25. The diagnostic testing section detailed, UA (urinalysis) with C&S (Culture and Sensitivity) if indicated. Straight cath with negative results. Negative Nitrates. Chest X-Ray if needed. The comments section detailed, Increased Confusion. When queried if the antibiotics were started on the same date, RN Y indicated they would need to review the resident's medical record. After reviewing the record, RN Y revealed the medications were not started on the same date. RN Y revealed the second antibiotic was started days after the first one was completed. When asked why they were listed on the same line, RN Y relayed they were for the same resident, so they added it to the same line. RN Y was asked if they complete a McGeer criteria form for each infection and/or antibiotic and stated, No. RN Y revealed have a template they use as a reference but do not complete for each resident. When queried if McGeer criteria was meet for the first antibiotic, RN Y reviewed the medical record and revealed it did not. Unsampled Resident #2 was listed as having a Urinary Tract Infection and receiving antibiotic treatment. The line listing indicated the Resident was admitted on antibiotics but did not specify the organism. When asked when the infection started and the organism, RN Y stated they did not know as the Resident was admitted on the antibiotic. When queried regarding the importance of knowing the causative organism to identify and mitigate spread, RN Y verbalized understanding. Further review revealed eight Residents included on the list did not have any symptoms of infection listed. When asked, RN Y revealed they would need to review each chart to provide the signs/symptoms and when the infection first began. Review also reviewed multiple residents were listed as receiving different antibiotics, some with different infections, on the same line without clear delineation of the infection and/or dates. Resident #36 was listed as receiving two antibiotics for a diagnosis of prostatitis. The line list did not identify if the Resident was admitted on antibiotics or if the infection was acquired at the facility. The Date listed was 1/27/24 but the line list indicated a UA was sent on 1/26/24. When queried why a UA was obtained prior to the Resident having signs and symptoms, RN Y revealed the Date column on the Infection Control Surveillance Form is actually reflective of when they begin tracking the infection and not necessarily when signs and symptoms began. When queried regarding the importance of signs/symptom start date for mitigation and tracking, RN Y indicated staff usually notify them immediately. No further explanation was provided. Different values were obtained when the number of residents listed as receiving antibiotics on the antibiotic order list and the Infection Control Surveillance Forms for January 2024 were compared and did not match. When asked the reason, RN Y indicated they must have made an error. The monthly summary for infection control did not address infections which did not meet criteria for treatment, facility vs community acquired infections, any trends, and/or process surveillance completion. When queried regarding the lack of readily accessible information and unclear documentation of infections, RN Y verbalized understanding and indicated they were going to make changes in the process. No further explanation was provided. Review of facility provided policy/procedure entitled, General Infection Prevention and Control Policy (Revised: 3/24/23) revealed, The facility has established and maintains an infection prevention and control program designed to . help prevent the development and transmission of communicable diseases and infections . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections . for all residents, staff . 39083 Based on interview and record review, the facility failed to monitor and assess legionella presence in premise plumbing, resulting in an increased risk of legionellosis infection, affecting all residents in the facility. Findings include: On 3/11/24 at 1:47 PM, during a review of the facility's Water Management Program, revised 9/27/23, it identifies consistent detection of legionella in the water samples conducted biannually. A review of the testing laboratory's Legionella Summary Sheet, for sample date 3/14/23, it identifies the following: Sample Location Results (CFU/mL) 2W Side Shower Sink 3.0 Laboratory Sink 38.0 Beauty Shop Hairwash Sink 32.0 During an interview on 3/11/24 a 1:47 PM, Plant Operations Assistant (POA) O stated that as a result of the legionella samples, some water fixtures were disinfected, and the same fixtures were retested with no legionella isolated. A review of the testing laboratory's Legionella Summary Sheet, for sample date 8/17/23, it identified the following: Sample Location Results (CFU/mL) Privacy Room Sink 5.0 1E Soiled Utility Sink 3.0 1W Kitchen Beverage Sink 5.0 2E Main Shower 1.0 Domestic HW Tank 1.0 During an interview on 3/11/24 at 1:55 PM, POA O was queried on the corrective actions for the positive legionella results of 8/17/23 and stated that they used biocide treatment on the positive fixtures but must not have retested as the CFU/mL's were on the lower end. POA O continued to say that they use the laboratory's recommended remedial actions. According to the Laboratory's Action Criteria for Legionella, it notes for ranges 1-9 CFU/ml for Potable water, Level 3: Implement Action 2. Conduct review of premises for the direct and indirect bioaerosols contact with occupants and health risk status of people who may come in contact with bioaerosols. Depending on the results of the review of the premises, action related to cleaning and/or biocide treatment of the equipment may be indicated. This level of Legionella represents a low but increased concern. According to the CDC's Legionella Control Toolkit, at https://www.cdc.gov/legionella/wmp/control-toolkit/routine-testing-figure-01.html, it notes, . The detection of 1.0-9.9 CFU/mL in potable water or the detection of 10-99 CFU/mL in non-potable water indicates that Legionella Growth appears poorly controlled. The CDC publication further illustrates, . Extent indicates that Legionella growth appears: Poorly Controlled (when) Detection in more than one location within a water system. According to the Facility's Water Management Program, revised 9/27/23, it notes, . 6. Testing protocols and control limits will be established for each control measure. a. Individuals responsible for testing or visual inspections will document findings. b. When control limits are not maintained, corrective actions will be taken and documented accordingly c. Protocols and corrective actions will reflect current industry guidelines During an interview on 3/13/24 at 1:07 PM, Inservice Infection Preventionist I was queried on their involvement with the Water Management Plan and stated that Plant Operations Assistant O took over the program and they review it once a year. Inservice Infection Preventionist I continued to say that they were not aware of the positive legionella samples in the facility water distribution system.

Based on interview and record review, the facility failed is placed in immediate jeopardy for its failure to provide every attempt to clear the airway for one resident (Resident #189) of 16 sampled residents, resulting in Resident #189 beginning to cough with some gurgling in the upper airway, respiratory distress and harm and/or death. Immediate Jeopardy: Immediate Jeopardy was begun on [DATE]. Immediately Jeopardy was identified on [DATE]. NHA was notified of the Immediate Jeopardy on [DATE] at 11:35 AM. Immediate Jeopardy was abated or removed on [DATE]. Immediate Jeopardy was identified on [DATE]. The Administrator and Director of Nursing were notified on [DATE] at 10:35 AM of the Immediate Jeopardy that began on [DATE] due to the facility's failure to make attempts or maneuvers to clear Resident #189's airway, implement an abdominal thrust or Heimlich maneuver during a choking event on [DATE] at 5:58 PM. Immediate Jeopardy began on [DATE] at 5:47 PM when, per record review and interview done on, [DATE] at 02:14 PM with the Nursing Home Administrator (NHA) of a record review of Resident #189's progress notes and code status and a record review of the facility-provided 'Aid to a Choking Victim: Conscious or Unconscious' policy. Record review of facility 'Aid to a Choking Victim: Conscious or Unconscious' policy reviewed date [DATE], revealed the purpose: Choking is considered an acute emergency and regardless of code status every attempt to clear the airway must be made . The American Heart Association choking protocol will be initiated by Licensed Nursing staff for suspected obstructed airway. All nurses will be taught cooking techniques according to the American Heart Association procedures . In a conscious victim start abdominal thrust If victim becomes unconscious lower them to the floor and begin chest compressions. Findings include: Resident #189: Record review of Resident #189 revealed an elderly female with a medical diagnosis of dementia and cognitive decline. Record review of Resident #189's Care plans pages ,d+[DATE] revealed: Cognitive/Communication: diagnosis of dementia with behavioral disturbance and cognitive social or emotional deficit . Nutrition care plan: Biting/chewing (masticatory) difficulty related to partial edentulism, does not wear upper dentures with meals . Intervention of independent at meals after set-up. Activities of Daily Living (ADL) I require more assist daily care needs due to recent fall . Record review of Resident #189's [DATE] Hospital record revealed that Resident had fall at the long-term care facility and fractured her left hip on [DATE]. Hospital records indicated the Resident #189 was stable for surgery and had surgical repair on [DATE] prior to returning back to the facility on [DATE]. Record review of Resident #189's electronic medical record noted resident #189 progress notes dated [DATE] at 4:28 PM written by Registered Nurse (RN) HH resident #189 returned from hospital via stretcher with 2 EMT's (Emergency Medical Technicians) at this time. EMT's stated that resident was given Norco (opioid analgesic- side effects of sedation, drowsiness, mental clouding, lethargy, impairment of mental and physical performance . Nursing 2017 Drug Handbook, pg. ,d+[DATE].) before transfer. Resident is stable condition. Resident BBS (Bilateral breath sounds) clear, BS (bowel sounds) heard in all 4Q (four quads). Resident alert and talking during care. 1:1 Certified Nursing assistant (CNA) present. Resident made comfortable before leaving room . Record review of Resident #198's progress note dated [DATE] at 5:56 PM written by Licensed Practical Nurse (LPN) Y revealed: Certified Nurse Assistant (CNA) called this nurse into resident's room. CNA stated that resident is coughing after drinking fluids at supper. CNA reported that resident needed assist with eating and starting coughing after taking a drink of water. Resident noted to be coughing with some gurgling in upper airway. Resident respirations suddenly became hiccup like and shallow. Color pale, this nurse instructed CNA to find nurse manager. Nurse manager in to assess resident. Record review of Resident #198's progress note dated [DATE] at 5:58 PM written by Licensed Practical Nurse (LPN) Y revealed: Nurse Manager instructed this nurse to call 911. 911 called at this time. EMS (Emergency Medical Services) canceled due to resident expired. Record review of Resident #198's progress note dated [DATE] at 5:58 PM written by Registered Nurse (RN) C revealed: Called into resident's room due to resident's condition. Upon entering resident's room she's noted to be in bed in an elevated position with silent hiccup like cough, and a greyish-yellow waxy appearing skin. Resident's head of bed elevated higher. Instructed LPN to call 911. Resident with noted eyes fixed and non-reactive. Resident un-responsive to both verbal and tactile stimuli. BBS (Bilateral Breath Sounds) with no sound. Resident's O2 sat (Oxygen saturation) and pulse not reading on vital machine. Radial pulse attempted to be obtained and not able. No heart rate or respirations x 1 minute both. Time of death at 5:58 (PM). In an interview on [DATE] at 02:30 PM with Registered Nurse (RN) C, who has worked at the facility of 9 years, stated that Resident #189, she did not appear to be choking to me, she appeared short of breath. I elevated her head of her bed and instructed the Licensed Practical Nurse (LPN) Y to call 911, it was an emergency situation. Then Resident #189 stopped breathing, I listened to heart sounds, and she was a DNR, and I pronounced her deceased . Before this she was having her meal, it was between 5:30 and 6:00 PM dinner time, the Certified Nurse Assist (CNA) Z was in the room. The CNA Z came out of the room and told me that Resident #189 was coughing after she took a drink and could I come and see her. I asked if I needed to come immediately or if I could finish my progress note. CNA Z said no it could wait. Licensed Practical Nurse (LPN) Y said that she would go look at her (Resident #189) for me. LPN Y then came out and got me, and I finished my note and then went right away. I walked in Resident #189 was in the bed not elevated halfway or a little upward. Resident #189 had that silent hiccupping, chest was moving, she did not make eye contact. I instructed the LPN Y to go call 911 and to bring back the oxygen tank. Resident #189 stopped breathing, I listened to lung sounds and apical pulse for 1 minute and then I pronounced her deceased . She did have a meal tray at the bedside, but the meal tray was pushed aside on the bedside table. When I went into the room, she was not responding to calling her name, tactile touch to her hand. Yes, there was a meal tray in the room it was during the dinner time meal, I believe that she was eating prior. In an interview on [DATE] at 11:50 AM with Licensed Practical Nurse (LPN) Y of Resident #189's death at the facility revealed: That Resident #189 had just gotten back from the hospital after a fall. Resident #189 was having dinner at the time; she had a 1:1 (one to one) supervision Certified Nursing Assistant (CNA) Z when she came back from the hospital. The CNA Z came out of the room to report that she had to help (Resident #189) with eating by spooning food to her is what I heard at the nursing station. It was bite by bite per the CNA Z had to feed her. The CNA Z was helping her to eat. While she was lying in bed, the tray was set up. Resident #189 was not like herself when she came back from the hospital. Resident #189 was a lot weaker; she had only been back for a couple of hours. The CNA Z came out to the nurse's station and said that someone needed to go look at Resident #189. Resident #189 wasn't my resident, but I went to the room, I saw she was awake sitting up, but not enough in my opinion to be eating, she wasn't up high enough. The CNA Z said that she was feeding her, when Resident #189 started to have trouble swallowing her food and trouble with all over-eating. When I got in the room, we tried to get her to cough it up. She might have said a word or two, but she was clearly in distress. It all happened within a minute or two. No, no one tried the Heimlich maneuver, she was coughing and then she just stopped. LPN Y left the room to get a breathing treatment and to call 911. It happened during her meal; the CNA Z was feeding her. I went into the room and then went back out to get the RN C and call 911. and then the RN C said to cancel the 911 call because she expired. No, the crash cart wasn't brought in. In an interview on [DATE] at 09:38 AM with Certified Nursing Assistant (CNA) Z that Resident #189 had just came back from the hospital. CNA Z stated that she pickup an extra shift to be the 1:1 (one on one), supervision due to her dementia. CNA Z stated that Resident #189 came back really tired and lethargic, she had just had surgery, she was out of it, but she was talking to me. CNA Z stated that Resident #189 was just really tired, on and off sleeping. CNA Z stated that she got Resident #189 situated and took her off the gurney, slide across to the bed, I just made her comfortable. We chit chatted a little bit. I believe that she came back around 4 PM. Then it was dinner time, and CNA Z went to the dining room to get her water, pop and residents' meal. CNA Z stated that she did not remember what was on the meal tray or the texture. CNA Z took it (tray) back to Resident #189's room and set her up to eat. CNA Z stated that I don't believe I feed her, and then she took a drink of water and she started to cough, and I asked if she was OK. Resident #189 continued to cough; she thought it was phlem. Resident #189 continued to inter-mitten cough and then I went to get the nurse. I went to the nursing station; I asked if they could come and assess Resident #189 for the cough. Registered Nurse (RN) C, she was the nurse manager, she said wait, 'I'll be right there'. CNA Z stated that she went back to the room with the vital signs machine, I got her vitals. She continued to cough and got a raspy gurgle, and she turned blue, she took her last breath and that was that. Registered Nurse (RN) HH came into room also. The nurses assessed her and took her vitals and then her blood pressure went, we were going to get the crash cart, but she had already started the slow last couple of breaths. It all happened within 10 minutes it was so fast. The crash cart was mentioned but we didn't go get it. She just died . In a phone interview on [DATE] at 10:32 AM with Registered Nurse (RN) HH revealed that she was on vacation. But the facility said to call the surveyor. RN HH stated that she remembered Resident #189, and was asked if she had been in the room the day Resident #189 died ? RN HH stated: That was so long ago, I don't believe I was. I was working that day she passes away, but I don't believe that I had anything to do with it. She wasn't my resident and I pretty sure I was not in her room. I don't have any notes to review here. That's all I can tell you. On [DATE] at 4:15 PM received Abatement plan from facility and was reviewed and sent to survey manager via email. On [DATE] at 5:02 PM surveyor received phone call acceptance of the abatement plan from the surveyor manager. Abatement: The Immediate Jeopardy was abated on [DATE], based on confirmation during interviews conducted on [DATE] and [DATE] that the facility had implemented the following to remove the immediate jeopardy. 1.) On [DATE] the facility identified the nurse manager involved in the incident was educated on the facility's CPR and Choking episode policy including response to situation. 2.) On [DATE] the In-service department began facility wide training on the facility's CPR and Choking policy. Training will be ongoing until all staff have been educated on the facility's CPR and choking policy. 3.) The Certified Nursing Assistant (CNA) involved in the incident will be educated immediately upon her first return to workday. The Licensed Practical Nurse (LPN) involved in the incident no longer employed at the facility. Record review of the facility 'All Staff Mandatory Plan of Correction In-Service' documents revealed in-services on [DATE]th, 7th, 8th, 9th 2023 at 7 am, 10:30 am, 2:30 pm, 3 pm. Staff must attend one in-service. Location: In-service room. Will last approximately 15 minutes. Document attached to the in-service announcement stated: Notify your nurse if a resident is coughing or choking when eating. Nurses need to do assessment or resident, if choking start Heimlich maneuver and have someone call 911 immediately. Send resident out to hospital for evaluation even if you dislodge the food item. They need to be seen to make sure there is no injury to resident. As of [DATE], there were 115 out 279 staff members were educated on the 'Aid to a Choking Victim: Conscious or Unconscious' policy. Staff signature sheets were reviewed.

Based on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcers for three residents (Resident #3, Resident #58, Resident #61) of 21 sampled residents, resulting in the worsening of pressure ulcers for Resident #3-the coccyx to open, Resident #58 to acquire pressure ulcers of the left heel and Resident #61 to have a facility-acquired Stage III pressure ulcer to the left ear with the likelihood for pain and discomfort and prolonged illness. Findings include: Record review of the facility 'pressure Ulcer Guidelines/Standards of Care' policy dated 9/28/2022, revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate 'Suspected deep tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue form pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjunct tissue. 'Stage III' is a full thickness loss where subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss and undermining and tunneling can be present. Resident #3: Record review on 02/28/23 at 03:18 PM of Resident #3's electronic medical record revealed a Facility acquired Pressure Ulcer noted as Unstageable. In an interview on 03/02/23 at 08:30 AM with both Registered Nurse (RN) FF and Licensed Practical Nurse (LPN) GG both are wound care nurses for the facility. They do wound rounds one time weekly. Doctors do not round with wound care nurses. Review of Resident #3: He was in the COVID unit and that's where his facility acquired pressure ulcer started, at first it was unstageable, but now it is open, and we are packing the wound (Stage III). Resident #58 also has a facility acquired Deep tissue injury; it started here when she had a left foot splint from therapy that rubbed on her heel. It did open (Stage II), and we had to do treatments to it. Now, it is closed with a protective dressing. Observation on 03/02/23 at 10:05 AM of Resident #3's coccyx wound dressing change observation with LPN GG and RN FF to hold the resident in position on his side, revealed an old dressing dated 3/1/23, remove of old dressing revealed a packed wound with AG material. Observed an open wound, RN FF stated that it was smaller and became larger. Wound cleanser with Prophase for 5 minutes held to the wound. The wound to the coccyx started in May 2022 while he was in the COVID unit. Measurement of length 0.7 cm x 0.9 cm in width (there was no depth measurement taken). Area cleansed and packed with pluragel via Q tip, and then packed with Opticel material with Q tip. Resident #58: In an interview on 02/28/23 at 01:57 PM with Resident #58 revealed that the wounds to her heel on the left foot started here and so did her butt areas. They are healing here, and yes, they do the treatments. Observation and interview on 03/02/23 at 10:25 AM of Resident #58's left heel wound area with Registered Nurse (RN) FF revealed that the residents wound started at the facility on 3/4/2022 as a Deep Tissue Injury and progressed to an open wound. Observed dressing dated 3/1/23. Observation revealed a closed deep tissue injury, slow to blanch around the wound site. RN FF stated that the wound started from a left leg splint that went from the calf and down under the heel and foot, the heel rubbed on the leg splint. Observation of epithelial measuring 0.7 cm X 1.20 cm intact. Resident complained of pain rated at a level of 5. 38471 Resident #61: On 2/28/2023 during initial tour, Resident #61 was observed resting in bed and behind his left ear was a bandage. At the time it did not appear to be causing the resident any distress as he appeared to be content and comfortable. On 2/28/2023 at 12:24 PM, a review was completed of Resident #61's medical record and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dysphagia, Chronic Kidney Disease, Syncope and Collapse and Atrial Fibrillation. Resident #61 is dependent on staff for his Activities of Daily Living (ADL). Further review of Resident #61's records revealed the following: Physician Notes: 2/6/2023: .patient is noted to have Stage III left posterior ear pressure injury .Patient is being closely followed by the facility wound care nurse. Patient's appetite is poor at times so the recommendation is for protein supplementation twice daily to help with skin integrity and wound healing . Pressure Injury Awareness From: .Site: lt (left) posterior ear, upper crease: Facility acquired: 1/27/2023 .Unstageable pressure injury notes to it posterior ear, upper crease, measuring 0.5cm (centimeters) x 0.4cm , 100% slough notes to wound bed, wound edge well defined, surrounding skin red and blanchable, no tunneling or undermining noted, scant bloody drainage noted no odor noted. Lt posterior ear, upper crease: Soak with prophase wound wash for 5 minute, rinse with NS (normal saline), pat dry, apply sureprep skin barrier to surrounding skin, apply plurogel to wound bed, cover with optiform QOD and PRN .avoidable . Care Plan: Problem: Mobility: I need help to transfer and with my mobility due to having R (right)-sided weakness (r/t (related to) CVA in October 2017), contractures in both my legs (knees) and my left hand, dementia, and generalized weakness . ADLS: I need assistance with bathing, dressing, and grooming due to having generalized weakness, dementia . Skin Management: I am at risk for skin breakdown r/t right-sided weakness following a stroke .I have dry and fragile skin which places me at risk for skin tears and bruising. I have HX (history) of pressure areas to b/l (bilateral) heels, b/l hips, left elbow & right mid back. My left hip has an area of indentation which is scarring from previous pressure area and I sometimes get blisters on my left hip .March March 2021: The toenails on my left great toe and right 2nd toe are lifting (left great toenail came off). 4/22/2022: I developed a Stage 1 pressure area on my left medial hand r/t brace (resolved 4/29/2022). 3/30/2022: I developed a Stage 2 pressure area on my left ear top of crease (resolved 4/15/2022). 4/29/2022: Dry, flaky growth on my right lower arm. 8/5/22: DTI proximal left thumb base and Stage 1 distal left thumb base, both resolved. breakdown, through next review. Approach: I am dependent to turn and reposition in bed at routine intervals of every 2 hours, going from back to right side . I am dependent for shaving and combing hair and for bathing and dressing .I receive a complete bed bath with shampoo weekly. Resident #61's care plan did not address his posterior left ear pressure area. On 3/1/2023 at 3:50 PM, an interview was conducted with Wound Nurse GG and FF, regarding Resident #61's facility acquired wound. The wound nurses reported Resident #61's left posterior ear wound opened on 1/27/2023 and they were informed by his nurse that he had a new skin issue. They went to his room to assess the area and found a facility acquired wound to his left ear from the resident not wearing 02 foam protectors. The wound nurses were queried if 02 foam protectors were readily available at the facility and nurse stated they are. They reported this was a preventable Stage 3 wound if his 02 foam protectors were in place. Nurse GG explained a facility nurse changed Resident #61's nasal cannula tubing the night prior and should have saw the wound. Nurse GG then completed an in-service with the nurse regarding the incident. Nurse GG and FF stated the wound was unstageable when it opened on 1/27/23 and on 1/31/2023 staged it at Stage III. Further review was completed of Resident #61's medical records: Wound Notes: 1/27/2023 at 10:11: Resident assessed d/t nurse concern. Unstageable pressure injury noted to lt (left) posterior ear, upper crease, measuring 0.5cm x0.4cm, 100% slough noted to wound bed .Foam ear protectors places on oxygen per standard of care . 1/31/2023 at 11:38: Previously noted unstageable pressure injury to L posterior ear, upper crease is now a Stage 3. Wound measuring 0.2cm x 0.1cm x0.1cm. Wound bed 100% beefy-red granulation tissue w/edges .foam ear protections in place to 02 tubing per standard of care . 2/06/2023 at 13:30: Stage 3 remains to posterior ear, upper crease, measuring 0.3cm x0.2cm, 100% epithelial skin noted, non-blanchable, surrounding skin pink and blanchable, no tunneling or undermining noted, no drainage noted, no odor noted .02 with foam ear protectors in place per standard of care . 2/14/2023 at 10:00: Lt posterior ear, upper crease remains with stage 3, measuring 0.4cm x 0.3cm, 100% epithelial skin noted slow to blanch, surrounding skin and blanchable, no tunneling or undermining noted, no drainage noted, no odor noted . 2/22/2023 at 13:20: Stage 3 remains to left posterior ear, upper crease, measuring 0.4cm x 0.3cm, 100% epithelial skin noted, slow to blanch, surrounding skin pink and blanchable no drainage noted, no odor noted . Respiratory Supply and Equipment for Resident #61: January 27, 2023: Log indicated Resident #61's 02 concentrator and cannula tubing were changed by Nurse MM on 1/27/2023. On 3/2/2023 at 11:30 AM, Nurse FF and GG preformed wound care on Resident #61's wound. The wound was located at the crease, at the top of his ear. Nurse FF reported the wound was slow to blanch, 100% epithelial with no odor or drainage. Nurse FF stated the wound has been stagnant and looks the same as wound rounds last week. On 3/2/2023 at 11:55 AM, an interview was held with Nurse BB regarding 02 form protectors' availability in the facility. Nurse BB showed this writer the oxygen room and the multiple 02 protectors that were accessible in the storage room The nurse reported they recently received nasal cannula tubing that already have the 02 ear protectors attached to them. Nurse BB reported 02 protectors are always accessible and available for residents.

