Every finding on record at Corewell Health Greenville Hospital Rehabilitation

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 06/01/2026 at 8:33AM, observed that the seal, on the door of the freezer, was cracked and separating. Dietary Supervisor (DS) G observed the cracked seal and stated that there was a replacement seal available. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. On 06/01/2026 at 8:35AM, observed the counter stand mixer had debris on the metal guard and on the mechanism that rotates the mixing arm. The stand mixer had been covered with a plastic bag; there was a sign on the wall behind the mixer stating the mixer was clean if it was covered. DS G confirmed observation of debris on the mixer.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to provide dignified care for three residents (R8, R4, R30) of four residents reviewed for dignity. Findings include: Resident #8 (R8) Review of the Minimum Data Set (MDS) dated [DATE] reflected R8 was admitted to the facility 1/14/22 and had a history of stroke and hemiplegia (weakness to one side of the body). The MDS reflected R8 required maximum assist with chair and toilet transfers. The MDS reflected R8 was frequently incontinent of urine but always continent of stool. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 was cognitively intact. On 4/15/25 at 9:14 AM an interview was conducted with R8 in his room. R8 reported he had experienced slow call light response resulting in soiling himself because of the delay. R8 reported incidents when staff had responded timely but leave after turning off the light promising to return but fail to. R8 was asked how often this had happened and R8 stated, more often than I like. On 4/17/25 at 10:29 AM a follow up interview was conducted with R8 in his room. R8 reported a common time for delayed response was during shift change times in the morning and afternoon. R8 stated no more at one time than the other. R8 reported that staff tell him they are busy and do not offer any other reason or apologize. R8 was asked if he had complained of this. R8 stated what are you going to do when you poop your pants? and no sense in getting mad about it. Resident #4 (R4) Review of the MDS dated [DATE] reflected R4 originally admitted to the facility 2/14/24 with diagnoses that included obstructive uropathy and a history of stroke. This MDS reflected R4 experienced occasional urinary incontinence and required moderate assistance with transferring on and off the toilet. The MDS reflected a BIMS score of 13 out of 15 which indicated R4 was cognitively intact. On 4/15/25 at 8:52 AM an interview was conducted with R4 in his room. R4 reported delayed call light response by staff in the morning. R4 reported I have to sit here and wait .I pee my pants. R4 reported this makes him feel bad. 45410 Resident #30 (R30) Review of an Face Sheet revealed Resident #30 (R30) admitted to the facility on [DATE] with pertinent diagnoses which included multiple fractures and pain. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R30, with a reference date of 3/10/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12, out of a total possible score of 15, which indicated R30 was moderately cognitively impaired. Further review of same MDS assessment revealed R30 required assistance with toileting. Review of R30's Resident Care Summary active 4/17/2025 revealed R30 required the assistance of two staff with transferring and toileting. In an interview on 4/15/2025 at 10:04 AM, R30 reported long call light wait times at the facility caused her to have episodes of incontinence. R30 reported she was continent as long as staff were able to provide assistance in a timely manner. R30 reported last week on second shift about dinner time she was up in her chair after visiting with family and pressed her call light because she needed to use the bathroom. R30 reported a Certified Nursing Assistant came into the room and told her she would return as soon as she was able to provide assistance. R30 reported it took 30 minutes for staff to come back to her room to provide assistance and by that time she had been incontinent of urine and stool. R30 stated the episode made her feel terrible, very embarrassed. R30 reported she has had incontinent episodes related to long call wait times on multiple occurrences since being admitted to the facility. Review of facility policy/procedure Resident Rights- Continuing Care, effective 10/30/2023, revealed .Every resident shall be entitled to humane care and treatment provided with dignity and respect . Review of facility policy/procedure Call Light Accessibility, Use and Response- Continuing Care, effective 9/23/2022, revealed .The purpose of this policy is to ensure each resident call light is accessible, functional for use and responded to appropriately . process for responding to call lights . listen to resident's request and respond accordingly . Inform the resident if you cannot meet the need and assure them that you will notify the appropriate personnel . Call light should remain on, or be turned back on, until the resident's needs are met .

Based on interview and record review, the facility failed to administer antibiotics according to the provider's order for one resident (R88) of two residents reviewed for antibiotic use. Findings: Review of the medical record reflected R88 admitted to the facility on [DATE] with pertinent diagnoses that included Complicated Urinary Tract Infection and Chronic Indwelling Foley Catheter. On 4/15/25 at 12:39 PM a review of the Electronic Medical Record (EMR) for R88 reflected a Doctor's Order (DO) for cefdinir 300 milligrams (mg) (a cephalosporin antibiotic) to be administered 2 times daily. The DO reflected Product Instructions. Take at least 2 hours before or 2 hours after antacids or iron supplements (including those found in multivitamins) with a start date of 4/9/25. The EMR review of 4/15/25 at 12:39 PM also reflected a DO for ferrous sulfate tablet (iron supplement) 325 mg to be administered 2 times a day with a start date of 4/9/25. Review of the Medication Administration Record (MAR) documentation for R88 reflected the cefdinir and the ferrous sulfate were administered at the same time regularly. The documentation of the MAR did not reflect these two medications were separated by at least 2 hours as indicated in the Product instructions of the DO for the cefdinir. On 4/16/25 at 2