Based on observation, interview and record review, the facility failed to prevent recurrent Urinary Tract Infection (UTI) for 1 (#44) of 16 sampled residents, resulting in Resident #44 sustaining recurrent urinary tract infections with prolonged illness and bacteremia with hospitalization and antibiotic therapy. Findings include: Record review of the facility provided staff education/skills fair stations documents dated for June 2022, revealed that Peri-Care and Catheter Care were covered. Bullet point 'Providing Catheter Care' Procedure and 'Standards of Care Delivery for CNA's- Peri and Cath Care' were part of the skills fair packet. Staff signature sign-in sheets noted June 22 and 23 at 7am, 2pm and 3pm were reviewed. Resident #44: Record review of Resident #44's electronic medical record revealed an elderly male resident with noted times of confusion. Record review of Resident #44's care plan for Cognitive loss/dementia: hallucinations/psychosis related to diagnosis of Parkinson's disease . Care plan for Continence: continence of urine; occasional incontinence of bowel movements. My incontinence may vary in times of increased confusion . In an interview on 02/28/23 at 02:11 PM with Resident #44 revealed that the resident had a urinary tract infection (UTI) and was sent out to the hospital in late August or early September 2022. Resident #44 stated that he came back to the facility on antibiotic for UTI. Resident #44 stated then a couple of weeks later he felt the same way again, Resident #44 stated that he told them (nurses) that he didn't feel good, the nurses said that his urine smelled bad, but nothing was done. Resident #44 Then started to feel really sick and asked to go back to the hospital and that's when the infection was found in my blood from another UTI. Resident #44 had antibiotic for that and was sent back here. You need to look into that, look at my records, it's all got to be in there. Urine was smelly and the nurses didn't do anything different for him, he went out to the hospital for stomach cramps and the hospital found a UTI and it went to his blood (sepsis). Record review of Resident #44's August progress notes: 8/12/22 at 7:12am blood draw for labs in right hand. Record review of Resident #44's August progress notes: 8/12/22 at 2:53pm dietary noted Resident #44 had complaints of upset stomach and refusing meals. Record review of Resident #44's August progress notes: 8/13/22 at 8:56pm Resident #44 complained of nausea, had a poor appetite and Zofran medication (Zoran: antiemetics to prevent nausea and vomiting, adverse reaction: urine retention. Nursing 2017 Drug Handbook, pg. 1084-1087.), was given. Record review of Resident #44's August progress notes: 8/14/22 at 8:35am Resident #44 complained of upset stomach, Zofran (medication) given. Record review of Resident #44's August progress notes: 8/15/22 at 4:32am Resident #44 complained of upset stomach and Zofran (medication) given. Record review of Resident #44's August progress notes: 8/16/22 at 12:31pm Resident #44 complained of nausea and Zofran (medication) given. Record review of Resident #44's August progress notes: 8/18/22 at 1:50pm Resident #44 complained of upset stomach and stomach pains. Resident #44 was noted to request Zofran, medication given. Record review of Resident #44's August progress notes: 8/18/22 at 2:08pm dietary noted resident had meal intake as poor and feeling queasy . Record review of Resident #44's August progress notes: 8/19/22 at 10:51am Nurse Practioner noted new order to send to hospital for abnormal labs and abdominal pain. Record review of Resident #44's August progress notes: 8/19/22 at 4:22pm Nurse Practioner noted: long-term resident at this facility had labs drawn due to complaint of fatigues and malaise. Resident white blood cells elevated . has had significant nausea and vomiting over the last 24-48 hours and the nausea is not responding to Zofran. No noted hematemesis. All other systems reviewed and negative. Record review of progress notes dated on 8/25/2022 at 10:07am resident #44 was readmitted after hospitalization and treatment for UTI (Urinary Tract Infection) . Keflex antibiotic therapy was noted in other progress notes. Record review of Resident #44's hospital history & physical medical record dated 8/20/2022 noted resident was admitted to hospital for leukocytosis and urinary tract infection with IV antibiotic therapy. Record review of progress notes dated on 9/12/22 at 4:56 PM noted Resident #44 complained of shortness of breath and abdominal pain. Resident #44 requested to go to the hospital . Record review of Resident #44's progress note dated 9/21/2022 revealed the resident was readmitted from hospital setting. Record review of Resident #44's Hospital discharge note dated 9/21/2022 noted acute urinary tract infection with E. Coli and blood cultures done on 9/12/22 were positive for E. Coli . In an interview and records review on 03/03/23 at 10:43 AM with Registered Nurse/Infection Control Preventionist (RN/ICP) K of Resident #44's record review of the August and September antibiotic use logs revealed Resident #44 on 8/25/2022 the resident was readmitted from the hospital setting on cephalexin 500mg every 8 hours for urinary tract infection. Review of Resident #44's August 'Infection Control Surveillance' log noted that on 8/25/2022. Resident #44 tested positive for greater than 100,000 E. coli (Escherichia coli) and gram-negative bacilli organisms. Record review of the September 2022 'Infection Control Surveillance' antibiotic log revealed that the Resident #44 was noted on 9/21/2022. Resident #44 teste positive for urinalysis with E. coli (Escherichia coli) in the urine and blood cultures with E. coli in the blood system. Resident #44 was readmitted from the hospital with antibiotic of Bactrim 800/160mg twice daily for Bacteremia (infection of blood) and urinary tract infection. Review of progress notes that the resident complained of abdominal discomforts and requested to go to the hospital.

Based on observation, interview and record review, the facility failed to prevent fractures for two residents (Resident #2, Resident #189) of three residents reviewed for accidents and falls, resulting in a left tibia fracture, a hospital stay with surgery for Resident #2 and two left femur fractures with a hospital stay for surgical repair for Resident #189, pain, hospitalization and decreased mobility. Findings include: Resident #2: On 2/28/23, at 2:30 PM, a record review of the facility reported incident revealed Resident . has a diagnosis of Traumatic Brain Injury . On 5/15/22 at 2104 (9:04 PM) a bruise was identified on her left outer knee . measured approximately 4.5 cm (centimeters) in diameter and was with dark, pink in center . the cause of the bruise was unknown . On 5/16/22 at 0600, the nurse aide reported the bruise was enlarging . to be 10 cm x (by) 1 cm and dark purple in color . At 0840, the nurse noted the resident o be more anxious and starting to display symptoms of pain. The knee and leg were now swollen . At 1:21 PM . received notification of a fracture of the proximal left tibia . On 5/20/22, resident underwent an ORIF of the left Tibia . Resident can be easily upset with any changes in her routine and will yell out loudly at times. She will grab and flail arms and legs when she is either upset, changes in her routine, in pain or over stimulated . The fracture is described as a comminuted acute fracture. Due to the type of fracture and her Osteoporosis, the medical director did state it may have happened spontaneous or pathological in nature, perhaps with transferring or turning in bed . On 3/01/23, at 08:00 AM, CNA SS was interviewed regarding Resident #2 injury of unknown origin. CNA SS stated they were told she had a bruise to her knee but when they pulled the blanket back, there was more than a bruise. There was swelling and her foot was rotating inward, so they went to get the nurse. CNA SS stated that they had worked three days prior and no bruising or swelling was seen. CNA SS was asked if they thought Resident #2 had gotten up on their own and CNA SS stated, no, she can't get up on her own. CNA SS stated that Resident #2 was only able to twist with their transfers from bed to chair and did not take any steps at all back then. On 3/01/23, at 8:17 AM, assistant director of nursing (ADON) OO was interviewed regarding Resident #2's type of fracture and ADON OO offered that they thought the fracture happened during a transfer. ADON OO was asked if Resident #2 was ever combative during care for example receiving an enema and ADON OO offered that they day it happened the only thing that came up was the bruise so we thought maybe she hit her knee on the heater cover as the staff did state she would could come close to hitting it at times On 3/01/23, at 8:39 AM, an observation of Resident #2 was conducted along with CNA QQ and RR. Resident #2 was lying on their back in bed with there legs crossed over and squeezed together. Resident #2 was grabbing at the headboard and smiling. CNA QQ touched Resident #2's left leg and said please let me help you and at that time Resident #2 released the squeeze on her legs and CNA QQ was able to perform care. Both CNA QQ and RR assisted Resident #2 to their chair. Resident #2 did not bear weight on either leg and was transferred completely by the staff. CNA QQ and RR were both asked if Resident #2 ever kicks at them and CNAQQ stated, no she is unable to move her legs much but will grab at the head board with her arms like she is doing now. CNA QQ and RR were asked if they felt a Hoyer would work better for her transfers seems she doesn't put her feet on the floor and CNA QQ stated, she is easy and doesn't weigh much so we can lift her. On 3/1/23, at 10:00 AM, a record review of Resident #2's electronic medical record revealed an admission on 6/17/2005 with diagnoses of Osteoporosis, Osteoarthritis and dementia. Resident #2 is non-verbal and is dependent for all Activities of Daily Living. A review of the MOBILITY Problem Start Date: 05/22/2008 revealed (the resident) has impaired mobility r/t (related to) muscle weakness/atrophy, spastic extremity movements, bilateral ankle contractures . She is non-ambulatory . she was recently hospitalized on ,d+[DATE]-[DATE] for Left Tibia Fracture resulting in ORIF (open reduction and Internal Fixation/surgical procedure) On 3/01/23, at 2:07 PM, CNA PP was interviewed regarding Resident #2's fracture and CNA PP stated they do remember getting the resident but the odd thing was that she had her pants on which she never did while in bed. CNA PP stated, that they did not see the bruised knee until later in the shift about 7:30 PM when they assisted Resident #2 to bed. CNA PP stated, that Resident #2 was a one person transfer at the time. CNA PP stated that they removed her pants and observed the bruise to be green and yellow, swollen and was huge. CNA PP offered that they thought maybe they could have hit her knee on her wheelchair but don't remember hearing anything or noticing the resident in any type of pain that day. CNA PP was asked how they though she had got the fracture and CNA PP stated that a new person had put her to bed earlier that day and that she also had an enema prior as well. CNA PP also offered that maybe they had rolled her into the heater cover and bumped her knee but did not think they did. On 3/01/23, at 2:43 PM, CNA TT was interviewed regarding the day they worked with Resident #2 when the bruise/fracture showed up. CNA TT stated they normally work restorative and when they get pulled to floor for an assignment they work in pairs. CNA TT stated that they worked alongside CNA SS during all cares for Resident #2 that day. CNA TT stated both of them assisted the resident into the chair using the gait belt. Later that day, CNA TT offered that when they lied her down they did remove her pants and did not see a bruise. CNA TT was asked if they had transferred the resident or did any care with her alone that day and CNA TT stated, no and that CNA SS was with her. CNA TT stated, there was nothing out of the ordinary that day. CNA TT was further questioned regarding Resident #2 receiving an enema that day and CNA TT stated, oh yes I did have to give her a fleets. CNA TT stated, that there was nothing out of the ordinary and both her and CNA SS gave the enema because we know how she flails. CNA TT stated at the end of the shift they checked on the resident as well as the nurse for bowel movement results and that the resident did not have pants on. On 3/02/23, at 8:39 AM, CNA UU was interviewed regarding Resident #2's fracture/bruising and CNA UU stated, that they helped CNA UU with dressing for the morning and into her chair. CNA UU further offered that in the afternoon they were headed towards the linen room and heard (Resident #2) yelling out so I opened the door a little bit and asked if (CNA TT) needed help. CNA UU further stated that Resident #2 will yell out and that she does keep her legs squeezed together at times and that they don't open up that much. CNA UU stated, that they did not help CNA TT assist Resident #2 back into bed, with the enema and any other cares that day. On 3/02/23, at 12:33 PM, The Director of Nursing (DON) was interviewed regarding Resident #2's fracture and the DON stated, that Resident #2 is very vocal especially if anything is different from her normal routine. The DON was asked what their hypothesis was, and the DON offered that after speaking with the physician that felt with the history of her osteoporosis and the twisting motion with the transfer that is how it happened. The DON was alerted that CNA TT and CNA UU interviews don't match up and could they get CNA TT on the phone. On 3/02/23, at 1:31 PM, An interview was conducted with the DON, CNA UU and along with CNA TT on the phone in the DON's office. CNA TT was asked again what they remembered and CNA TT stated, they got her washed up by themselves and CNA UU spoke up and offered, that they assisted with morning cares and then CNA TT stated, oh yeah. CNA TT was asked if they had help with Resident #2 for the remainder of the day and CNA TT stated, oh I did give her enema by myself. CNA TT denied ever transferring Resident #2 by themselves but did agree that CNA UU was not in there helping for the remainder of the shift. On 3/02/23, at 1:40 PM, The DON again stated, the only thing I can think of is with the transfer when asked how they thought Resident #2 got the fracture. 22927 Resident #189: Record review of facility report incident on 4/21/2022 at 3:30PM revealed a dietary server alerted nurse that Resident #189 was on the floor. Nurse responded to resident room to find resident lying on her back, feet towards the door. Resident #189 was noted to state she lost her balance when standing up from wheelchair. Resident #189 was noted to have her own slippers on which did not have good grips. Nurse noted 1cm X 1cm elevated area to left top of head and left foot inward and shortened. Resident #189 sent to the hospital for fracture of left femur. Record review of Resident #189's 'Event History' document dated 3/1/2023, revealed that in 2021 Resident #189 sustained five (5) falls while residing in the facility. On 4/21/2022 Resident #189 sustained a fall and a dietary staff member responded to Resident #189's call for help and was found on the floor in her room. Record review of Resident #189's April 26, 2022, hospital record revealed that on 4/22/2022 the resident had a surgical repair of left hip fracture and returned to the long-term care facility on 4/26/2022 at 4:25 pm. Record review of Resident #189's June 2, 2022, at 7:40 pm facility report incident form revealed that the nurse heard Resident 3189 calling out for help and responded. Resident #189 was yelling out My hip, my hip. I think it's broke. Resident #189 was noted to state that she broke her hip, and her pain was ten (10) out of ten (10). Resident #189 was sent to the hospital and admitted with left hip fracture. Record review of resident #189's June 6, 2022, hospital record revealed 'admitted from extended care facility (EFC) with recurrent left hip fracture around the hip replacement which was just last month .' In an interview on 03/01/23 at 11:29 AM with Licensed Practical Nurse II Restorative nurse, reviewed Resident #189's falls. The fall on April 21, 2022, was in her room, she was found by the dietary aide on the floor. Resident #189 had Fractured left femur and was sent to the hospital. It was at change of shift when she fell from days to afternoons shift. The resident did go to the hospital for hip repair surgery and came back. LPN II acknowledged Resident #189 did have a diagnosis of dementia. LPN II stated that so on June 2, 2022, she was work with therapy and we had her on 1:1 supervision from 7 am to 7 pm, at 7:40 PM the LPN found her on the floor at the foot of the bed. We had a one to one from 7 AM to 7 PM and then we start a 15-minute checks on her, Resident #189 was found on the floor at 7:40 PM. The surveyor asked if the falls preventable. LPN II stated that well the 1st fall she was independent and unexpected, but the June 2022 fall we thought that she had adjusted and was working with therapy, but still had a history of falls. In an interview on 3/2/23 at 11:27 AM with the Assistant Director of Nursing ADON OO reviewed Resident #189's falls: April 2022 her BIMS was 11 and she had a history of self-transfer and falls prior to the fall with her fracture hip. Resident #189 was found on the floor, we sent her to the hospital for repair of hip and she came back. Then Resident #189 had therapy and in June 2022 she was found on the floor again by staff and fractured the same hip again. Resident #189 did have the history of falls, we had her on one-to-one supervision from 7 AM to 7 PM and then 15-minute checks after 7 PM. She fell at 7:40 PM after the one to one was stopped for the day and the 15 minutes checks were in place. That didn't work because she fell anyways. In an interview on 03/02/23 at 1:29 PM with Certified Nurse Assistant (CNA) PP revealed that she was Resident #189's CNA when she fell in April 2022, she was my resident and during report I was told to check on her first, because of her history of falls and self-transfers. CNA PP stated that she put color crayons and a book in reach of Resident #189. CNA PP stated that within 20 minutes someone found Resident #189 on the floor. Resident #189 was alert, and she would self-transfer, she would get up and straighten items in her room. CNA PP acknowledged that Resident #189 had a fall history.

This Citation pertains to Intake Number MI 295. Based on observation, interview and record review, the facility failed to perform a Hoyer transfer safely for one resident (Resident #1) of one resident reviewed for Hoyer lift transfers, resulting in a fall into the bed, a fracture of the left shoulder and pain. Findings include: Resident #1: On 3/29/22, at 2:30 PM, Resident #1 was lying in their bed. Resident #1 states their shoulder is still hurting. Resident #1 stated when the aides were putting me into bed the Hoyer broke and dropped on top of me breaking my left shoulder. Resident #1 was asked what the facility had told them what broke on the Hoyer and Resident #1 stated, they told me the Hoyer malfunctioned and denied being told it was the bed cord that was the cause. On 3/29/22, at 3:00 PM, a record review Resident #1's electronic medical record revealed an admission on 8/22/16 with diagnoses that included Diabetes Mellitus (DM), Heart Failure and [CONDITION(S)] of the liver. Resident #1 required extensive assistance with Activities of Daily Living including the use of a Hoyer mechanical lift for transportation and had intact cognition. A record review of the facility provided incident investigation revealed Resident is a [AGE] year old female that had an incident with a lift on 1/30/22 at 1:50 PM. She was being transferred from her chair to her bed with a lift. The lift began tipping forward, resident was over the bed as the lift started to tip, the 2 CNAs' attempted to support the lift but it did still fell over onto the residents left shoulder. CNA alerted licensed staff immediately who assisted with removing the lift sling from under the resident. Resident was assessed and did complain of left shoulder pain. (the doctor) was notified an X-ray was ordered along with additional pain medications. (the doctor) notified of X-rays results which state, a fracture involving the humeral neck with minimal displacement and the conclusion of an old healing fracture as described above. At this time a CT scan has been ordered for clarification. Resident has a primary diagnosis of [CONDITION(S)] of the liver, heart failure, [CONDITION(S)] and age related [CONDITION(S)] and DM (Diabetes Mellitus) with RAKA (right above the knee amputation.) She is alert and orientated to person place and time and did give a statement about the incident. It is presumed the fracture is a result of the lift falling on her shoulder . On 1/31/22 staff did perform a reenactment of the lift transfer. It was determined that the cord from the air mattress was laying on the floor stopping the lift from going any further which ultimately caused the lift to fall forward. The cord has been corrected and secured up off the floor . Lift Incident On 1/31/22. A reenactment was created to demonstrate how a maxi lift fell forward with a resident in it, hitting her in the shoulder. A staff member, (Staff J) was sitting in a recliner and was transferred out of the chair using the maxi laydown lift. The sling was attached to the lift placing it on the second loops, just as it was when (Resident #1)was in the sling. A cord was placed under the bed as it was found in (Resident #1's) room and as (CNA D) transferred (staff J) onto over the bed with a second person. (Therapy Director C) was guiding the lift arm as (CNA D) described. The lift was not unsteady at this time and (staff J) was lowered in bed. As discussion occurred, we had (staff J) bend her knee when up in the lift since (Resident #1) has a RAKA. It was noted to be more unsteady and the right back wheel was slightly off the floor. (CNA D) stated that (CNA G) noticed it being unsteady and guided it over the bed. Once over the bed it is believed that the lift wheels were stopped by the cord under the bed jerking the lift to a stop, startling the CNA who lost her footing as she was attempting to support the resident from getting hurt. On 3/29/22, at 4:05 PM, CNA D was interviewed regarding Resident #1's incident. CNA D offered, (CNA G) and I were putting the resident to bed from the wheelchair. The sling was under the resident. We hooked her up and began to move her to the bed, the lift got tipsy. CNA G quickly grabbed the resident near the shoulders to help support the resident into bed. CNA D was asked if they ran into in the bed or something on the floor and CNA stated, I don't think so. CNA D was asked in their history have they ever ran into a cord during a transfer using the Hoyer and CNA D stated, yes, and the Hoyer stops in place and won't let yet you move any further. A review of the Computed Tomography 1/31/2022 for Resident #1 revealed Report 1. Mildly impacted/displaced and slightly comminuted fracture of the left humeral head/neck junction. Ultimately the age of the fracture is uncertain and may reflect a more subacute injury. 2. Mild glenohumeral and acromioclavicular [CONDITION(S)] . On 3/29/22, at 4:30 PM, CNA G was interviewed regarding Resident #1's incident. CNA G offered, we hooked the resident to the lift from the wheelchair. The wheelchair was in the middle of the room and the sling was underneath the resident in the wheelchair. We began to lift the resident up and rotated the lift around from the left towards the bed. We wheeled the lift in a circular motion towards the bed and the lift got tipsy. CNA G offered that they quickly grabbed Resident 1#'s shoulders to assist with the fall. CNA G was asked how far from the bed the lift was when it began to tip and CNA G stated, We weren't over the bed completely. CNA G was asked if the legs were open or closed and CNA G was not sure but when the lift tipped to the left towards the bed the legs of the lift swept me off my feet. CNA G was asked if they ran into the bed or the bed cord and CNA G could not remember. On 3/29/22, at 4:45 PM, Director of Nursing (DON) was interviewed regarding Resident 1#'s incident. The DON stated that they did a full reenactment and felt that their best guess was the cord that caused the Hoyer to tip. The DON stated the Hoyer did seem top heavy during the reenactment therefore the lift was taken out of use and had the ARJO representative do a full inspection on the lift which found the lift to be working properly. On 3/30/22, at 11:00 AM, Therapy Director C was interviewed regarding Resident #1's incident. Therapy Director C stated they did not find fault with how the Hoyer was used. Therapy Director C offered that the resident was in the weight limit of the lift and when the assisted with the reenactment that they felt there was a couple possibilities; one being the weight distribution and the possibility of the lift hitting the bed cord. Therapy Director C offered that they do the Hoyer education for the CNA's. They do education on the on the lay down lift on new hires and on all lifts since 2019 when it became their responsibility. Therapy Director C was unsure who did the education prior to 2019 but did mention they were sure the 2 CNAs involved in the incident had used the lay down previously. On 3/30/22, at 11:30 AM, Nurse K was interviewed regarding Resident #1's incident. Nurse K stated they got called to the room to assist with removing the Hoyer lift off the resident. Nurse K stated, the blue sling was used, all 8 points were still hooked to the lift. Nurse K further offered that they don't remember anything in the way of the Hoyer, the legs were tipped up and angled to the left. On 3/30/22, at 11:40 AM, an observation along with Nurse K was conducted in Resident 1's room. The blue Hoyer sling hanging on the door per Nurse K was the same sling used the day of the incident. On 3/30/22, at 11:45 AM, Along with Nurse K, an observation of the Hoyer lift that was used was conducted along with Maintenance staff H which was in the basement marked do not use. The Hoyer appeared intact with all bolts. Maintenance staff H further offered that they do monthly inspections on all Hoyer in use. On 3/30/22, at 12:30 PM, Resident #1 was lying in their bed. They complained their shoulder still hurts and does get therapy for it. Resident #1 stated that there is always two aides that assist with them in and out of bed with the Hoyer. Resident #1 stated on a scale of 1 to 10 being upset over the incident was at 8 but quickly offered it was an accident. On 3/30/22, at 1:00 PM, a phone interview was conducted with ARJO representative I who stated there was an inspection on the Hoyer lift and there was nothing wrong with the lift and the lift did not have an extender jib. On 3/30/22, at 4:10 PM, a further interview was conducted via phone with CNA D regarding Resident #1's incident. CNA D was asked what position the Hoyer legs were in and CNA D stated the legs were spread out around the chair when they lifted the resident. CNA D was asked if the wheelchair was moved out of the way and CNA D was unsure. CNA D was asked how high the resident was while in the lift and CNA D stated, she was about chest high and that they were about 5'3 tall. CNA was asked if they moved the resident to the left or to the right CNA stated, to the left around toward the bed. CNA D was again asked what position the Hoyer legs were in and CNA D stated, we were closing them as we were turning her, the Hoyer tipped and the resident fell into bed. On 3/30/22, at 4:40 PM, the DON was asked again why they felt it was a cord under the bed that caused the Hoyer to tip and DON stated the cord was under the bed and they had a picture of it. On 3/30/22, at 5:00 PM, a further interview was conducted with Therapy Director C who was asked to explain how they educate the CNA's on the Hoyer lift when moving a resident from a chair to their bed and if the legs should be open or closed when moving a resident and Therapy Director C stated, the legs would be open when around the wheelchair and they should close them but not necessarily all the way. Therapy Director C was asked if the legs needed to be open or closed prior to moving the resident and Therapy Director C stated, you can move a resident with the legs open or closed that it doesn't make a difference. On 3/30/22, at 5:00 PM, a record review of the facility provided manual for the Hoyer/ARJO MAXI MOVE revealed . Before using your Maxi Move, familiarize yourself with the various parts and controls as illustrated in Fig. 3, and other illustrations. Then, read this manual thoroughly in its entirety before using your Maxi Move . Adjustable Width Chassis Legs (see Fig. 12) To open the chassis legs, press the legs open button on either the control handset or control panel. When the button is released, movement will stop and the chassis legs will remain securely in position. Always transfer patients with the chassis legs in the closed position .

This Citation pertains to Intake Numbers MI 727, MI 775, MI 886, and MI 393. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to (1.) follow accepted standards of practice for Infection Control for COVID-19, (2.) failed to immediately isolate and segregate residents who tested positive for the COVID-19 virus, (3.) failed to utilize isolation wing for COVID-19 positive residents, (4.) failed to follow CDC guidance regarding wearing eye protection, N-95 or equivalent respirator, and face masks for COVID-19 positive residents, (5.) failed to quarantine readmissions for 14 days and ( 6.) failed to contain, follow up and report an outbreak of Scabies, resulting in COVID-19 positive residents remaining in the general population, staff not wearing appropriate Personal Protective Equipment (PPE), staff and residents testing positive for COVID-19, staff and residents being treated for [REDACTED]. Immediate Jeopardy: Immediate Jeopardy began on 06/08/2020. Immediate Jeopardy was identified on 08/06/2020. The Administrator was notified on the Immediate Jeopardy on 08/11/2020 at 1230 hours. The Immediate Jeopardy was removed or abated on 08/11/2020 after verifying the facility's Abatement Plan. F880 INFECTION PREVENTION AND CONTROL ABATEMENT PLAN: THE ADMINISTRATOR, DIRECTOR OF NURSING, ASSISTANT DIRECTOR OF NURSING AND THE IN-SERVICE DEPARTMENT IMPLEMENTED THE FOLLOWING IMMEDIATE INTERVENTIONS: ON 8/11/20 THE FACILITY IMPLEMENTED PROCESS CHANGES AS FOLLOWS: ALL NEW/READMISSION RESIDENTS WILL BE PLACED IN A DESIGNATED ISOLATION AREA FOR 14 DAYS OR 2 NEGATIVE TESTS (THIS IS BASED ON CDC TEST BASED STRAGEDY). ALL DIRECT CARE EMPLOYEES WILL WEAR N-95, OR EQUIVALENT, FACE MASK WHILE PROVIDING DIRECT CARE TO SUSPECTED OR COVID-POSITIVE RESIDENTS. ALL SUSPECTED OR CONFIRMED POSITIVE RESIDENTS WILL BE MOVED TO A DESIGNATED ISOLATION AREA. ON 8/11/20 THE FACILITY BEGAN WORKING WITH THE PHARMACY FOR FACILITY WIDE SCABIE TREATMENT TO ALL RESIDENTS AND EMPLOYEES. ON 8/11/20 THE FACILITY BEGAN UPDATING AND REVISING THE FACILITY COVID-19 POLICY. ON 8/11/20 THE ADMINISTRATOR, DON, ADON AND THE IN-SERVICE DEPARTMENT REVIEWED REPORTABLE OUTBREAK CONDITIONS. ALL RESIDENTS HAVE THE POTENTIAL TO BE AFFECTED BY THIS PRACTICE. THE DIRECTOR OF NURSING, ASSISTANT DIRECTOR OF NURSING AND THE IN-SERVICE DEPARTMENT WILL IMPLEMENT MEASURES TO ENSURE THIS PRACTICE DOES NOT RECUR BY: ON 8/11/20 EDUCATION WAS INITIATED ON N-95, OR EQUIVALENT, FACE MASK USE WHILE PROVIDING DIRECT CARE TO SUSPECTED OR COVID-POSITIVE RESIDENTS, MOVING ALL SUSPECTED OR CONFIRMED POSITIVE RESIDENTS TO THE DESIGNATED ISOLATION UNIT IMMEDIATELY AND ALL NEW/READMISSION RESIDENTS WILL BE PLACED IN DESIGNATED ISOLATION UNIT FOR 14 DAYS OR 2 NEGATIVE TESTS. ON 8/11/20 EDUCATION WAS INITIATED ON SCABIES TO INCLUDE treatment of [REDACTED]. THE DIRECTOR OF NURSING, ASSISTANT DIRECTOR OF NURSING, QUALITY MANAGER AND THE IN-SERVICE DEPARTMENT WILL MONITOR THE CORRECTIVE ACTIONS TO ENSURE EFFECTIVENESS BY: ON 8-11-20 THE FACILITY BEGAN TO DEVELOP AN AUDIT ON THE USE OF ALL APPROPRIATE PPE WITH SUSPECTED OR CONFIRMED POSITIVE RESIDENTS FOLLOWING CDC GUIDELINES. ON 8-11-20 THE FACILITY BEGAN TO DEVELOP AN AUDIT ON ALL NEW/READMISSION RESIDENTS ON REMAINING IN ISOLATION FOR 14 DAYS OR 2 NEGATIVE TESTS. THE AUDIT WILL ALSO INCLUDE TO MONITOR ALL SUSPECTED OR CONFIRMED RESIDENTS TO ENSURE THEY ARE BEING MOVED TO ISOLATION. ON 8-11-20 THE FACILITY BEGAN TO DEVELOP AN AUDIT ON RASHES TO ENSURE ALL RASHES ARE BEING ASSESSED AND ADDRESSED TIMELY. ON 8-11-20 THE FACILITY BEGAN TO DEVELOP AN AUDIT TO RANDOMLY QUESTION THE STAFF ON KNOWLEDGE OF SCABIES RASH AND TREATMENT. ON 8-11-20 THE FACILITY BEGAN TO DEVELOP AN AUDIT ON ANY AND ALL REPORTABLE OUTBREAK CONDITIONS TO ENSURE THEY ARE REPORTED AS DIRECTED. ALL RESULTS WILL BE REPORTED TO THE QUALITY ASSURANCE AND PROCESS IMPROVEMENT COMMITTEE UNTIL DEEMED NO LONGER NECESSARY. Findings include: On 8/6/20, at 11:45 AM, Resident #61 was observed sitting in their wheelchair in their room. There was a small laminated sign with a red hand on the frame of the door. The door was open. CNA E was sitting assisting Resident #61's roommate with their meal. CNA E had on gloves, surgical mask and a gown. CNA E was asked if there was eye protection and an N 95 available for use and CNA E stated, I only use it when I work with (Resident #61) or within 6 feet of her. Nurse G was asked how the facility alerts others of an isolation room and Nurse G stated, we use the red hands. Nurse G was asked if the red hands were on the door frame to Resident #61's room because of her COVID-19 positive test result and Nurse G stated, Yes, she's asymptomatic but treating as if she were positive. On 8/6/20, at 11:55 AM, a small sign with a red hand was observed on the door frame to Resident #63's room. There was no room number noted. CNA M was asked what the sign was for and CNA M stated we all know to look at the report board. An observation along with CNA M of the report board that revealed Precautions Rash . Resident #63's name was on the list along with five other residents. Under Equipment/supply issues . USE NEEM Soap on all residents . Under Resident Concerns . 8/6/20 All need showers - Beds stripped + washed and clothes bagged up . Nurses- make sure you are charting on rashes! Make sure you are using the neem soap on all residents CNA M stated, we had scabies again last month. We got a handout on how to approach it, workers were positive. We got cream and soap to help prevent it. The scabies started in February. (Resident#70) was case zero. We complained about it and were told you have treatment. We had to call down to central supply to get gowns and they weren't putting anything on the doors because all the residents got the pill and a shower. On 8/6/20, at 12:15 PM, a small sign with a red hand was observed on the door frame to Resident #60's room. Resident #60 was heard from the hallway coughing from behind the pulled curtain. Housekeeper I entered Resident #60's room and had a gown, gloves and a surgical mask on. Housekeeper I was asked if Resident #60 was eating lunch and Housekeeper I pulled back the curtain and stated, no. Housekeeper I then pointed to Resident #60's pulled curtain when asked if Resident #60 was the person coughing. On 8/6/20, at 12:45 PM, CNA N was asked if the facility had a scabies outbreak and CNA N state, I had it in June. We got cream just 1 tube. I had to go to my doctor to get more. CNA N further stated, not all the staff got the cream. They are not checking on us. I don't know what the protocol is but nobody has come to check on me. I have not been asked if I still have it. On 8/6/20, at 12:50 PM, CNA O was asked if the facility had a scabies outbreak and CNA O stated, In February I got a rash. I went to the doctor and was treated for [REDACTED]. On 8/6/20, at 1:10 PM, CNA J offered, I had my N 95 on today because I have 2 residents that tested positive and I was told to take it off. CNA J was asked who told them to remove their N 95 and CNA J stated, the DON told me I needed to put a surgical mask on and that the surgical mask and face shield should protect me. CNA J further offered that their N 95 mask was locked up in their locker. On 8/6/20, at 1:15 PM, Nurse D was asked if they were caring for COVID-19 positive residents this shift and Nurse D stated, we had one resident in 290 that moved to 271 because his roommate was positive and he requested to move out of the room. On 8/6/20, at 1:20 PM, Nurse L was asked if they had proper Personal Protection Equipment (PPE) available and Nurse L stated, that she was not given an N 95. Nurse L further stated that if a resident tested positive that they treat the whole room as positive and would need a face shield. Nurse L was asked to clarify what type of mask they would wear and Nurse L stated, the DON told us our policy is that we just wear a regular mask. A positive Covid test doesn't require an N 95. On 8/6/2020, at 2:40 PM, the Director of Nursing (DON) was asked if the facility had residents with Scabies and the DON stated, we had them a while ago. The DON further stated, We had them in July. Yes, it was more than one, it was an outbreak. The Health department assisted us. The DON was asked to provide any documents from the health department to prove their assistance with the Scabies outbreak and all infection line listing for staff and residents with scabies. The DON was asked how many residents tested positive for COVID-19 and the DON stated, we had eleven residents test positive. The DON offered, that there were seven staff members also. The DON was asked what personal protective equipment she expects her staff to wear while in a Covid-19 positive room and the DON stated, they should wear a mask, gloves, gown and a face shield and if a breathing treatment is done then the nurse is to be wearing a N 95. The CNA (certified nursing aide) is not allowed to enter for thirty minutes post treatment. The DON was asked if the facility isolated COVID-19 positive residents from residents who tested negative and the DON stated, No. that's the direction the health department gave us. The DON was asked to provide infection line listing for both residents and staff back to February 1st, 2020. The DON was asked what areas in the facility were designated for COVID-19, and the DON stated, 1 West is for new admissions and 2 west is for readmissions. On 8/6/20, at 4:40 PM, the facility provided the February 2020 Employee illnesses document from Infection Control Nurse K along with a written statement We had 1 employee with a rash in February, we looked at her and sent her to her healthcare provided to be looked at. On 8/10/20, at 7:00 AM, a record review of the facility provided Resident Census and Conditions of Residents . F 118 -13 Rashes . Date 8-6-2020 . revealed that 13 residents had rashes. A record review of the facility provided map of the COVID-19 isolation areas revealed Rms: (rooms) 168 170 171 173 1 West Rooms: 268 270 271 273 2 West Resident #60: On 8/10/20, at 8:00 AM, a record review of Resident #60's electronic medical record revealed an admission on 05/17/2019 with a readmission on 03/13/2020. Resident #60's Resident census revealed 03/14/2020 Information Change . Unit/Room/Bed 2 East/237-1 Semi-Private Bed . A review of Resident #60's lab results revealed Date Collected: 07/29/2020 Date Received: 07/31/2020 Date Reported: 08/05/2020 . Test Performed nCoV-2019 Lab Result POSITIVE . Resident #60 remained in a shared room with Resident #62 who tested negative for Covid-19. A review of progress notes revealed the following: 08/03/2020 Resident has a temp of 100.0 . 08/06/2020 . T(temperature)100.1 . Lung sounds clear but diminished to bases . 08/07/2020 . does have phlegm in his throat when sleeping but did cough and cleared . 08/09/2020 Res (resident) c/o (complaint of) h/a (headache) . 08/09/2020 Resident remained afebrile this shift, BBS (bilateral breath sounds) clear, non-productive cough . Resident #60 remained in a semi-private room with a COVID-19 negative resident despite having symptoms of COVID-19. Resident #61: On 8/10/20, at 9:00 AM, a record review of Resident #61's electronic medical record revealed an admission on 10/17/2018 with a readmission on 12/30/2018. Resident #61's Resident census read 06/26/2019 Information Change . Unit/Room/Bed 2 East/214-2 Semi-Private Bed . A review of Resident #61's lab results revealed Date Collected: 07/29/2020 Date Received: 07/31/2020 Date Reported: 08/05/2020 . Test Performed nCoV-2019 Lab Result . POSITIVE . Resident # 63: On 8/10/20/ at 9:15 AM, a record review of Resident #63's electronic medical record revealed an admission on 07/14/2017. A review of Resident Census revealed 02/17/2020 Information Change . Unit/Room/Bed 1 West/167-2 Semi-Private Bed . A review of Physician Order . Created Date: 07/29/2020 . Pharmacy Dispensed Drug: IVERMECTIN 3 MG (milligrams) Tablet Pharmacy Directions: Take *5* TABLETS (15 MG) BY MOUTH ONCE NOW, THEN REPEAT DOSE IN TWO WEEKS. A review of ANTIMICROBIAL DOSING RECOMMENDATION Date 7/29/20 . Medication Ivermectin - pharmacy to dose . Diagnosis/Type of Infection: Scabies . There was a second ANTIMICROBIAL DOSING RECOMMENDATION . Date 6/8/2020 . Medication: Ivermectin - pharm to dose . Diagnosis/Type of Infection: Scabies . A review of progress notes revealed the following: 06/06/2020 Resident with red scattered rash to right side of body . 06/06/2020 Resident remains with rash to rt (right) side of abdomen. Redness noted to forearm, resident states that he was rubbing his arm on the bedside table to stop the itching . 06/23/2020 Weekly Skin Assessment: Red dotted rashy areas scattered to chest, back, abdomen, bil arms, bil flanks, legs and feet, scattered scratch marks from res itching . 07/01/2020 Skin scrapings obtained, as the first specimen was not readable, resident tolerated well. 07/02/2020 Weekly Skin Assessment: . Scattered red rash to arms, legs, chest and abdomen with some scratch marks and scabs. Rash is itchy . 07/29/2020 (Physician P) in today, order received for one time dose Ivermectin r/t (related to) fading scattered rash to entire body . 08/11/2020 . Red rash remains to b/l (bilateral) arms, armpits, and torso. Denied itching when asked. Scattered scratch marks noted to arms and torso. On 8/11/20, at 11:00 AM, Infection Control Nurse K was interviewed regarding Scabies and why staff members are saying there has been Scabies since February. Infection Control Nurse K stated that there was one employee in February. She went to her own doctor and that follow up was done. Infection Control Nurse K further offered there was one resident (Resident #70) who had a rash for some time. Infection Control Nurse K was asked why now were they calling the rash scabies and Infection Control Nurse K stated, not until we figured it out in June using the fire fly (light magnifier allowing visual [DIAGNOSES REDACTED]. Infection Control Nurse K was asked what made the facility decide to use the fire fly machine and Infection Control Nurse K stated, because the rash had been there so long and they were able to see the mites on Resident #70. Infection Control Nurse K further stated that no residents were treated for [REDACTED]. Infection Control Nurse K further stated that all residents on 1 West were treated on June 8th, 2020 with Ivermectin and that the local health department was notified of the outbreak of Scabies. Infection Control Nurse K was asked to provide documentation of communication the facility had with the local health department and Infection Control Nurse K stated, the initial form was sent but the closing form has not been completed to date. Infection Control Nurse K was also asked why new admitted /readmitted residents were moved out of quarantine prior to 14 days and why the COVID-19 units are closed and Infection Control Nurse K stated, 2 West is for readmissions. We get 2 negative tests to move off. It took about 4 or 5 days. On 8/11/2020, at 1:50 PM, Physician P was asked if he knew COVID-19 positive residents were sharing rooms with negative residents in the facility and Physician P stated, No. Physician P was asked if COVID-19 positive residents should be in their own room under isolation and Physician P stated, Yes. Physician P further offered that he will get test messages at times but No, I did not get one on a positive, No. Physician P was asked if he was alerted that Resident #60 had tested positive for COVID-19 on 8/05/2020 and had symptoms of Covid-19 of headache, fever and cough and Physician P stated, No. On 8/11/20, at 3:50 PM, the DON was asked who in the facility followed up with the staff who had a rash/scabies and the DON stated, I did. The DON was asked to provide documentation of the follow up and the DON stated, I approached the staff one on one when I did my rounds. No documentation of follow up was provided for the staff/scabies follow up prior to exit. Resident #62: On 8/12/20, at 12:30 PM, a record review of Resident #62's electronic medical record revealed Resident Census 04/04/2020 . Unit/Room/Bed 2 East/214-2 . A review of Resident #62's lab results revealed Date Collected: 07/29/2020 Date Received: 07/31/2020 Date Reported: 08/05/2020 . Test Performed nCoV-2019 Lab Result NEGATIVE . Resident #62 tested negative for COVID-19 and remained in a shared room with a COVID-19 positive roommate. Resident #70: On 8/12/20, at 1:00 PM, a record review of Resident #70's electronic medical record revealed Resident #70 had an ongoing rash dated back to February of 2020. A review of progress notes revealed the following: 02/28/2020 Resident is continue on [MEDICATION NAME] dose pack for red, raised rash like all over her chest, the whole back area and some on her neck, resident at time c/o (complaints of) itching . 03/24/2020 Weekly skin assessment: . Red rash/irritation continues around moles on back. Pink speckled rash to back, arms, chest and legs . . DOS (date of service) 4/3/20 . Recurrent rash . seen today due to recurrent rash on the entire posterior torso, buttocks and upper thighs. The rash is also present on the posterior arms bilaterally. Patient has received a couple of [MEDICATION NAME] and has been initiated on oral [MEDICATION NAME] twice daily and with only mild improvement of symptoms. Patient has also received multiple topical treatments without significant improvement . 05/05/2020 Weekly skin assessment: . Pink/red rash/irritation continues around moles and on back, neck arms and abdomen . 06/06/2020 Faxed . referral to Dermatology Apt. Resident on rash monitoring until seen by Dermatology . 06/09/2020 Resident's rash remains unchanged, resident treated with Ivermectin today . 06/10/2020 Order received for [MEDICATION NAME] ([MEDICATION NAME]; it can treat head lice and scabies) cream with pharmacy to dose. apply today and then re-evaluate rash in 2 weeks (if needed, may apply second dose) . A record review of Resident #70's Dermatology consult revealed June 22, 2020 . Chief Complaint: Rash . who is being seeing for a chief complaint of Rash, located on the trunk. The rash has been present for 5 months . she reports household contacts with similar rash, no new medications, no new personal care products, and no recent infections. She is currently on the following treatments: [MEDICATION NAME] and [MEDICATION NAME] . A review of ANTIMCROBIAL DOSING RECOMMENDATION Date: 6/8/2020 . Ivermectin pharm to dose . Diagnosis/Type of Infection: Scabies . A second ANTIMCROBIAL DOSING RECOMMENDATION Date: 6/10/2020 . [MEDICATION NAME] 5% CREAM Massage cream into the skin from the head to the soles of the feet WASH CREAM OFF AFTER 8 - 14 HOURS . Diagnosis/Type of Infection: CRUSTED SCABIES . A further record review revealed 07/27/2020 Weekly skin assessment: . Scattered pink rash remains, continues to improve . There were no progress notes related to the facility use of a firefly machine or that there were Scabies/mites found on the resident. Resident #71: On 8/12/20, at 2:00 PM, a record review of Resident #71's electronic medical record revealed an admission on 11/29/2018 with a readmission on 03/20/2020. A review of the Resident Census . Unit/Room/Bed 2 East/237-2 . revealed that Resident #71 shared a room with Resident #60. A review of Resident #71's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/03/2020 . Test Performed nCoV-2019 Lab Result NEGATIVE . Resident #72: On 8/12/20, at 2:15 PM, a record review of Resident #72's electronic medical record revealed an admission on 10/30/2019. A review of the Resident Census . Unit/room/Bed 2 West/263-2 . revealed that Resident #72 was not moved to the facilities COVID-19 isolation unit. Resident #73: On 8/12/20, at 2:20 PM, a record review of Resident #73's electronic medical record revealed an admission on 11/21/2018 with a readmission on 02/24/2020. A review of Resident Census . Unit/Bed/room [ROOM NUMBER] West/255-1 . revealed that Resident #73 shared a room with Resident #84. A review of Resident 73's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/05/2020 Test Performed nCoV-2019 Lab Result POSITIVE . Resident #74: On 8/12/20, at 2:25 PM, a record review of Resident 74s electronic medical record revealed an admission on 11/13/2015 with a readmission on 01/15/2019. A review of Resident Census . Unit/Bed/room [ROOM NUMBER] West/293-1 . revealed Resident #74 shared a room with Resident #82. A review of Resident 74's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/05/2020 Test Performed nCoV-2019 Lab Result POSITIVE . Resident #76: On 8/12/20, at 2:30 PM, a record review of Resident 76's electronic medical record revealed an admission on 09/15/2014 with a readmission on 08/12/2019. A review of Resident Census . Unit/Bed/room [ROOM NUMBER] West/157-1 . revealed that Resident #76 shared a room with Resident #79. A review of Resident #76's lab results revealed Date Collected: 07/29/2020 . Date Reported: 07/31/2020 Test Performed nCoV-2019 Lab Result POSITIVE . Resident #77: On 8/12/20, at 2:35 PM, a record review of Resident 77's electronic medical record revealed an admission on 12/21/2016. A review of Resident Census . Unit/Bed/room [ROOM NUMBER] West/259-2 . revealed that Resident #77 shared a room with Resident #80. A review of Resident #77's lab results revealed Date Collected: 07/29/2020 . Date Reported: 07/31/2020 Test Performed nCoV-2019 Lab Result POSITIVE . Resident #79: On 8/12/20, at 2:40 PM, a record review of Resident #79's electronic medical record revealed an admission on 12/05/2012 with a readmission on 04/07/2020. A review of Resident Census . Unit/Bed/room [ROOM NUMBER] West 157-2 . revealed Resident #79 shared a room with Resident #76. A review of Resident #79's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/05/2020 Test Performed nCoV-2019 Lab Result NEGATIVE . Resident #80: On 8/12/20, at 2:45 PM, a record review of Resident #80's electronic medical record revealed an admission on 10/15/2015 with a readmission on 01/30/2020. A review of Resident Census Unit/Bed/room [ROOM NUMBER] West/259-1 . revealed that Resident #80 shared a room with Resident #77. A review of Resident #80's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/05/2020 Test Performed nCoV-2019 Lab Result NEGATIVE . Resident #81: On 8/12/20, at 2:50 PM, a record review of Resident #81's electronic medical record revealed an admission on 03/21/2018 with a readmission on 07/21/2020. A review of Resident Census Unit/Bed/room [ROOM NUMBER] West 265-2 . revealed that Resident #81 shared a room with Resident #83. A review of Resident #81's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/05/2020 Test Performed nCoV-2019 Lab Result NEGATIVE . Resident #82: On 8/12/20, at 2:55 PM, a record review of Resident #82's electronic medical record revealed an admission on 02/04/2012 with a readmission on 01/07/2016. A review of Resident Census Unit/Bed/room [ROOM NUMBER] West/293-2 . revealed that Resident #82 shared a room with Resident #74. A review of Resident #82's lab results revealed that Swab 07/231/2020 . COVID test canceled, specimen received . in an unapproved transport . Resident #82's COVID status was not determined. Resident #83: On 8/12/20, at 3:00 PM, a record review of Resident #83's electronic medical record revealed an admission on 01/25/2017. A review of Resident Census Unit/Bed/room [ROOM NUMBER] West/265-1 . revealed that Resident #83 shared a room with Resident #81. A review of Resident #83's lab results revealed Date Collected: 07/31/2020 . Date Reported: 08/05/2020 Test Performed nCov-2019 Lab Result POSITIVE . Resident #84: On 8/12/20, at 3:05 PM, a record review of Resident #84's electronic medical record revealed an admission on 10/26/2019 with a readmission on 07/06/2020. A review of Resident Census Unit/Bed/room [ROOM NUMBER] West/255-2 . revealed that Resident #84 shared a room with Resident #73. A review of Resident #84's lab results revealed Date Collected: 07/29/2020 . Date Reported: 08/05/2020 Test Performed nCov-2019 Lab Result NEGATIVE . On 8/12/20, at 3:30 PM, the DON, was asked to provide a copy of the CDC guidance the facility was using for readmissions not needing a full fourteen-day quarantine. On 8/12/20, at 3:35 PM, a record review of the facility provided document Discontinuation of Transmission-Base Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance) Discharging COVID-19 Patients Updated Aug, 2020 . revealed the facility had highlighted Test-Based Strategy for Discontinuing Transmission-Based Precautions. On 8/12/20, at 3:35 PM, during a phone conversation with the DON, Infection Control Nurse K and the Administrator, the DON was alerted the CDC guidance they were using was for positive COVID-19 patients and not the CDC guidance Responding to Coronavirus (COVID-19) in Nursing Homes Updated Apr. 30, 2020. On 8/12/20, at 4:00 PM, a record review of the facility policy Novel Coronavirus Prevention and Response Date: 4/7/2020 revealed . 4. Interventions to prevent the introduction of respiratory virus into the facility: . c. Designated 1 West 04 hall as the designated wing for new admissions and readmissions which is a 14 day quarantine area, additional private rooms maybe necessary . g. The 2 West 04 addition is the designated area of the facility for residents with suspected or confirmed cases of COVID-19 . 6. Procedure when COVID-19 is suspected or confirmed . b. Place resident in designated area of the facility . f. Implement standard, contact and droplet precautions. Wear gloves, gowns, goggles/face shields, and masks upon entering room and when caring for the resident . On 8/17/20, at 8:00 AM, a record review of the facility provided Feb Employee Line Listing revealed . 2/25/2020 (CNA O) . Scabies? On 8/17/20, at 1:00 PM, a record review of the facility provided spread sheet of residents who were treated for [REDACTED]. The document read all residents treated with Ivermectin on 6/8/2020. On 8/17/20, at 1:15 PM, a record review of the facility provided Cluster and Facility Outbreak Notification Report Form . Rash Number of Case with Symptoms 31 . The document did not have a date the health department was notified. The facility did not report the outbreak to the state agency. On 8/17/20, at 2:15 PM, the Administrator was asked to provide any facility documentation on the use of the firefly machine on Resident #70 and the DON responded via email, there is no documentation of the firefly being used on the resident. On 8/17/20, at 2:30 PM, a record review of the facility provided Resident and employee testing Covid revealed nine total staff with a positive next to their name with the first staff Last Date Worked 7/19/2020 . The Date tested column was blank. The Last Date Worked column was blank for the other eight staff members. The Resident tested Results had eleven residents listed with highlighted yellow positive and asymptomatic next to their names. There was no other information listed on the line listing for the eleven residents. Resident #67: Review of Resident #67's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #67's 'Census' revealed that on the day of admit (7/17/20), Resident #67 was placed on the 1 West side of the nursing facility. On 7/22/20, Resident #67 was moved to the 1 East side of the facility. Resident #67 did not stay in the same room or wing for the 14-day quarantine recommendation from the Center for Disease Control (CDC). A review of the CDC website (accessed 8/13/20 at 4:00 p.m.) https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed the following: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: .Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . .Page last reviewed : June 25, 2020 Resident #65 and Resident #66: On 8/6/20 at 12:39 PM, CNA R was observed delivering meal trays to Resident #65 and Resident #66 in their room. CNA R stated Resident #65 was currently positive for COVID . and is in isolation. When asked about the COVID status of Resident #66 (the other resident in the room), CNA R was unsure of the test results. CNA R stated that Resident #65 would be in isolation for two more days. On 8/6/20 at 12:41 PM, RN B stated Resident #65 had tested positive for COVID but the roommate (Resident #66) had tested negative. Record review of the document provided and created by the Infection Control RN K titled, Employee and Resident Testing for COVID revealed Resident #65 had tested positive on 7/29/20. During an interview on 8/6/20 at 3:39 PM, the Director of Nursing (DON) listed residents who had tested positive on 7/29/20 for COVID. Resident #65 was included on that list. All residents were tested on [DATE], and Resident #66, the roommate of Resident #65 did not test positive. The Center for Disease Control and Prevention (CDC) recommendations as updated 07/15/20 reads in part: Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (COVID) infection. Patient Placement: .place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom.

This Citation pertains to Intake Number MI 991. Based on observation, interview and record review the facility is placed in Immediate Jeopardy due to the facility's systemic failure to account for narcotics and other controlled substances on a daily basis and resolve discrepancies, resulting in the theft of 30 [MEDICATION NAME] tablets. There is a likelihood for a serious adverse outcome including harm and untreated pain if residents are not receiving necessary pain medications due to drug diversion. Immediate Jeopardy: Resident #1: On [DATE], a nurse reported to an ADON (Assistant Director of Nursing) that a 30-count full card of the Narcotic pain medication, [MEDICATION NAME], was missing from the narcotics' drawer. The paper document for the [MEDICATION NAME] was also missing. Resident #1 had 3 cards on [DATE] and 1 was missing by [DATE]. The facility did not begin an investigation into the missing [MEDICATION NAME] until [DATE], approximately 1 week after the incident, including not drug testing nurses. The facility did not interview all nurses with potential or actual access to the cart during the time-frame of [DATE]-[DATE]. The incident was not reported to law enforcement or the State Agency. On [DATE], while reviewing the Narcotics logs and counting the narcotics in each medication cart with a nurse and the Interim DON (Director of Nursing), it was identified that 3 of 10 nurses were signing in advance that they had completed their end-of-shift Narcotics' count'. The nurses also had not counted the narcotics with another nurse. Two nurses signed, dated, and timed the entry for 1430 (2:30 PM) on [DATE], but it was only 1330 (1:30 PM), when one nurse signed in advance, but did not time the entry. Nurses are supposed to count with another nurse and sign together confirming the accuracy of the count. In a review of the 2 East 30's Medication Cart- the volume of liquid in a bottle of liquid [MEDICATION NAME] did not match the volume on the Controlled Substance Proof of Use Form. The bottle=425 ml, while the document=350 ml, a 75 ml discrepancy. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. Findings Include: On [DATE] at 10:30 AM, the Administrator and Director of Nursing were queried about narcotic diversion. They were asked if there had been any instances of missing residents' narcotics and the Interim Director of Nursing said, During Christmas, we had a card of [MEDICATION NAME] (narcotic pain medication) missing. (Nurse A) counted (narcotics) on Christmas Eve and the Resident (#1) had 3 cards (of 30 [MEDICATION NAME] each). Everything was fine. The day after Christmas, the 26th, he came back and was counting with a Float person (Nurse N). When he counted, he noticed there were only 2 cards (of 30 [MEDICATION NAME] each card) for the resident (#1). He knew the resident had the medication cards for a while, since maybe [DATE] and thought maybe they (facility nurses/administration) destroyed them. He counted with the 3rd shift Nurse C. She said it was weird there was only 2 cards. The Interim DON continued and said, On [DATE]th, (Nurse A) worked and did not pursue anything. The Interim DON said Nurse A did not contact her or the Assistant Director of Nursing (ADON) B, until [DATE]st , when Nurse A saw the ADON with the Interim Director of Nursing (who was an ADON at that time). ADON B told Nurse A to contact the Medical Records department to see if a copy of the Narcotic sheet assigned to the missing [MEDICATION NAME] card was in Medical Records. It was not there. The Interim DON, ADON and Nurse Educator EE contacted Pharmacist FF ([DATE]st, 2019) who told them to complete an internal investigation. The Pharmacist also confirmed Resident #1 had 3 cards of [MEDICATION NAME] on [DATE]. The Interim DON and Administrator were asked about their process for receipt and storage of narcotics from the pharmacy and said when the pharmacy driver delivered the narcotic medications the nurse receiving them would compare the inventory sheets to the inventory. An inventory sheet was received for every cart and every Narcotic Card, Bottle or vial had a document (sheet) that provided information about the medication including the number received; every card had a sheet and they were placed in a Narcotics book. During the interview, the Interim DON stated, In my investigation, I requested statements from every nurse who had access to that med cart; written statements from all of them. We came to the conclusion that it was inconclusive. We do not know what happened to them. The policy was updated so that we could identify it (missing narcotics/diversion) in a more timely fashion. The Interim DON said the facility had since provided education to the nurses related to counting the Narcotic cards and documenting the count on a new log in the Narcotics book. The Interim DON stated, If a nurse identifies a discrepancy in the narc count, they notify the ADON or DON immediately. During the same interview, the Interim DON and Administrator were asked if they had contacted the local Police to report the missing narcotics and both said they had not. They were asked if they had reported the missing narcotics to the State Agency and they said they had not. The Administrator and Director of Nursing were asked if they had a policy to aid in the prevention and investigation of Drug Diversion and they said they did not. The Administrator and Interim DON said they had reviewed the regulations based on Pharmacy services, but did not realize that Misappropriation (Diversion) of Narcotics was considered a form of Abuse. A review of the facility policy titled, Resident/Staff/Family Abuse Reporting Policy and Procedure, undated provided It is the policy of the Facility to encourage and support all residents, staff and families in feeling free to report any suspected acts of abuse, neglect, mistreatment, involuntary seclusion or misappropriation of property . Any person witnessing or having knowledge of potential or actual abuse muse immediately report the incident to the Administrator . A review of the facility policy titled, Investigation and Reporting of Concerns, revealed Resident shall be protected from harm or the potential for harm. The facility shall conduct a professional review of complaints . The facility shall investigate each complaint involving a resident immediately . On [DATE] at 11:30 AM, a review of the facilities investigation of the missing narcotics was completed. The Interim DON interviewed 3 nurses during the investigation: Nurses A, C and GG. A review of the nursing schedule with the Interim DON, for [DATE]-26, 2019 indicated 6 nurses (A, C, N, Z, GG, HH) had access to the medication cart on the 1 East hall. The Interim DON was asked why all 6 nurses were not interviewed and she said (Nurse Z) was terminated for attendance problems on [DATE] and she didn't interview Nurse H and N or any other staff in the facility who may have witnessed something during that timeframe. When asked if the nurses were drug tested during the investigation, she said, No. On [DATE] at 12:40 PM, a review of the facilities Narcotics storage and Narcotics logs was initiated for each of the facilities 4 nursing units with the DON and Staff Nurse assigned to the cart: 1st Floor East, 1st Floor West, 2nd Floor East and 2nd Floor West. The Interim DON said there were ,[DATE] medication carts in each unit, and each had a narcotics storage drawer and Narcotics book per the following: Medication Cart 1 East-30's Hall: reviewed with Nurse J at 12:40 PM. Medication Cart 1 East- Teens Hall: reviewed with Nurse K at 12:45 PM. Medication Cart 1 West- Short Hall: reviewed with Nurse L at 1:30 PM, who had already signed the Narcotics log count with her initials and dated and timed it for 2:30 PM, that she had completed a Narcotics Count with another nurse at the end of her shift. Nurse L had not completed the Narcotics count and had falsified the document. When asked why she was initialing, timing and dating that she had completed the Narcotics count when she had not, the nurse said she didn't want to forget to complete the form. The Interim DON reviewed the nurses signing of the Narcotics log prior to actually counting. Medication Cart 1 West- 60's Hall: reviewed with Nurse M at 1:45 PM. Medication Cart 1 West- 90's Hall: reviewed with Nurse N at 1:53 PM. Medication Cart 2 East -30's Hall: reviewed with Nurse P at 2:05 PM. During the count, on inspection, a bottle of liquid [MEDICATION NAME] for Resident #5 contained approximately 350 ml. However, the Narcotics Sheet for the medication said there was 425 ml, a 75 ml discrepancy. There was no notation on the Narcotics Sheet to indicate anyone had questioned or investigated the discrepancy. Neither the Interim DON or Nurse P could explain why the count was off. Medication Cart 2 East- Teens Hall: reviewed with Nurse Q at 2:10 PM. Nurse Q had already initialed, dated and timed (,[DATE]:30 PM) that she had completed a Narcotics count for her cart at 2:30 PM with another nurse. When queried about this, Nurse Q argued that she was preparing for the count and it didn't mean that she had actually counted. When asked further if that was a Standard of Practice to sign that you did something ahead of time when you did not actually do what you were supposed to, Nurse Q said No. The Interim DON was present during the interview. Medication Cart 2 West- 90's Hall: reviewed with Nurse R at 2:15 PM. Medication Cart 2 West- 60's Hall: reviewed with Nurse S at 2:20 PM. Nurse S had already initialed that she had completed a Narcotics count with another nurse, but when asked if that occurred, she said, No, but she was told it was ok to initial ahead of time. Medication Cart 2 West- Shorts Hall: reviewed with Nurse T at 2:25 PM. After the review of the Medication Carts, on [DATE] at 2:30 PM, the Interim DON was asked about the nurses comments on initialing, dating and timing ahead of time that they had completed the Narcotics count with another nurse when they had not and she said, They were not taught that and no one told them that they could do that. It is unacceptable. The Interim DON was asked how the facility could ensure that Narcotics were safely stored and accounted for when the nurses were not following acceptable procedures and she said it would be addressed. On [DATE] at 4:20 PM an interview with the previous DON X provided, When I was on vacation, I spoke with my Administrator II and told her the staff had called and said 2 [MEDICATION NAME] (pills) could not be accounted for and they came back and said they found them on the 27th ([DATE]). There was nothing about the card of [MEDICATION NAME] missing. That same day they had 5 [MEDICATION NAME]es missing ([DATE]). They found them in the (back-up Medication Dispense). (Nurse B) texted me about that, but not the 30 [MEDICATION NAME] that were missing. On [DATE] at 9:00 AM, during an interview with ADON B she stated, On the 24th Christmas Eve (2019) when he (Nurse A) left he saw 3 cards of [MEDICATION NAME] for (Resident #1). On the 26th ([DATE]) he only saw 2 cards and thought that was weird. He thought maybe it was expired and they had to destroy it; He didn't know. When (Nurse C) came on (11:00 PM-7:00 AM), she too mentioned (Resident #1) only had 2 cards. ADON B said Nurse N was also working But not aware if there should be 2 or 3 cards (of [MEDICATION NAME] for Resident #1). During the same interview, the ADON said Nurse A reported the missing [MEDICATION NAME] card to her when she was in the 1 East Medication room with the Interim DON (who was an ADON at that time) and another nurse trying to locate 5 missing [MEDICATION NAME] (narcotic pain medicine) patches, on [DATE] about 3:30 PM. He said he thought a card was missing with the sheet. He went to Medical Records and it (the Narcotics sheet) wasn't there. ADON B said the missing [MEDICATION NAME] card was not on the Destruction Log and the investigation started at that time. The ADON said she met with Nurse A and provided discipline for not reporting the missing [MEDICATION NAME] card sooner. When I met with him on the 31st, (Nurse A) said he had talked to me on the 27th, but I do not recall having that conversation with him. He said he asked where the sheets might be, and he said I said Look in medical records. ADON B said she did not provide discipline to the other nurses who were aware that the [MEDICATION NAME] card was missing. None of the other nurses with access to the missing [MEDICATION NAME] had reported to the DON, ADON's, Nurse Supervisors or Administrator that the [MEDICATION NAME] was missing. On [DATE] at 9:00 AM during the interview with ADON B, she indicated the facility had a different DON (X) at the time of the missing [MEDICATION NAME] and investigation. ADON B said DON X was on vacation at the time the [MEDICATION NAME] went missing ([DATE]-[DATE]) and did not return until approximately [DATE]. The ADON said the DON (X) was not contacted about the missing [MEDICATION NAME] card of 30 pills and stated, Normally, I think we would call and let her know. An interview with Nurse A on [DATE] at 10:40 AM revealed, I worked [DATE], Christmas Eve. I worked the 1 East- Teens. I know there were 3 cards of [MEDICATION NAME] (for Resident #1). I was off Christmas day (2019) and came back on the 26th ([DATE]). I noticed (Resident #1) only had 2 cards; at that point I did nothing. I thought they had been destroyed It didn't occur to me it was missing. On that Friday, [DATE]th, there was something going on with the (Medication dispensing system). There were missing [MEDICATION NAME]es. Two ADON's (B and the Interim DON) and (Nurse DD) were there in the med room. I told (ADON B) about the [MEDICATION NAME] and she said Check with Medical records. I just knew they weren't in the cart. I thin I was naïve. It didn't occur to me that someone would take a whole card. I thought someone forgot to fill out the destruction sheet. I didn't follow up with Medical Records until Tuesday, [DATE]st, 2019. I said, Can you look at (Resident #1's) destruction logs. There were 2 and they weren't it. I went right to (the Interim DON's) office and she got (ADON B) and They wrote me up for late reporting. We had not received any education on what we were supposed to do; nothing on the process for missing medications. Then they said, It's been 5 days, what can we do now. During the interview, Nurse A was asked if ADON C or the Interim DON assisted him in investigating the missing [MEDICATION NAME] sheet in Medical Records and he said they did not. An investigation was not started until he told them it was not present in Medical Records. Nurse A said he had not followed up sooner with the Medical Records department as, they left at 4:00 PM Monday-Friday and soon after he arrived on his shift, he received report and then prepared for administering medications to the residents. On [DATE] at 11:01 AM, the facilities updated Narcotics policy Controlled Substance & Narcotic Count, ( dated updated [DATE] (1 ½ months after the incident) was reviewed with Nurse A. He said he was unaware of the updated policy and the facility had not provided education on the policy; Nurse A stated, They (nurses and Administration) didn't know what to do because they weren't prepared. An interview with Human Resources U, on [DATE] at 2:25 PM provided, I think I was heading out for the day, New Years Eve (2019), when (Interim DON) brought to my attention there was a missing card ([MEDICATION NAME]). Human Resources U was asked what the protocol for missing narcotics in the facility was and said, If there was any suspicion, they should drug test (the nurses). On [DATE] at 4:43 PM, an interview with Pharmacist Y confirmed the facility had received 3 cards of [MEDICATION NAME] for Resident #1 and it was the facilities responsibility to immediately begin an investigation and contacting the pharmacy as needed. The IJ Removal Plan was reviewed on [DATE] at 1:55 PM, with the Administrator, DON, ADON, Staff Development Nurse EE and Quality Manager JJ, and contained the following: [DATE]: The 3 nurses involved with initialing/dating or timing the Narcotic count prior to counting received education. [DATE]: A Drug Diversion Policy and Procedure was created and initiated by the facility. [DATE]: The facility Abuse Policy was updated. [DATE]: All nurses began to receive education on Narcotic counts, Misappropriation of resident property reporting of abuse and who the Facility Abuse Coordinator was/Administrator. [DATE]: All staff began education related to: Abuse/Reporting/Abuse Coordinator/Administrator. [DATE]: The Nursing Supervisors initiated auditing to ensure Narcotics counts including Narc card counts, and the shift to shift count were correct. [DATE]: The facility began an audit to ensure all resident Narcotics were accounted for and the resident's received them as ordered. [DATE]: The facility initiated a 2 Nurse process for receipt of Narcotics from the pharmacy. [DATE]: The facility began installing cameras in the Medication rooms. The IJ Removal Plan was approved on [DATE] with a Removal Date of [DATE]. On [DATE], the State Surveyor verified that the facility had initiated the Removal Plan and that the Immediacy was removed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimum harm that is not immediate jeopardy, pending completion of inservice training of all staff not yet inserviced and pending the facility's ability to sustain compliance, as verified by the State Agency (SA). On [DATE] at 2:46 PM, the Administrator was asked if she had reported the incident/drug diversion to the Police, she said she still had not, but would do that now. On [DATE] at approximately 3:30 PM, Officers V and W were observed interviewing the Administrator, Interim DON, ADON and Nurse A about the missing [MEDICATION NAME]. During an interview with the Administrator and Interim DON on [DATE] at 4:25 PM, about the Police Investigation of the missing [MEDICATION NAME], they said Officers V and W would be interviewing all nurses who had access to the East Hall Medication cart from ,[DATE]-[DATE]. The Administrator said the Officers said no one should have left the building upon suspicion of the missing narcotics. On [DATE] at 4:45 PM, this surveyor confirmed the facility had enacted their Plan of Correction for Narcotics Diversion.

Based on observation, interview and record review, the facility failed to maintain supervision of Resident #41 when up in the wheelchair, to reduce the recurrence of falls for one Resident (#41) of five residents reviewed for falls, resulting in an injury to the head with a laceration, pain and transfer to the emergency room and the potential for continuous falls and injuries. Findings include: A review of Resident #41's medical record, revealed an admission into the facility on [DATE], a re-admission on 11/4/19 and discharged on [DATE], with [DIAGNOSES REDACTED]. A review of Resident #41's Minimum Data Set assessment, revealed severely impaired cognition and needed extensive assistance with two+ person physical assist for bed mobility, transfers, dressing and toilet use. A review of Resident #41's Safety Events-Falls, for the past 3 months, included the following: -Event Date 8/26/19 at 4:15 PM, description, Dining room aid saw resident on knees between table and wheelchair in rec room. Resident then tried to get on his hands and knees to stand up. Dining room aid assisted resident back into wheelchair. Notes dated 8/28/19 at 12:45 PM, revealed, On 8/26/19 at 16:15 (4:15 PM) The Dining room aide found the resident on his knees in the Rec. room between his wheelchair and the table, as she walked over to him, he then tried to move onto his hands and knees to stand up. Nurses immediately responded and assessment was completed . Resident is unable to state what he was trying to do due to his confusion r/t (related to) advanced Dementia . Resident is unaware of his physical and safety limitations. He can be impulsive and is noted to attempt self transferring . Following safety interventions in place: touch pad call light along right side in bed, sure grip rubber soled slippers or slip grip socks on when in bed, rear anti tippers on w/c, (wheelchair), ABS on w/c, safety alert log, encouraged to be in supervised area when up in w/c . Safety measures in place may not eliminate all falls for this resident, but may lessen the risk for further occurrence and prevent serious injury . -Event Date 9/1/19 at 9:00 PM, description, Resident found on floor at approximately 2100 (9:00 PM) on his knees facing his bed with his arms and hands on the bed as in a praying position by staff doing a resident check. Resident was assisted to be around 2000 (8:00 PM), and was noted to be asleep shortly after laid down . -Event Date 10/9/19 at 8:40 PM, description, Unwitnessed fall. Found resident on floor laying on his right side, back toward the wall. Pants partially down and incont (incontinent) of bowel and bladder. Notes dated 10/9/19 at 20:40 (8:40 PM), Resident found on floor in hall by CN[NAME] No noted injuries. Resident was incontinent of bowel and bladder . Notes dated 10/9/19 at 21:58 (9:58 PM), During medication pass tonight resident was brought back from 2 West where he was found to have gotten up out of his W/C (wheelchair) and had gone into another resident's room. Resident was trying to have a bowel movement in the other resident's bed. Resident redirected from other resident's room throughout this shift. Resident combative at times with staff this shift. Removing his grippy socks constantly. Getting up from his W/C frequently. -Event 10/14/19 at 2:40 PM, description, Resident found laying on the floor in the dining room. Resident was laying on left side holding his head, head facing toward hallway and feet facing toward back of room. Resident wheel chair was at a table behind him towards the hallway. Location of injury, Back of head. Notes dated 10/14/19 at 3:16 PM, Res (Resident) transferred to hosp (hospital) via EMS/stretcher at 1510 (3:15 PM). This nurse was in the nurses station upon hearing a loud thud outside the door at 1440 (2:40 PM) upon going out in the hallway resident was observed to be laying on the floor in the dining room. Resident was laying on left side, head facing toward hallway and feet facing toward back of room. Resident wheel chair was at a table behind him towards the hallway. Resident holding back of head and had a 3 cm (centimeter) x (by) 2.5 cm blood filled open area to back of head with blood dripping onto floor . Note dated 10/15/19 at 1:52 PM, On 10/14/19 at 1440 (2:40 PM) licensed nurses responded to a loud noise coming from the direction of East dining room. Upon entering dining room they observed resident lying on his left side on floor near table . Residents wheelchair was noted to be parked by table approximately 6 feet from resident near entrance to dining room . Following safety measures in place: . encourage to be in supervised area when up in wheelchair . Safety measures in place may not eliminate all falls for this resident, but may lessen the risk for further occurrence and prevent serious injury . -Event 10/18/19 at 11:20 AM, description, CNA responded to residents call light. Upon entering room she observed resident kneeling on landing mat with his feet resting on seat of wheelchair and head resting on edge of bed. Notes dated 10/18/19 at 3:07 PM, On 10/18/19 at 1115 CNA responded to residents call light and found resident kneeling on landing mat next to bed. She immediately alerted nurse. Per licensed staff she was called to residents room regarding a fall. Upon entering room she observed resident positioned with his knees resting on landing mat on floor with bilateral feet resting on seat of wheelchair, and his head resting on edge of bed. Resident unable to give specifics of occurrence r/t dx (diagnoses) of Alzheimer's . -Event 10/31/19 at 4:42 PM, description, resident was kneeling on his hands and knees in front of the steam table and his WC (wheelchair). Notes dated 11/1/19 at 3:25 PM, On 10/31/19 at 16:42 (4:42 PM) Activity CNA was in 2 East dining room assisting when a resident stated that this resident had fallen. CNA immediately responded and observed resident on his knees on floor in dining room . Following safety measures in place: .encourage to be in supervised area when up in wheelchair . Safety measures in place may not eliminate all falls for this resident, but may lessen the risk for further occurrence and prevent serious injury . -Event 11/4/19 at 11:50 AM, description, resident was sitting up in his w/c in front of the dining room- resident was awake, and was witnessed to fall forward from his w/c suddenly onto his face . Location Of Injury bridge of nose approx. 0.5 cm, right eyebrow approx. 3 cm. Notes dated 11/5/19 at 1:04 PM, On 11/4/19 at 1150 while at nurses station licensed staff observed resident sitting in his wheelchair near doorway to 2 east dining room. Staff then witnessed resident suddenly fall forward out of his wheelchair face first onto the floor and roll onto his right side. Per licensed staff resident appeared to be awake at time of fall and did not lose consciousness. Resident unable to give specifics of occurrence r/t impaired thought process d/t dx of [MEDICAL CONDITION] . Resident noted to have facial grimacing and moaning at this time. 3 cm laceration noted above right eyebrow; 0.5 cm laceration on bridge of nose. Pressure and ice applied to areas. Moderate amount of blood noted in bilateral nares, gauze applied . A review of Resident #41's medical record, revealed a document entitled Daily Care Plan, included the intervention, My Safety Interventions Are: .Encourage (Resident #41) to stay in supervised area when up. On 11/13/19 at 2:31 PM, an observation was made of Resident #41 lying in bed. The Resident had sutures to his forehead. CNA (certified nursing assistant) Q was queried regarding the sutures on the Resident's forehead and stated, He fell asleep in his chair and did a face plant. The Resident was picking at the sutures, the CNA pulled the Resident's hand away from the area and encouraged the Resident to not pick at the sutures. The CNA indicated the Resident gets restless at times and stated, When he gets restless, we check on him because he will self-transfer. An observation was made of a fall mat on the floor next to the bed and a touch pad call light underneath a heating pad. The CNA was queried regarding the call light under the heating pad and indicated that the call light is placed there so it goes off when he attempts to get out of bed by rolling onto the touch pad. On 11/14/19 at 2:21 PM, an interview was conducted with Unit Manager P regarding frequent falls for Resident #41. When queried regarding the frequency of falls and interventions in place to keep him safe, the Unit Manager stated, We keep him in a supervised area. CNA's will take him to activities or walk with him, try to keep him busy throughout the day. A review of the documentation for the fall on 10/9/19 when an unwitnessed fall occurred in the hall and the Resident had been having behaviors throughout the shift that had put the Resident at risk for falls. The Unit Manager was queried if the Resident was supervised when the fall occurred and stated, It was an unwitnessed fall. When queried regarding increased supervision during the shift with fall risk behaviors, the Unit Manager reviewed the medical record and stated, I do not see increased supervision prior to the fall on 10/9/19. We have him with a tag on his wheelchair. When queried what the tag indicated the Unit Manager stated, It's a yellow tag. He is to be kept in a supervised area. When queried regarding the fall on 10/14/19, if the Resident had been in a supervised area, the Unit Manager stated, It was shift change. It was not witnessed. No one saw him fall. The Nurses went in to do report, there were still staff out on the floor. They came out (of the report room) after he fell . On 11/14/19 at 5:26 PM, an interview was conducted with the Director of Nursing (DON) and the Restorative Nurse R who reviewed Residents falls. Resident #41's falls and interventions on the care plan for falls were reviewed with the DON and Restorative Nurse. When queried regarding the yellow tag on the Resident's wheelchair, the Restorative Nurse stated, It's a tag so that staff see that yellow tag and he is to be in a supervised area. When queried regarding sufficient staff available to supervise Residents during report, the DON stated, Not all staff go into report, some stay out. When queried if the Resident was to be supervised when up in the wheelchair, the DON stated, The care plan says to encourage the Resident to stay in a supervised area. When queried when the intervention for the yellow tag on the wheelchair was initiated, the DON reviewed the medical record and stated, 7/2/18. When queried if the Resident propels himself in his wheelchair, the Restorative Nurse indicated the Resident does propel himself and stated, He usually does not go that far.

This citation pertains to intake numbers MI 884 and MI 937. Based upon observation, interviews, and record review, three of three sampled residents (residents #1, #2, #3) reviewed for accidents, failed to have assistance devices used or functioning as the plan of care directed, to prevent falls, resulting in resident #1 falling with a resultant harmful femur fracture as a result of not being transferred with a gait belt. Findings include: On June 13, 2016 at approximately 10:00 a.m., resident #1 was observed lying in her bed on her back. She was not awake. Resident #1's daughter was in the room, and was interviewed at that time. Resident #1's daughter stated that on May 20, 2016 at around 7:00 p.m. she had received a phone call from the facility that her mother had fallen and was being sent to the local hospital emergency room . The daughter stated that she was told her mother was being transferred off of the toilet at the facility by a nursing aide who had not used a gait belt during this transfer and fell from her wheelchair sustaining a fractured right femur. The review of the facility Event Report form dated May 20, 2016 at 7:56 p.m., documented that resident #1 had fallen at 7:01 p.m. in the bathroom as resident #1 did not sit far enough back in her wheelchair and slid out. This report noted that the care plan was not followed because the resident was not wearing a gait belt. Included in this report was documentation the the Certified Nursing Aide (CENA) did not apply a gait belt for her transfer, and that resident #1 was care planned for a one-person assist with a gait belt and use of grab bars for support on and off the toilet. On June 13, 2016 at 11:50 a.m. CENA (B) was interviewed over the telephone. He stated that he was taking care of resident #1 on May 20, 2016 on the second shift. CENA (B) confirmed that he did not use a gait belt to transfer resident #1 off of the toilet around 7:00 p.m. that night and she slid from the edge of her wheelchair to the floor. CENA (B) stated he then went to report this fall to the hall nurse. The review of resident #1's Daily Care Plan dated 3/10/2016, and observed inside resident #1's room documented that for toilet transfers, she was to have one assist, gait belt with use of grab bar for support. One June 13, 2016 at 4:10 p.m. facility staff Licensed Practice Nurse (C) was interviewed inside the facility conference room. Nurse (C) stated she was on duty on May 20, 2016 when resident #1 had fallen. Nurse (C) confirmed that she had authored the Event Report noted above dated May 20, 2016. Nurse (C) confirmed that CENA (B) had not used a gait belt as directed in the care plan to transfer resident #1 from the toilet to her wheelchair, and spoke to CENA (B) about this error. On June 14, 2016 at 9:00 a.m., facility Licensed Practice Nurse (D) was interviewed over the facility telephone. Nurse (D) stated she was on duty May 20, 2016 when at about 6:45 p.m. CENA (B) came to her, really nervous, and told her that resident #1 had fallen. Nurse (D) went to resident #1's room and found her on the bathroom floor, sitting facing the door with her head and right should on the wall. Nurse (D) stated that resident #1 complained of pain, and during the assessment, Nurse (D) observed resident #1's right foot having an abnormal inward position. Nurse (D) stated she administered routine Tylenol to resident #1 for her pain which on palpitation hurt. Nurse (D) stated the physician was called, and an order was given to send resident #1 to the hospital emergency room . On June 13, 2016 at 9:30 a.m., the facility Director of Nursing (A) was interviewed inside the facility conference room. She stated that CENA (B) was suspended from duty after resident #1's fall on May 20, 2016, and then was terminated from employment because he did not follow resident #1's care plan for using a gait belt during the transfer. According to the hospital radiology report dated May 20, 2016 at 9:56 p.m., the exam of resident #1's right knee showed an impression of an acute comminuted spiral fracture of the distal right femur which extends through the femoral component of the right knee prosthetic device. Hospital surgical results dated May 23, 2016 documented that an open reduction and fixation of the right femur was completed. As a result of this preventable fall to resident #1 on May 20, 2016, the following changes have occurred to her activities of daily living which determines harm. Resident #1 has not been out of bed. Resident #1 has become incontinent of bowel and bladder. Resident #1 has not been to an activity. She cannot feed herself. She cannot drink by herself. She is in pain. As of June 12, 2016, the facility has started a significant change of condition assessment. Resident #1's previous assessment dated [DATE] and documented on a minimum data set (MDS) documented that her bed mobility, toilet use and locomotion on the unit were extensive assistance with one person assist. Resident #1's eating was assessed as limited assist with one person. Resident #1's bowel and bladder assessment was noted as always continent. Re-admission physician's orders [REDACTED]. In addition, Ativan (Lorazepam) 0.5 mg by mouth every four hours for restlessness/anxiety. Nursing progress notes dated June 12, 2016 at 11:16 a.m. documented resident #1 moaning out in pain. Nursing progress notes dated June 12, 2016 at 1:31 p.m. documented resident #1 starting to moan out at this time with routine Morphine administered. During an interview with the facility Director of Nursing on June 13, 2016 at 9:30 a.m. inside the conference room, she requested that the facility be held on past non-compliance for not following resident care plans and not following the facility gait belt policy. A corrective action plan was presented, with a compliance date of June 1, 2016 noted. One of the components of this corrective action plan was that CENA's were to review each resident's care plan that they were assigned to care for and initial each shift that the care plan was reviewed for any changes. The following CENA shifts for resident #1 failed to be initialed as reviewed: 6/7/16 (11 to 7 shift) 6/7/16 (3 to 11 shift) 6/11/16 (11 to 7 shift) 6/13/16 (3 to 11 shift). The review of resident #2's medical record found that she had a fall out of bed on June 6, 2016 at 4:41 p.m According to the Event Report dated June 6, 2016 at 6:30 p.m. resident #2 was noted to sitting on the floor at the foot of the bed facing the door. The alarm was not functioning properly. According to progress notes dated June 7, 2016 at 12:48 p.m., per staff at the time of the event, resident #2's bed alarm did not sound, or that a large stuffed dog that she holds were noted along with her pillows on the bed. The Resident Care Flowsheet care plan check by CENA's each shift found the following CENA shifts failed to be initialed as reviewed: 6/4/16 (11 to 7 shift) 6/5/16 (7 to 3 shift) 6/8/16 (7 to 3 shift) 6/10/16 (11 to 7 shift) 6/11/16 (3 to 11 shift) 6/12/16 (3 to 11 shift). The review of resident #3's medical record found that she had a fall out of bed on June 11, 2016 at 2:15 p.m According to the Event Report date June 11. 2016 at 2:24 p.m. resident #3's call light was on and staff responded to observe resident #3 sitting on her buttock on the right side of the bed on the mat. No injuries were noted. According to progress notes dated June 13, 2016 at 3:41 p.m., staff assessed resident #3's room after the fall event and it was noted that resident #3 did not have a defined perimeter mattress on her bed as care planned. Interviews with two 7 to 3 staff members who provided care for resident #3 were unable to state when defined perimeter mattress was changed out to a regular mattress. Maintenance department was notified to change the regular mattress to a defined perimeter mattress as care planned. In addition, upon review of the Resident Care Flowsheet posted inside the locker door in resident #3's room on June 14, 2015 at 10:20 a.m., care plan checks by CENA each shift found the following shift 6/9/2016 (7 to 3 shift) not be be initialed as reviewed. ( )

Based on observation, interview and record review, the facility reported a fall with fracture for 1 resident (Resident #1) of 4 sampled residents, as a result of the resident ambulating without a gait belt. Findings: Record review of the facility computer-generated 'Safety Events-Falls' report, dated 3/10/16 at 12:33 PM, revealed that at 12:10 PM a staff Certified Nurse Assistant (CNA) assisted the resident #1 up out of her bedside recliner in her room and was going to ambulate her to the dining room with her 4 ww (wheeled walker) and as the resident took three steps with staff member right behind her, resident right knee appeared to give out and rotate inwards towards residents left inner knee and the left knee then gave out and resident fell to the floor onto her left hip between the beds and in front of her bedside recliner per staff CNA present at the time of fall event .Resident was supposed to wear gait belt for ambulation and care plan was not followed per CNA staff member at time of fall event and staff was counseled on failure to follow care plan. Record review of Certified Nurse Assistant's 'Employee Counseling Form, dated 3/10/16, revealed that the CNA was suspended that day and then terminated on 3/16/16. Record review of the Certified Nurse Assistant's employee work time clock revealed that the CNA did not work after 3/10/16. Record review of 'Individual/Small group in-service', dated 3/11/16, was signed by licensed staff and certified nurse assistants related to reading care plans and make sure staff were using gait belts if care plan states to use. If resident refuses gait belt, make sure it is charted on care plans. Record review of the Resident #1's Minimum Data Set (MDS), dated [DATE], revealed an elderly woman with cognitive impairment, who ambulated with a wheeled walker. Record review of the Resident #1's physical therapy notes, dated 2/29/16 through 3/13/16, revealed 'Supervision with minimal assist (Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity intermittently).' Record review of the Resident #1's care plans, dated 2/27/16, revealed care plans related to impaired mobility and fall risk due to osteoarthritis, muscle weakness, gait and mobility abnormalities, osteoporosis, PVD (peripheral vascular disease) cardiac impairments, and balance impairments with history of bilateral total knee arthroplasty. Approaches to care planned included to transfer per the bedside care plan (located in residents' rooms). Record review of the Resident #1's 'Daily Care Plan' (bedside care plan), dated 3/9/16, revealed: Transfers with- 1 assist, GB (gait belt) with 4ww (4 wheeled walker). Safety interventions noted: Bed alarm. In an interview on 3/30/16 at 8:25 AM with the Resident #1, who scored an 11 out of 15 on the Brief Interview of Mental status (BIMs) on 3/21/16, revealed that she was getting up for lunch and her knee's gave out and she just went down. The Resident of Concern stated My legs just gave out. Observation at the time of the interview revealed the Resident of Concern to have a CPM (continuous passive motion) machine for therapy in use to the left leg. In an interview on 3/30/16 at 9:30 AM with the Resident #1's Durable Power of Attorney (DPOA) family member revealed that he was notified by the facility of the incident and that he came to the facility that day and that the facility physician reviewed the x-rays and recommended hospital transfer due to bilateral fractures of legs. The DPOA stated the hospital physician told him that the residents bones were like crepe paper. Record review of physician progress notes [REDACTED].#1 revealed serve pain on movement of her left knee with flexion and extension, not able to do it herself. Right knee, she is able to flex and extend with some pain, but pulses ae palpable in the bilateral foot and does not show any joint effusion or swelling. Stat x-ray was done, results of which were seen by myself, the results were reviewed. The patient does have distal femur fracture bilaterally there is a question of possible pathological fracture as well since patient knees all of sudden gave out and she fell . The patient does have history of osteoporosis as well . The facility reported incident was substantiated during the survey process and past non-compliance was submitted on 3/30/16, during the investigation period. #

This Citation pertains to intake # MI 647 Based on observations, interview and record review, the facility failed to ensure a safe environment in 1 (Resident #101) of 3 sampled residents for falls, in a total sample of 3, resulting in hospitalization for injuries of a subdural hematoma (bleeding in the brain), sutures to the forehead and rib pain for Resident #101. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was a [AGE] year old female who had been admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #101 had moderately impaired cognition with a Brief Mental Score (BIMS a test used to determine cognitive status) of 12, required extensive assist of 2 staff for transfers, extensive assist for bed mobility, dressing, hygiene, and total staff assist for toileting, hygiene and bathing. Review of the MDS dated [DATE] revealed resident #101 was non- ambulatory (did not walk), had balance problems, limited range of motion in upper and lower body and used a wheelchair for mobility with staff assistance to propel the wheelchair in the room and on and off the unit at the facility. Review of the Resident Falls/Risk of Falls policy dated 12-15-10 and revised 3-5-12 revealed #5. Procedure: If resident struck their head a Neurological Check Form will be initiated. #8. Plan of care will be reviewed with new interventions initiated as deemed necessary to lessen risk for further incident and or serious injury. #10 An analysis of falls event will be completed with summary statement that includes contributing factors of fall and interventions initiated to prevent reoccurrence. Review of the facility Incident and Accident Report dated 5-11-13 at 4:20 pm revealed Resident #101 had fell in her room, from the wheelchair. The Summary on the Incident report dated 5-11-13 at 4:20 revealed "Pathway between bed two and furniture against wall (television on stand and a chair) very narrow. There were also cords dangling from the bed, including cord and tubing from air mattress control and from bed control. CNA stated w/c (wheelchair) became caught in cords when propelling resident forward through pathway." "Resident refused neurological checks." Under intervention it was listed, "Staff education as to safe transportation of residents in wheelchair. Cords/tubing placed safely." Under Summary it was written, "Residents room was re-arranged to lessen the risk for further incident." In an interview on 5-17-13 at 2:30 pm, Certified Nurses Aide (CNA#8) reported that on 5-11-13 before the supper hour, CNA #8 had transferred Resident #101 from her bed to her wheelchair, and had pushed the wheelchair without footpedals from the window side of the room to the door side of the room. CNA #8 reported that the wheelchairs' left brake handle then got caught on the air mattress control unit which was attached to the exterior of the footboard on the roommates bed, got caught up in the two air hoses on the unit which were hanging freely, and got caught up in the bed control cord which had been hanging freely at the foot of bed. CNA #8 reported that Resident #101's wheelchair front wheel ran into a chair on the right side and projected Resident #101 out of the wheelchair and onto the floor head first and lying more on her right side. CNA #8 reported that there was a large pool of blood coming from Resident #101's head. CNA #8 reported that she called out for help and Licensed Practical Nurse (LPN#6) and Registered Nurse (RN#13) came in to assist and assess Resident #101. CNA #8 reported she did not have the foot pedals and leather foot cradle (a device used to position the feet and legs from slipping on the foot pedals of wheelchair) on the wheelchair, as she was going to the other side of the room where she had more room, to put the foot pedals on the wheelchair. CNA #8 reported that room #238 was "very cluttered and congested, that people trip on cords all the time." CNA #8 reported that on 5-13-13 she reenacted the fall with two nurses, Registered Nurse #4 and another nurse. CNA #8 reported "I was surprised the room arrangement had not changed. It is the same at it has been, its exactly the same. They did move a chair out into the hall, a small straight back chair, that was all." CNA #8 reported that "During the reenactment, I pushed the nurse in the wheelchair, and the same thing happened! The wheelchair caught on the hoses and I didn't purposely catch it on them. The nurse fell out of the wheelchair, the exact way as (Resident #101) did, I couldn't believe it! And the room is still in the same configuration as it was the day of the fall." In a telephone interview on 5-17-13 at 3:10 pm, Family Member #9 reported that she had gotten caught up in the cords at the foot of Resident #101's roommates bed before, while pushing Resident #101 in her wheelchair out of the room. Family Member #9 reported, "There were so many cords, there was a lot of stuff in the room. My daughter tried to move the bed around at one point but was told she couldn't due to the power outlets, I talked to ( CNA #11) and she told me we couldn't move things around." Family member #9 reported that no staff had ever asked her if the room could be changed around, or the bed be moved or switched, or rooms be switched to provide for a less cluttered and safer environment. In a telephone interview on 5-17-13 at 3:30 pm, Family Member #10 reported that she had looked at the room since the fall on 5-11-13. "It's the same, my husband even said that there is no room in here to move around. I believe when we first moved (Resident #101) in there (room 238) that we had discussed the room being cluttered, we shoved the chair in the corner and tried to make more room." In an interview with CNA #11 on 5-17-13 at 3:55 pm, CNA #11 reported that she was the usual full time nurse aide for Resident #101 and knew her well. CNA #11 reported that "Sometimes I would have to reconnect the hoses at the foot of the roommates bed when I brought (Residents roommate) back to the room. Someone must have gotten caught up in the cords. CNA #11 reported, "I am always tripping on cords." CNA #11 reported that since returning from the hospital, Resident #101 is noted to be "much weaker in the right arm and her speech seems slower." In observations made on facility rounds on 5-17-13 at 11:00 am, the Surveyor observed the 1 West unit to have 4 (Rooms 168, 173, 192 bed closest to door, and room 196 bed closest to the window) bed control unit coil cords free hanging at the foot of the beds on the floor, causing a potential trip hazard. On 5-17-13 at 11:05 am the Surveyor observed the 1 East unit to have 3 (Rooms 132 bed closest to the door, 117, 111 bed closest to the window) bed control unit coil cords free hanging at the foot of the beds on the floor, causing a potential trip hazard. 1 East unit Room 134 right side of the room, was observed to have a long call light cord draped across the floor from the wall, to the resident sitting up in her recliner chair approximately 8 feet across the room (the Surveyor counted the floor tiles to approximate feet) , causing a potential trip hazard. 1 East Room 113 right side of the room was observed to have the call light cord draped hanging across the floor approximately 5 feet across to the bed where the resident was lying in bed. 1 East Room 121 right side of room was noted to have the call light draped across the air in the room approximately 4 feet from the bed causing a potential trip hazard. On 5-17-13 at 11:15 the Surveyor observed the 2 West unit to have 6 (Rooms 264 bed by door, 266 bed by door, 267 bed by door and bed by window, 292, and 281) bed control unit coil cords free hanging at the foot of the beds on the floor, causing a potential trip hazard. Room 259 bed by window was observed to have 2 plastic air mattress cords with approximately 3 feet length, hanging on the right side of the foot of bed toward the door causing a potential trip hazard or getting caught on a wheelchair. On 5-17-13 at 11:25 am the Surveyor observed the 2 East unit to have 6 (Rooms 207 bed by window, 209 bed by window, 212, 216 bed by door and bed by window, 220) bed control unit coil cords free hanging at the foot of beds on the floor, causing a potential trip hazard. Room 213 right side of room was observed to have a long call light cord dragging on the floor, a fall sensor cord dragging on the floor and 2 plug in cords loosely lying on the floor all at the head of bed and left side of the bed towards the door, causing a potential trip hazard. On 5-17-13 at 11:20 am, an observation and interview were held with Resident #101. Resident #101 was lying in her bed, her bed was in low position near the window, the floor mat was on the floor and the bed fall sensor was on the bed. Resident #101's room was observed to be very cluttered with 2 dressers, a television stand with television on it, and an over the bed tray table all lined up along the wall as you entered and exited the room. It was observed that between the furniture and the Roommates bed, there was less than 3 feet of space to walk through. The Roommates foot of bed had a air mattress control unit on the outside of the bed protruding another few inches, with the 2 clear air hoses attached protruding out from the bed. Resident #101 reported that she felt "Miserable, my head hurts and it is miserable." In an interview with Occupational Therapist, (OT #5) on 5-17-13 at 1:30 pm, OT #5 reported that before the fall on 5-11-13, Resident #101 had a leather foot cradle available to use on the foot pedals of the wheelchair. OT #5 reported that it was safer to have the leg rests on due to Resident #101 having had a stroke and her right foot did not always stay on the wheelchair legs and foot pedals without the foot cradle. OT #5 reported that it was care planned for Resident #101 to have the foot pedal and the foot cradle on for transporting Resident #101 in the wheelchair. OT #5 reported that since the fall on 5-11-13, Resident #101 is much weaker, is now using a maxi lift (a machine to transfer from chair to bed) for transfers, is having increased pain and now pain in her right ribs and head. OT #5 reported that Resident #101 has shown a decline and is now leaning in the wheelchair to the left and she is evaluating her for a seating device to position Resident #101 upright in the wheelchair. OT #5 reported, "I was just up in (Resident #101) the room, her room is exactly the same arrangement as before the fall. It has not been changed around. The roommates bed with the air mattress control unit is in the same position, the nightstand is in the same position, the dressers and tv stand are all in the same position, there isn't any more room in there as before the fall." In an interview with Registered Nurse (RN #7) on 5-17-13 at 2:15 pm, RN #7 reported that on 5-11-13 prior to the supper hour, she heard a page and went to room 238. RN #7 reported that CNA # 8, RN #13 and LPN # 6 were all present in room #238 assisting Resident #101. RN #7 reported that she assessed the room for cause of the fall. RN #7 reported, "The tubes from the air mattress were laying on the floor, the bed control cord was hanging down low and the cord to plug in the air mattress were all hanging very low. RN #7 reported that immediately after the fall "We had moved the chair out in the hall, tall hard back chair, and moved the TV stand over a foot or so." RN #7 reported that when she noticed the cords hanging low after Resident #101 fall, she called housekeeping to the room and they tucked the cords up under the mattress." RN #7 reported that Resident #101 "was not able to propel her self in the wheelchair and that staff needed to slow down and be more cautious." RN #7 reported that they could not move the bed against the wall due to a power outlet sticking out on the wall and the hi- lo beds could catch on the plug causing a hazard. When asked by the Surveyor, "Why wasn't the bed switched around to make more room", RN #7 reported that "the first thought was to switch beds around but needed to get permission from the family." RN #7 and the Surveyor went to room #238 to observe the room placement. The room was observed to be unchanged from the morning observation, with less than 3 feet between foot of Roommates bed and the furniture against the wall. The beds were noted to have an extender at the head of bed keeping the head of bed from scraping the wall when the the bed went up and down, protruding the beds out another 6 inches from the wall. The roommates' bed closet to the door, had the air mattress control unit protruding from the bed. The beds were in the same location in the room as observed earlier in the day. RN #7 confirmed the room placement, other than one dresser being moved over a foot and the high back chair being removed, to be the same as the day Resident #101 fell and got injured, and was sent to the hospital. In an interview on 5-17-13 at 5:00 pm, Director of Nursing (DON #2) and RN #14 reported that the facility does not have a policy for foot pedal usage on the wheelchairs. RN #14 reported that if someone can't use their feet to propel a wheelchair or has edema (swelling in feet) then foot pedals are to be used. RN #14 reported that when she reviewed the fall on 5-11-13 for Resident #101, she noted that the brake on the left side of Resident 101's wheelchair was bent way out, had got caught on the tubing on the bed, and she called maintenance to come and fix the bent brake handle. RN #7 reported that she felt the movement of the chair out of the room, was acceptable space to get a wheelchair through the area to the window bed, with the roommates' bed in same position with air mattress control box on the foot of the bed protruding. RN #7 reported when Surveyor had asked if family had been asked about switching beds around to make more space, RN #7 reported, "No, No one has asked the family to move beds." On 5-20-13 at 11:20 am, the Surveyor observed the 2 West unit to have room 261 bed by door and room 296 bed by the door, had the bed control coil cords hanging very low onto the ground, the controls were Velcro to the foot of bed, but the the cords were stretched out long and loosely hanging on the floor causing a potential trip hazard. Review of the hospital history and physical dated 5-11-13 revealed Resident #101 had been diagnosed with [REDACTED]. Laceration to right forehead status [REDACTED]. Review of the hospital history and physical dated 5-11-13 revealed Resident #101 had been admitted to the Intensive Care Unit (ICU). Review of the hospital CT Scan of the head dated 5-11-13 revealed Impression: "Rather large right subdural hematoma with mass effect (bleeding in the brain), right to left shift." ( )

This citation pertains to intake #MI 416. Based on interview and record review, the facility failed to provide supervision to prevent a fall in 1 of 4 sampled residents (#500), reviewed for significant cognitive impairment, immobility and who was at high risk for falls, resulting in an acute fall with severe bruising around both eyes, bridge of nose, forehead and pain. Resident #500 subsequently died . Findings include: Resident #500 did not reside at the facility at the time of the investigation ([DATE] to [DATE]). Review of the Face Sheet, Minimum Data Set ((MDS) dated [DATE], Physician, Nurses and Social Worker notes dated ,[DATE] and ,[DATE], and Hospital records dated [DATE], revealed Resident #500 was admitted to the facility on [DATE] after a fall at home. Resident #500 had a history of [REDACTED]. Resident #500's [DIAGNOSES REDACTED]. Review of the Facility fall risk assessments dated [DATE] and [DATE], revealed Resident #500 had "disorientation/confusion, dizziness, was unable to rise without assistance, received Ativan and was coded as a number "7", high risk for falls. Review of the Impaired mobility care plan dated [DATE], revealed Resident #500 "May nap as desired in bed or recliner chair (not wheelchair), encourage to elevate legs on w/c leg rest." Review of the Cardiac care plan dated [DATE], revealed staff were to "organize care to allow for rest & periods of uninterrupted sleep" for Resident #500. Review of Resident #500's Certified Nurse Aide (CNA) daily care plan dated [DATE], revealed "encourage to elevate legs on w/c legs rest or in recliner chair." Review of the Facility incident investigation dated [DATE], revealed on [DATE] at 8:30 p.m., Resident #500 fell out of her wheelchair while being pushed to her room by a Nursing Assistant (CNA #1) and fell directly onto her face. The investigation indicated, "she (CNA #1) was going to take the resident to bed since she appeared to be sleeping. She shook the residents shoulder to awaken her and stated she only mumbled and did not open her eyes, (CNA #1) states she proceeded to move the wheelchair, as they neared the doorway of the dining room the resident just suddenly slumped forward and to the left going out of the wheelchair. (CNA #1) further stated that when the resident started to fall forward she grabbed the back of her shirt, she was unable to stop the fall." In an interview on [DATE] at 3:10 p.m., CNA #1 stated, "normally we kept her in front of the nurses' station to watch her. (Licensed Practical Nurse/LPN #1) put oxygen on her and put her in the dining room, she told me between 7:00 p.m. and 7:30 p.m. It was not uncommon for her to fall asleep in her wheelchair. She was different in the 2 weeks before her fall, more confused. I unhooked her oxygen, she was sleeping, she didn't respond to me shaking her. I pushed her forward; she was still lethargic and sleeping. I saw her tipping forward and I grabbed the back of her shirt and I watched her fall. I was yelling for help as I was watching her fall. I could hear her feet sliding (indicating they were not on foot rests). I don't have a good answer why I did not ask for help, I have pushed her like that before. The fall could have been prevented. I should of gotten help or pulled her backwards." CNA #1 said when she was talking to Resident #500, she was "behind" her and Resident #500 did not respond to her. Review of LPN #1's written statement dated [DATE], said "assisted res (resident) to roll over so she was facing us, res had large amount of bruising over left eye, over top of L (left) head, bridge of nose. Also a 3 cm laceration under R (right) eye that was superficial. Res had mumbled speech but did state "help me." In interviews on [DATE] at 10:00 a.m. and 3:45 p.m., LPN #1 stated, "The resident (Resident #500) was in the main dining room at 8:30 p.m. There may have been one or two other residents in the dining room. I saw her about 1 hour before she fell , watching TV. I did put oxygen on her because she said she could not breath it was for her comfort; there was no staff in the dining room. Then I went and passed meds (the nurse passed medications at the end of the hall, not within sight of the dining room). I think it could have been prevented (the fall)." In an interview on [DATE] at 11:45 a.m., LPN #2 stated, "the CNA (CNA #1) told me the resident was sleeping. She did not have leg rests on her wheelchair, no lap buddy, no foot pedals. She (CNA #1) said she (the resident) was sleeping and she said lets go to bed. The CNA said she started leaning forward and she tried to grab her and she was too heavy and she fell ." Review of LPN #2's written statement dated [DATE], said "After this resident fell I was told by her CNA (CNA #1) that she thought she was sleeping in her chair & that she was leaning to the left. She then decided to take her to her room to get ready for bed. As she started to push her in her w/c (wheelchair), res (resident) fell forward out of her w/c & onto her face." Review of the Facility transfer sheet dated [DATE] for Resident #500 revealed, "Transfer to ER (emergency room ) for evaluation and treatment, [DATE], 2030 (at 8:30 p.m.), fell face forward out of w/c (wheelchair) injuring face and L (left) top hand, had 1900 routine Ativan 0.5 mg, 1845 Vicodin ,[DATE], less responsive since fall." Review of the EMS (emergency medical services) run report dated [DATE], revealed Resident #500 "fell about 8:30 p.m., noticed lethargy and left side facial droop about 11 p.m., fell face first off wheelchair." Review of the Hospital record dated [DATE], revealed Resident #500 had a "Acute fall with secondary cardiopulmonary arrest (heart attack). The patient reportedly was in a wheelchair at the nursing home where she was noticed to have slumped to her right side then subsequently, she fell from the wheelchair face down onto the floor, striking her head and face, death in the ER, total critical care time was 20 minutes." Review of Resident #500's certificate of death dated [DATE], revealed the date of death was "[DATE] " at "12:20 a.m." and cause of death was a heart attack. An interview was done on [DATE] at 2:25 p.m., with the facility Physical Therapist (PT #1). PT #1 confirmed that according to the care plans, resident #500 should have had foot pedals on her wheelchair and due to the residents physical limitations, she was unable to stop herself from falling from her wheelchair. In an interview on [DATE] at 11:10 a.m., In-service Nurse #1 confirmed that CNA's had been educated on how to safely move residents in their wheelchairs and not to wheel a resident forward in their wheelchair if they were lethargic or sleeping. In an interview on [DATE] at 11:08 a.m., RN #1 stated "(LPN #1) called me to the floor. They said she (Resident #500) fell out when they pushed her wheelchair forward; she was lethargic before the CNA moved her. No lap buddy, no foot pedals were on her wheelchair. They put her (Resident #500) on UTI (urinary tract infection) monitoring because she had been acting differently 2 weeks prior to her fall. I thought she fell because of her feet hanging and being tired. After her fall, she was more lethargic and her speech was more slurred." ( )

THIS CITATION PERTAINS TO INTAKES #MI 605, #MI 849 AND #MI 919. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT SAFETY INTERVENTIONS AND SUPERVISION TO PREVENT ACCIDENTS IN 3 (#101 #102 AND #103) OF TOTAL SAMPLE OF 6 RESIDENTS ALL REVIEWED FOR FALLS AS WELL AS TO 1 OFF SAMPLE RESIDENT (#188), RESULTING IN FALLS WITH INJURY (FRACTURES). FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #101 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 WAS ABLE TO COMMUNICATE HER NEEDS AND REQUIRED THE STAFF MEMBERS PROVIDE SUPERVISION FOR ALL TRANSFERS AND TOILETING. RESIDENT #101 HAD [DIAGNOSES REDACTED]. ACCORDING TO THE CAA (CARE AREA ASSESSMENT) DATED 9/9/2011, RESIDENT #101 WAS ASSESSED BY THE FACILITY AS BEING AT RISK FOR FALLS DUE TO HER IMPAIRED MOBILITY, SIDE EFFECTS OF MEDICATIONS, BALANCE DEFICITS, AND GENERALIZED WEAKNESS. ACCORDING TO RESIDENT #101'S PLAN OF CARE DATED 12/8/2010, THE FACILITY IMPLEMENTED SEVERAL INTERVENTIONS TO REDUCE THE RISK OF ACCIDENTS INCLUDING CALL LIGHT IN REACH, CLUTTER FREE ENVIRONMENT, WHEELCHAIR NEXT TO BED, AND A LOW BED SET AT A MID HEIGHT TO MAKE TRANSFERS EASIER FOR THE RESIDENT. A THREE MONTH REVIEW OF RESIDENT #101'S ACCIDENT REPORTS REVEALED THAT RESIDENT #101 fell THREE TIMES IN THE THREE MONTHS REVIEWED. ACCORDING TO THE NURSE'S NOTE DATED 12/5/2011 RESIDENT #101 WAS VERY WEAK AND REQUIRED 1 TO 2 STAFF MEMBERS WITH A GAIT BELT TO PROVIDE PHYSICAL ASSISTANCE FOR TRANSFERS. ACCORDING TO THE NURSE'S NOTE DATED 12/6/2011, RESIDENT #101 WAS "...WEAKER AND MORE DEPENDANT FOR CARE..." RESIDENT #101 REQUIRED 1 TO 2 STAFF MEMBERS WITH A GAIT BELT TO PROVIDE PHYSICAL ASSISTANCE FOR TRANSFERS. NO EVIDENCE COULD BE FOUND IN RESIDENT #101'S CLINICAL RECORD TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #101 BASED ON THESE ASSESSMENTS. ACCORDING TO THE NURSE'S NOTE DATED 12/7/2011, AT 1:50 A.M., RESIDENT #101 WAS IN BED, TRYING TO REACH THE CALL LIGHT, COULD NOT REACH IT AND fell . ACCORDING TO THE NURSE'S NOTE, "...HER FACE HIT THE TRASH CAN CAUSING A BRUISE ON HER RIGHT CHEEK, HER CHEST HIT THE TRASH CAN CAUSING A BRUISE TO THE RIGHT SIDE OF HER CHEST AND BREAST. HER LEFT KNEE HIT THE GROUND CAUSING IT TO BRUISE ALSO..." ACCORDING TO THE RESTORATIVE NURSE'S NOTE DATED 12/7/2011, RESIDENT #101 SUSTAINED A 1 CM X 3 CM SKIN TEAR ON HER RIGHT UPPER ARM, AND A 4 CM X 3 CM SKIN TEAR ON THE LOWER RIGHT ARM NEAR THE ELBOW. ACCORDING TO THE RESTORATIVE NURSE'S NOTE, BRUISING ON THE RIGHT ARM MEASURED 3 CM X 7 CM, BRUISING ON THE RIGHT CHEEK MEASURED 3 CM IRREGULARLY ROUND AND BRUISING ON THE LEFT KNEE MEASURED 4 CM IRREGULARLY ROUND. ACCORDING TO THE RESTORATIVE NURSE'S NOTE RESIDENT #101 fell WHILE REACHING FOR A CALL LIGHT "...SHE COULD NOT FIND..." AND SLID OFF THE BED. RESIDENT #101'S PLAN OF CARE WAS MODIFIED ON 12/7/2011 TO INCLUDE A DEFINED PERIMETER MATTRESS. ACCORDING TO THE RADIOLOGY REPORT DATED 12/7/2011, RESIDENT #101 SUFFERED AN ACUTE FRACTURE OF THE 7, 8, AND 9TH RIBS ON THE RIGHT SIDE. RESIDENT #101'S PLAN OF CARE WAS MODIFIED ON 12/8/2011 TO INCLUDE A BED ALARM "...WITH FUNCTIONING CHECKS Q (EVERY) SHIFT AND PRIOR TO USE..." ACCORDING TO THE NURSE'S NOTE DATED 12/12/2011, AT APPROXIMATELY 10:59 P.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND TOILETING. RESIDENT #101 ATTEMPTED TO SELF TRANSFER FROM THE BED AND fell . RESIDENT #101 WAS FOUND ON THE FLOOR ON HER BACK IN HER ROOM. RESIDENT #101 COMPLAINED OF RIGHT ARM PAIN, WAS ASSESSED AND WAS FOUND TO HAVE NO INJURIES. ACCORDING TO THE NURSE'S NOTE, "...WHEN PUT RESIDENT BACK IN BED ALARM WAS WORKING..." ACCORDING TO THE RESTORATIVE NURSE'S NOTE DATED 12/13/2011, RESIDENT #101 WAS FOUND ON THE FLOOR, INCONTINENT OF URINE AND RESIDENT #101'S BED ALARM DID NOT SOUND WHEN RESIDENT #101 GOT OUT OF BED. ACCORDING TO THE EVENT REPORT DATED 12/12/2011, THE BED ALARM WAS IN PLACE WHEN RESIDENT #101 fell , HOWEVER IT DID NOT SOUND. ACCORDING TO THE EVENT REPORT THE "...BED ALARM WAS ON 'HOLD' SETTING..." AND WAS NOT OPERATIONAL. DURING AN INTERVIEW ON 2/21/2012 AT 1:21 P.M., THE DIRECTOR OF NURSING (DON) #1 REVIEWED RESIDENT #101'S CLINICAL RECORD AND SAID THAT ON 12/7/2011 RESIDENT #101 fell WHILE TRYING TO FIND HER CALL LIGHT. DON #1 WAS UNABLE TO EXPLAIN WHERE RESIDENT #101'S CALL LIGHT WAS AND WHY RESIDENT #101 HAD NOT BEEN PROVIDED WITH A CALL LIGHT IN REACH IN ACCORDANCE WITH THE PLAN OF CARE. DON #1 SAID THAT ON 12/12/2011, RESIDENT #101'S BED ALARM WAS "...ON HOLD..." DON #1 SAID THAT WHEN ON THE HOLD SETTING, NO ALARM SOUNDS, AND THE ALARM DOES NOT WORK. DON #1 SAID RESIDENT #101 SHOULD HAVE BEEN IN BED WITH HER ALARM ACTIVATED, AS THE PLAN OF CARE INDICATED. DON #1 SAID ALARMS ARE CHECKED FOR FUNCTIONING, BUT THAT THERE WAS NO PROCESS THAT THE STAFF OR MANAGEMENT USE TO DOCUMENT THE EVALUATION OF THE ALARM. DON #1 SAID THERE WAS NO EVIDENCE THAT THE STAFF ENSURED THE FUNCTIONING OF THE ALARM WHEN IT WAS PUT INTO PLACE. DON #1 SAID, "...TRUST..." WAS ALL THAT WAS USED TO ENSURE THE STAFF FOLLOWED THE PLAN OF CARE. THE DON OFFERED NO ADDITIONAL EXPLANATION REGARDING NON-FUNCTIONAL ALARMS. ( ) RESIDENT #102 ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #102 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 WAS ABLE TO COMMUNICATE HER NEEDS VERBALLY AND REQUIRED THE EXTENSIVE PHYSICAL ASSISTANCE OF STAFF FOR ALL TRANSFERS AND TOILETING. RESIDENT #101 HAD [DIAGNOSES REDACTED]. THE DAILY CARE PLAN DATED 12/12/2011, IDENTIFIED FALLS AS AN AREA OF CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ASSISTANCE WITH TRANSFERS, A LOW BED, A BED AND CHAIR ALARM WITH FUNCTIONING CHECKS Q (EVERY) SHIFT AND PRIOR TO USE, AND POSITIONING ASSIST BARS ON THE BED. A THREE MONTH REVIEW OF RESIDENT #101'S ACCIDENT REPORTS REVEALED THAT RESIDENT #101 fell SIX TIMES IN THE THREE MONTHS REVIEWED ACCORDING TO THE NURSE'S NOTE DATED 12/15/2011 AT 3:15 P.M., RESIDENT #102 WAS FOUND ON THE FLOOR AT THE BEDSIDE WITH HER WHEELCHAIR RESTING ON HER BACK. RESIDENT #102 WAS ASSESSED AND WAS FOUND TO HAVE NO INJURIES. RESIDENT #102 SAID SHE WAS NOT TRYING TO TRANSFER OUT OF THE WHEELCHAIR, BUT SIMPLY TIPPED OVER IN THE CHAIR. RESIDENT #102'S PLAN OF CARE WAS MODIFIED ON 12/15/11 TO INCLUDE A PUMMEL CUSHION IN THE WHEELCHAIR ACCORDING TO THE NURSE'S NOTE DATED 12/16/2011 RESIDENT #102'S STANDARD WHEELCHAIR WAS REPLACED WITH A LOWER HEMI HIGH BACK WHEELCHAIR, AND HER PUMMEL CUSHION WAS REPLACED WITH A WAFFLE CUSHION WITH SLIP GRIPS. ACCORDING TO THE NURSE'S NOTE DATED 12/19/2011 AT 3:15 P.M., FACILITY STAFF RESPONDED TO AN ALARM AND FOUND RESIDENT #102 ON THE FLOOR NEXT TO HER WHEELCHAIR. RESIDENT #102 SAID SHE WAS REACHING FOR HER BED AND fell OUT OF THE WHEELCHAIR. RESIDENT #102 COMPLAINED OF PAIN IN THE LEFT HIP AND WAS UNABLE TO MOVE HER LEG BELOW THE KNEE. ACCORDING TO THE RESTORATIVE NURSE'S NOTE DATED RESIDENT #102'S LEFT LEG WAS EXTERNALLY ROTATED AND SHORTENED. RESIDENT #102'S PHYSICIAN WAS CONTACTED AND RESIDENT #102 WAS SENT TO A LOCAL AREA HOSPITAL. ACCORDING TO THE FACILITY INVESTIGATION REPORT DATED 12/23/2011, IT WAS CONFIRMED AT THE HOSPITAL THAT RESIDENT #102 SUFFERED A LEFT HIP FRACTURE, AND A SURGICAL REPAIR WAS COMPLETED. ACCORDING TO THE EVENT REPORT DATED 12/19/2011, THE CARE PLAN WAS NOT UPDATED WITH ANY CHANGES. NO EVIDENCE COULD BE FOUND IN RESIDENT #102'S CLINICAL RECORD TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. ACCORDING TO THE NURSE'S NOTE DATED 1/6/2012 AT 12:04 P.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 WAS FOUND ON THE FLOOR AT HER BEDSIDE NEXT TO THE FLOOR MAT NEXT TO THE BED. RESIDENT #102 WAS ASSESSED AND WAS FOUND TO HAVE NO INJURIES. ACCORDING TO THE NURSE'S NOTE RESIDENT #102 COULD NOT EXPLAIN WHAT SHE WAS TRYING TO DO WHEN SHE fell . ON 1/6/2012 RESIDENT #102'S PLAN OF CARE WAS MODIFIED TO INCLUDE A DEFINED PERIMETER MATTRESS ON THE BED. ACCORDING TO THE NURSE'S NOTE DATED 1/6/2012 AT 10:28 P.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 WAS FOUND ON THE FLOOR AT HER BEDSIDE. ACCORDING TO THE NURSE'S NOTES, RESIDENT #102'S ALARM DID NOT SOUND "...DUE TO MALFUNCTION OF EQUIPMENT ..." RESIDENT #102 WAS ASSESSED AND WAS FOUND TO HAVE NO INJURIES. ACCORDING TO THE EVENT REPORT DATED 1/6/2012, RESIDENT #102'S BED ALARM "...DID NOT SOUND, MALFUNCTION OF EQUIPMENT..." ON 1/6/2012 RESIDENT #102'S PLAN OF CARE WAS MODIFIED TO INCLUDE Q (EVERY) 15 MINUTE CHECKS. ACCORDING TO THE NURSE'S NOTE DATED 1/8/2012 AT 12:26 A.M., NURSING STAFF HEARD RESIDENT #102 CALL OUT, "I'M COMING." THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 fell TO THE FLOOR. RESIDENT #102 WAS ASSESSED AND WAS FOUND TO HAVE NO INJURIES. ACCORDING TO THE NURSE'S NOTE DATED 1/9/2012, RESIDENT #102 WAS VERY IMPULSIVE AND QUICK, LACKED SAFETY AWARENESS AND MADE "...SEVERAL ATTEMPTS TO TRANSFER WITHOUT ASSIST (ANCE)..." NO EVIDENCE COULD BE FOUND IN RESIDENT #102'S CLINICAL RECORD TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. ACCORDING TO THE NURSE'S NOTE DATED 1/26/2012 AT 6:20 A.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 fell . RESIDENT #102 WAS FOUND ON THE FLOOR AT THE BEDSIDE, AND THE "...ALARM DID NOT SOUND AT (THE) TIME OF (THE) FALL..." ACCORDING TO THE NURSE'S NOTE, RESIDENT #102 HAD MADE ATTEMPTS TO TRANSFER WITHOUT ASSISTANCE SEVERAL TIMES THROUGHOUT THE SHIFT. RESIDENT #102 WAS ASSESSED AND WAS FOUND TO HAVE NO INJURIES. ACCORDING TO THE EVENT REPORT DATED 1/26/2012 RESIDENT #102'S BED ALARM AGAIN "...DID NOT SOUND AT TIME OF EVENT..." RESIDENT #102'S PLAN OF CARE WAS MODIFIED ON 1/26/2012 TO INCLUDE "...CHECK PLACEMENT OF BED ALARM,." AN INTERVENTION IN PLACE SINCE 12/12/2011. NO EVIDENCE COULD BE FOUND IN RESIDENT #102'S CLINICAL RECORD TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. ON 2/15/2012 AT 11:45 A.M., RESIDENT #102'S Q 15 MINUTE CHECK FORMS WERE OBTAINED. ACCORDING TO THE 15-MINUTE CHECK FORM DATED 2/15/2012, SUPERVISION HAD NOT BEEN PROVIDED TO RESIDENT #102 IN ACCORDANCE WITH THE PLAN OF CARE BETWEEN 6:45 A.M. AND 11:45 A.M. DURING AN INTERVIEW ON 2/21/2012 AT 1:21 P.M., THE DIRECTOR OF NURSING (DON) #1 REVIEWED RESIDENT #102 ' S CLINICAL RECORD AND SAID THAT ON 12/19/2011 RESIDENT #102'S CARE PLANNED SAFETY MEASURES WERE IN PLACE AND THE PLAN OF CARE WAS FOLLOWED. DON #1 SAID THAT AFTER THE FALL ON 12/19/2011, THE PLAN OF CARE WAS NOT MODIFIED ALTHOUGH THERE WAS NO EVIDENCE THE PLAN WAS WORKING. DON #1 SAID THERE "WAS A WHOLE LIST OF INTERVENTIONS...THERE WAS NOT A WHOLE LOT LEFT TO CHOOSE..." DON #1 SAID THAT WHEN RESIDENT #102 RETURNED ON 12/23/2012, SHE HAD MORE CONFUSION AND RESTLESSNESS. DON #1 SAID RESIDENT #102 MADE ATTEMPTS TO TRANSFER WITHOUT ASSISTANCE SEVERAL TIMES BUT THEY CHOSE TO MONITOR THE RESIDENT, AND CONTINUE THE PLAN OF CARE THAT "...WAS NOT WORKING..." DON #1 SAID THAT AFTER RESIDENT #102'S FALL ON 1/9/2012, FACILITY STAFF MADE "...NO REAL CHANGES ..." IN THE PLAN OF CARE. DON #1 SAID THAT ON TWO OF THE SIX FALLS RESIDENT #102 EXPERIENCED, A WORKING ALARM WAS NOT PROVIDED TO THE RESIDENT, AND SHE HAD FOUND THAT THERE WERE INCONSISTENCIES IN THE WAY BED ALARMS WERE BEING PLACED. DON #1 WAS UNABLE TO PROVIDE EVIDENCE THAT FOUR OF RESIDENT #102'S FALLS WERE UNAVOIDABLE. DURING AN INTERVIEW ON 2/21/2012 AT 2:00 P.M., DON #1 SAID WE TRUST THAT PEOPLE WERE FOLLOWING THAT PLAN, AND SUPERVISING RESIDENT #102 AS REQUIRED, "...BUT ALL WE HAVE IS TRUST. WE DON'T ENSURE THE PLAN FOR SUPERVISION WAS FOLLOWED AS DESIGNED..." ( ) RESIDENT #103 ACCORDING TO THE UNDATED FACE SHEET, RESIDENT #103 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 WAS ABLE TO COMMUNICATE HER NEEDS VERBALLY AND REQUIRED THE PHYSICAL ASSISTANCE OF STAFF FOR ALL TRANSFERS AND TOILETING. RESIDENT #101 HAD [DIAGNOSES REDACTED]. THE CARE PLAN DATED 10/17/2008, IDENTIFIED FALLS AS AN AREA OF CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING Q (EVERY) 15 MINUTE CHECKS. ON 2/15/2012 AT 11:45 A.M., THE SURVEYOR REVIEWED THE Q 15 MINUTE CHECK FORMS FOR THE DAY. NO 15 MINUTE CHECKS WERE FOUND FOR RESIDENT #103 IN ANY OF THE 15 MINUTE CHECK BOOKS ON THE NURSING UNITS. ON 2/21/2012 AT 11:45 A.M., THE SURVEYOR REVIEWED THE Q 15 MINUTE CHECK FORMS FOR THE DAY. NO 15 MINUTE CHECKS WERE FOUND FOR RESIDENT #103 IN ANY OF THE 15 MINUTE CHECK BOOKS ON THE NURSING UNITS. DURING AN INTERVIEW ON 2/21/2012 AT 1:37 P.M., THE DIRECTOR OF NURSING (DON) #1 REVIEWED RESIDENT #103'S CLINICAL RECORD AND SAID THAT ACCORDING TO THE PLAN OF CARE, STAFF WERE TO OBSERVE RESIDENT #103 EVERY 15 MINUTES AND DOCUMENT HER LOCATION. DON #1 WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #103 WAS BEING SUPERVISED IN ACCORDANCE WITH THE PLAN OF CARE. ( ) IN AN INTERVIEW ON 2/15/2012 AT 11:45 A.M., THE DIRECTOR OF NURSING (DON) #1 REVIEWED THE DAILY 15 MINUTE CHECK FORMS FOR 2/15/2012. DON #1 SAID THAT ACCORDING TO THE DOCUMENTATION, SOME RESIDENTS HAD NOT BEEN SUPERVISED ACCORDING TO THE PLAN OF CARE SINCE 7:00 A.M., AND ONE OF THE DAILY 15 MINUTE CHECK FORMS WAS PRE-DOCUMENTED. DON #1 SAID THAT ONE OF THE DAILY 15 MINUTE CHECK FORMS ALREADY DOCUMENTED THE LOCATION OF OFF SAMPLE RESIDENT #188 THROUGH 9:00 P.M. THAT NIGHT (2/15/12). ON 2/21/2012 AT 11:50 A.M. LPN #1 WAS OBSERVED DOCUMENTING ON ALL OF THE Q 15 MINUTE CHECK FORMS FOR THE UNIT STARTING FROM THE 7:00 A.M. HOUR. DURING AN INTERVIEW ON 2/21/2012 AT 12:10 P.M. THE LICENSED PRACTICAL NURSE (LPN) #1 SAID THE CERTIFIED NURSE ASSISTANTS WERE SUPPOSED TO BE FILLING OUT THE FORMS IN A REAL TIME BASIS, BUT THEY DO NOT. LPN #1 SAID SHE HAD NO WAY OF KNOWING THAT RESIDENTS WERE BEING SUPERVISED AS THEY NEEDED TO BE SINCE THE STAFF REGULARLY DID NOT DOCUMENT ON THE CHECK FORMS UNTIL THE END OF THE SHIFT. IN AN INTERVIEW ON 2/21/2012 AT 2:00 P.M., THE ASSISTANT DIRECTOR OF NURSING (ADON) #1 REVIEWED THE Q 15 MINUTE CHECK FORMS FROM 2/15/2012 AND 2/21/2012 AND SAID THE FACILITY COULD NOT BE SURE THAT SUPERVISION WAS BEING PROVIDED TO THE RESIDENTS AS REQUIRED. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER (S): MI 019, MI 023 BASED ON OBSERVATIONS, INTERVIEWS AN RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT A FALL FOR ONE (#501) AND FAILED TO USE A GAIT BELT DURING AMBULATION FOR ONE (#502) FROM A TOTAL OF EIGHT SAMPLED RESIDENTS, RESULTING IN RESIDENT #501 FALLING FROM HER BED AND SUSTAINING A FRACTURE, AND RESIDENT #502 FALLING TO THE FLOOR WITH INJURY AND COMPLAINTS OF PAIN. FINDINGS INCLUDE: RESIDENT #501 ACCORDING TO THE RESIDENT ADMISSION RECORD, RESIDENT #501 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) 12/1/10 INDICATED THAT RESIDENT #501 HAD SEVERELY IMPAIRED COGNITION, SHORT AND LONG TERM MEMORY PROBLEMS AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING EATING, PERSONAL HYGIENE BATHING AND TOILETING. ON 12/8/10 AT 10:00 A.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #501 WAS OBSERVED IN HER ROOM LYING IN BED ASLEEP. RESIDENT #501 WAS OBSERVED IN AN OLDER MODEL BARIATRIC BED AND WAS OBSERVED TO BE IN A HIGH POSITION. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 11/21/10 DOCUMENTED THE FOLLOWING: "...RESIDENT #501 ROLLED OUT OF BED. STAFF HEARD HER YELL AND RESPONDED IMMEDIATELY. HER (#501) BED WAS IN THE LOWEST POSITION WITH A MAT ON THE FLOOR NEXT TO THE BED. BED ALARM ON BED AND FUNCTIONING BUT DID NOT SOUND DUE TO WAFFLE CUSHION OVER BED ALARM PAD...". "...X-RAY DONE IN AM WHICH REVEALED A FRACTURE..." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 11/20/10 DOCUMENTED THE FOLLOWING: "...THREE VIEWS OF THE RIGHT KNEE REVEAL A RECENT FRACTURE OF THE DISTAL METAPHYSEAL AREA OF THE FEMUR WITH SLIGHT IMPACTION...". A REVIEW OF THE FACILITY'S SUMMARY OF INVESTIGATION, UNDATED, DOCUMENTED THE FOLLOWING: "...RESIDENT (#501) FOUND ON MATS NEXT TO BED CALLING FOR HELP. THIS WAS AT 12:30 A.M., HER (#501) BED ALARM WAS NOT SOUNDING ALTHOUGH THE LIGHT ON IT INDICATED IT WAS ON. HER (#501) RIGHT KNEE WAS BENT UP UNDERNEATH HER AND HER ARM WAS RESTING ON THE BED...". "...THE X-RAY DID SHOW A FRACTURE OF THE DISTAL FEMUR WITH SLIGHT IMPACTION. THE RESIDENT (#501) WAS SENT TO THE HOSPITAL, admitted AND HAD A SURGICAL REPAIR DONE...". "...AN INTERVIEW WITH THE DAY SHIFT AIDE (CNA #1) REVEALED THAT THE RESIDENT (#501) OCCASIONALLY HAD STATED SHE (#501) WONDERED IF SHE COULD STAND...". THE SUMMARY OF INVESTIGATION REPORT REVEALED THAT ON THE MORNING FOLLOWING THE FALL, RESDIENT #501 HAD REPLIED "...THAT SHE HAD JUST WANTED TO SEE IF SHE COULD STAND...". "...THE RESIDENT (#501) HAD ACTED IMPULSIVELY AT THE TIME SHE TRIED TO STAND..." IN WITH THE FACILITY'S SUMMARY OF INVESTIGATION WAS AN UNSIGNED AND UNDATED NOTE THAT DOCUMENTED: "...SHE (#501) HAD A BED ALARM IN PLACE THAT WAS FUNCTIONING BUT DID NOT ALARM DUE TO WAFFLE CUSHIONS (USED TO RELIEVE PRESSURE ON BUTTOCKS) BEING ON TOP OF THE BED ALARM SENSOR PAD...". A REVIEW OF AN UNNAMED FACILITY DOCUMENT DATED 11/23/10, ADDRESSED TO THE FACILITY'S NURSING STAFF DOCUMENTED: "...ALSO REMIND THEM (NURSING STAFF) TO MAKE SURE BED SENSOR PAD IS PLACED OVER THE WAFFLE CUSHION TO ENSURE BED ALARM WILL SOUND...". FURTHER REVIEW OF THE FACILITY'S SUMMARY OF INVESTIGATION AND WITNESS STATEMENTS INDICATED THAT RESIDENT #501 HAD EXPERIENCED BOUTS OF CONFUSION, RESTLESSNESS AND WAS REPORTED TO HAVE BEEN MORE TALKATIVE THAN USUAL PRIOR TO HER FALL TO THE FLOOR WITH A RESULTANT FRACTURE. THERE WAS NO DOCUMENTED EVIDENCE IN RESIDENT #501'S CLINICAL RECORD THAT THESE BEHAVIORS HAD BEEN ADDRESS PRIOR TO RESIDENT #501'S FALL. A REVIEW OF THE FACILITY'S SAFETY EVENTS-FALLS FORM DOCUMENTED THE FOLLOWING: "...AT 12:30 A.M., THIS NURSE NOTED RESIDENT YELLING OUT "HELP". THIS NURSE ENTERED RESIDENT'S ROOM NOTING RESIDENT SITTING ON THE MAT ON THE FLOOR WITH RIGHT KNEE BEND UNDERNEATH HER BUTTOCKS AND RIGHT ARM WRAPPED AROUND THE HAND RAIL. NOTING BILATERAL EYES ROLLING BACK, DIAPHORETIC (SWEATING PROFUSELY) AND RIGHT KNEE PAIN. RESIDENT STATING THAT HER RIGHT KNEE IS PAINFUL NOTING SLIGHT EDEMA (SWELLING)...". A REVIEW OF RESIDENT #501'S FALL RISK ASSESSMENT FOR THE MONTHS OF 6/2/10 AND 9/2/10 INDICATED THAT RESIDENT #501 HAD A FALLS RISK SCORE OF 10. " ... (SCORE OF 5 OR MORE EQUALS HIGH RISK)..." RESIDENT #501'S FALL RISK CARE PLAN DATED 6/3/08 DOCUMENTED THE FOLLOWING: "...BALANCE DEFICITS, IMPAIRED MOBILITY, COGNITIVE IMPAIRMENTS, PERIODS OF RESTLESSNESS, POTENTIAL SIDE EFFECTS OF MEDS (MEDICATIONS)...". "...KEEP CALL LIGHT WITHIN EASY REACH AND ANSWER TIMELY, BED ALARM, STAFF TO CHECK ALARM FOR FUNCTIONING EVERY SHIFT PRIOR TO USE, BARIATRIC BED WITH BILATERAL MESH COVERED ASSIST BARS TO ENHANCE BED MOBILITY. EXTRA LARGE RECLINER CHAIR FOR SAFETY AND COMFORT OUT OF BED...". THE CARE PLAN HAD AN ENTRY DATED 3/26/10 THAT DOCUMENTED "...MATS ON BILATERAL SIDES OF BED..." THIS ENTRY HAD BEEN CROSSED OUT AND HAD A BLACK LINE THROUGH IT WITH NO INITIALS OR RATIONALE. THE CARE PLAN FURTHER INDICATED "...11/20/10 MAT LEFT SIDE OF BED-DOUBLE STACKED MATTRESSES WITH SLIP GRIP ON FLOOR...". ON 12/8/10 AT 12:41 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) SAID "...SHE (#501) WAS VERY CONFUSED AND TALKED ABOUT STANDING AND WALKING TO ONE OF THE AIDES...". "...PRIOR TO HER FALL, SHE (#501) TOLD THE CNA (CERTIFIED NURSING ASSISTANT) TO PUT HER LEGS AND FEET DOWN ON THE FLOOR SO SHE COULD WALK...". WHEN ASKED IF THE CNA REPORTED RESIDENT #501'S REQUEST TO THE NURSE, THE DON SAID "...I DON'T KNOW...". THE SURVEYOR REQUESTED TO INTERVIEW THE CNA THAT RESIDENT #501 ASKED TO ASSIST HER WITH WALKING, BUT THE DON DID NOT INFORM THE CNA OF THIS REQUEST AND ALLOWED THE CNA TO LEAVE THE FACILITY. THE DON FURTHER STATED "...I DIDN'T KNOW YOU WANTED TO TALK TO HER...". THE DON WAS INFORMED THAT THE SURVEYOR WOULD NEED TO INTERVIEW THE CNA INVOLVED DURING START OF HER NEXT SHIFT. ON 12/8/10 AT 3:30 P.M., THE DON SAID THAT RESIDENT #501'S BED WAS TO BE IN THE LOWEST POSSIBLE POSITION. WHEN ASKED IF RESIDENT #501'S BED WAS IN THE LOWEST HORIZONTAL POSITION, THE DON SAID "...IT WAS IN THE LOWEST POSITION POSSIBLE CONSIDERING IT WAS A BARIATRIC BED. THE SURVEYOR INFORMED THE DON THAT RESIDENT #501'S BED WAS OBSERVED IN A HIGH POSITION DURING THE INITIAL TOUR. WHEN ASKED WHY THE BED WAS NOT IN A LOW BED POSITION AS INDICATED IN THE CARE PLAN, THE DON OFFERED NO EXPLANATION. ON 12/9/10 AT 8:52 A.M., AN INTERVIEW WAS CONDUCTED WITH CNA #1. WHEN QUERIED ABOUT RESIDENT #501'S FALL ON 11/20/10, CNA #1 REPORTED THE FOLLOWING: "...SHE (#501) WAS CONFUSED...". "...SHE HAS A BARIATRIC BED BUT IT'S AN OLDER MODEL AND DOESN'T GO AS LOW TO THE FLOOR AS THE OTHER BEDS BECAUSE OF THE SIZE AND PLACEMENT OF THE WHEELS ON THE BED...". "...THE OTHER BEDS ARE NEWER AND GO ALL THE WAY TO THE GROUND...". CNA #1 FURTHER STATED "...I SPOKE WITH HER (#501) EARLIER THAT AFTERNOON AND SHE WAS SITTING IN HER RECLINER CHAIR...". "...SHE (#501) ASKED ME TO PUT HER FEET DOWN SO SHE COULD STAND AND WALK...". "...I REMINDED HER (#501) THAT SHE HADN'T WALKED IN SOME TIME. HER (#501) DAUGHTER CAME IN TO VISIT SO I JUST LEFT TO FINISH MY WORK...". WHEN ASKED IF SHE REPORTED RESIDENT #501'S REQUEST TO STAND AND WALK TO THE NURSE, CNA #1 SAID YES. WHEN ASKED TO RECALL WHAT NURSE SHE REPORTED TO, CNA #1 HAD NO RESPONSE AND COULD NOT RECALL THE NAME OF THE NURSE SHE ALLEGEDLY REPORTED TO REGARDING RESIDENT #501'S REQUEST TO STAND AND WALK. FURTHER, THERE WAS NO DOCUMENTED EVIDENCE IN RESIDENT #501'S CLINICAL RECORD THAT INDICATED THE NURSE HAD BEEN MADE AWARE OF RESIDENT #501'S REQUEST AND ATTEMPT TO STAND AND WALK. ON 12/9/10 AT 9:50 A.M., RESIDENT #501 WAS OBSERVED IN HER ROOM LYING IN BED ASLEEP IN A HIGH FOWLER'S POSITION (SITTING UPRIGHT). RESIDENT #501'S BED WAS IN A HIGH HORIZONTAL LEVEL OF POSITION. RESIDENT #501'S BED WAS NOT IN A LOW BED POSITION AS INDICATED IN THE PLAN OF CARE. ON 12/9/10 AT 10:00 A.M., THE SURVEYOR NOTIFIED THE MAINTENANCE DEPARTMENT AND REQUESTED THAT THE HEIGHT OF RESIDENT #501'S BED BE MEASURED TO DETERMINE IF THE BED WAS IN THE LOW POSITION ACCORDING TO THE PLAN OF CARE. MAINTENANCE STAFF #2 SAID "...THE BED ONLY GOES TO THE TOP OF THE WHEELS ON THE BED...". MEASUREMENTS TAKEN FROM THE MID HEIGHT OF RESIDENT #501'S TORSO REVEALED 32.5 INCHES FROM THE FLOOR WHICH EQUALS OVER 2 FEET FROM RESIDENT #501 TO THE FLOOR. MAINTENANCE STAFF #2 THEN LOWERED THE BED TO THE LOWEST POSITION THE BED WOULD GO AS IT IS AN OLDER MODEL AND WOULD NOT GO TO THE LOWEST POSITION OF THE OTHER BEDS IN THE FACILITY. MAINTENANCE STAFF #2 SAID "...I USE TO BE A CNA, AND IF THE BED WAS SUPPOSED TO BE IN THE LOWEST POSITION, IT WASN'T, BECAUSE WE JUST LOWERED IT...". THE FACILITY'S FALL POLICY WAS REQUESTED BUT WAS NOT RECEIVED DURING THE INVESTIGATION. THE DON STATED "...WE DON'T HAVE A FALLS POLICY BECAUSE WE JUST DO THE STEPS...". ON 12/9/10 AT 10:15 A.M., DURING A FOLLOW UP INTERVIEW, THE DON WAS INFORMED THAT RESIDENT #501'S BED WAS NOT IN A LOW BED POSITION ACCORDING TO THE PLAN OF CARE. WHEN ASKED IF THERE WAS A REASON THAT RESIDENT #501'S BED WAS NOT IN A LOW BED POSITION, THE DON SAID "...NON THAT IS ACCEPTABLE..". THE DON FURTHER STATED "...THAT MEANS THAT THE PERSON WHO WAS TAKING CARE OF HER DIDN'T LOWER THE BED...". THE DIRECTOR OF NURSING COULD NOT EXPLAIN WHY RESIDENT #501'S BED WAS NOT IN its LOWEST HORIZONTAL POSITION AS INDICATED IN THE PLAN OF CARE. FURTHER, THE DIRECTOR OF NURSING COULD NOT EXPLAIN WHY RESIDENT #501'S SENSOR PAD ALARM HAD BEEN PLACED UNDERNEATH THE WAFFLE CUSHION SO AS TO MUFFLE OR ELIMINATE THE SOUNDING OF THE ALARM AND THEREBY NOT ALERT STAFF TO RESIDENT #501'S SHIFT IN MOVEMENT AND SUBSEQUENT FALL TO THE FLOOR WITH A RESULTANT FRACTURE. RESIDENT #502 ACCORDING TO THE FACILITY'S RESIDENT ADMISSION RECORD, RESIDENT #502 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #502 HAD MODERATELY IMPAIRED COGNITION, SHORT TERM MEMORY PROBLEMS, AND REQUIRED LIMITED TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, DRESSING, PERSONAL HYGIENE, BATHING AND TOILETING. ON 12/8/10 AT 10:26 A.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #502 WAS OBSERVED IN HER ROOM SITTING IN A CHAIR WATCHING TELEVISION. ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 11/19/10, ON 11/18/10 AT 10:05 A.M., "...RESIDENT #502 WAS BEING AMBULATED TO THE BATHROOM WITH HER WALKER BY A CNA (CERTIFIED NURSING ASSISTANT), RESIDENT LOST HER BALANCE, fell AGAINST THE CNA'S KNEE AND fell TO THE FLOOR...". "...AT 6:30 P.M., RESIDENT #502 STARTED COMPLAINING OF BACK PAIN...". "...THE CNA HAS BEEN PLACED ON SUSPENSION DUE TO NOT USING A GAIL BELT...". THE FACILITY'S SUMMARY OF INVESTIGATION DATED 11/19/10, DOCUMENTED THE FOLLOWING: "...ON 11/18/10 AT 10:05 A.M., THE CNA WAS AMBULATING RESIDENT #502 TO THE BATHROOM WITH HER WALKER AND ONE ASSIST. RESIDENT #502'S LEGS BECAME WEAK AND SHE fell BACKWARD INTO THE CNA, THEN TO THE FLOOR...". "...RESIDENT #502 STARTED COMPLAINING OF INCREASED BACK AND RIGHT SHOULDER PAIN FOLLOWING THE FALL...". "...X-RAYS COMPLETED (LUMBOSACRAL SPINE, RIGHT AND LEFT SHOULDERS AND CERVICAL SPINE) AND ALL WERE NEGATIVE..." A REVIEW OF RESIDENT #502'S X-RAY REPORT DATED 11/19/10 DOCUMENTED THE FOLLOWING: "...THERE IS A PREVIOUS DISPLACED FRACTURE OF THE PROXIMAL SHAFT OF THE HUMERUS...". "...A RE-FRACTURE CANNOT BE EXCLUDED...". "...EXAMINATION OF THE LEFT SHOULDER IN TWO VIEWS REVEAL NO EVIDENCE OF FRACTURE...". "...EXAMINATION OF THE DORSAL SPINE IN TWO VIEWS REVEALS DEGENERATIVE SPURRING...". "...NO EVIDENCE OF FRACTURE IS NOTED..." ACCORDING TO RESIDENT #502'S FALL RISK assessment dated [DATE], RESIDENT #502 had a history of [REDACTED]. THE FALL RISK ASSESSMENT FURTHER INDICATED THAT RESIDENT #502 HAD A FALLS RISK SCORE OF 7 "...(SCORE OF 5 OR MORE EQUALS HIGH RISK)...". RESIDENT #502'S DAILY CARE PLAN DATED 9/13/10, DOCUMENTED: "...TRANSFERS WITH 1-2 ASSIST AND GAIT BELT. DO NOT LIFT UNDER ARMS...". "...AMBULATION: AMBULATES WITH 1-2 ASSIST, GAIT BELT AND WALKER 40-75 FEET AS TOLERATED...". A LINE WAS DRAWN THROUGH THE STATEMENT THAT READ "...IF NOT FAMILIAR WITH RESIDENT, USE 2 ASSIST TO AMBULATE TO BATHROOM AND CUE AS NEEDED...".THE ABOVE ENTRY WAS DISCONTINUED 11/19/10 WHICH WAS THE DAY AFTER RESIDENT #502'S FALL TO THE FLOOR WITH RESULTANT INJURY. ON 12/8/10 AT 12:12 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED THE FOLLOWING: "...THE AIDE AMBULATED THE RESIDENT (#502) TO THE BATHROOM WITHOUT A GAIT BELT. BASICALLY, THE RESIDENT LOST HER BALANCE AND THE CNA GUIDED HER TO THE FLOOR. THE RESIDENT COMPLAINED OF BACK PAIN THAT NIGHT...". "...THE RESIDENT (#502) HAD NOT COMPLAINED OF BACK PAIN THE DAY BEFORE HER FALL..." THE CNA WHO AMBULATED RESIDENT #502 TO THE BATHROOM WITHOUT THE USE OF A GAIT BELT, WAS NOT AVAILABLE FOR INTERVIEW. A STATEMENT WRITTEN BY THE CNA INVOLVED DOCUMENTED THE FOLLOWING: "...I WAS IN GIVING ANOTHER RESIDENT A SHOWER WHEN THE NURSE CAME IN AN TOLD ME THAT RESIDENT #502 HAD TO USE THE REST ROOM SO I FINISHED UP WITH THE OTHER RESIDENT AND WENT TO RESIDENT #502'S ROOM TO TAKE HER. I GRABBED HER WALKER AND PUT IT IN FRONT OF HER AND SHE (#502) GRABBED IT, STOOD UP AND STARTED WALKING VERY FAST TOWARDS THE BATHROOM. I WAS NEXT TO HER, HAD MY LEFT ARM HOLDING HERS, SHE LOST HER FOOTING AND LET GO OF THE WALKER. SHE (#502) STARTED FALLING BACK SO I PUT MY ARM BEHIND HER, STUCK MY KNEE OUT AND BRACED HER WHEN SHE (#502) fell ...". IN THE STATEMENT WRITTEN BY THE CNA, THERE WAS NO MENTION OR INDICATION THAT A GAIT BELT WAS USED TO AMBULATE RESIDENT #502 TO THE BATHROOM ACCORDING TO THE PLAN OF CARE. ON 12/9/10 AT 9:20 A.M., THE PHYSICAL THERAPIST (PT) WAS INTERVIEWED REGARDING THE PROPER PROCEDURES FOR AMBULATING RESIDENTS. THE PT SAID: "...BEFORE AMBULATING, THE RESIDENTS CAPACITY TO AMBULATE IS EVALUATED AND THE NUMBER OF PERSONS REQUIRED TO AMBULATE THE RESIDENT IS ASSESSED...". "...FOR RESIDENTS WHO USE A WALKER TO AMBULATE, A GAIT BELT SHOULD ALWAYS BE USED AT THE SAME TIME...". WHEN ASKED OF THE RATIONALE FOR THE USE OF A GAIT BELT WHEN AMBULATING, THE PT SAID "...WE WOULD PLACE A GAIT BELT AROUND THE RESIDENT SO IF THE RESIDENT SHOULD BUCKLE AT THE KNEES, THE GAIT BELT WOULD BE USED TO AVOID FALLING...". FURTHER, THE PT SAID THAT A GAIT BELT SHOULD HAVE BEEN USED WHEN RESIDENT #502 WAS AMBULATED TO THE BATHROOM. THE FACILITY'S FALL POLICY WAS REQUESTED BUT NOT SUBMITTED DURING THE INVESTIGATION. THE DON STATED THAT THE FACILITY DOES NOT HAVE A FALLS POLICY.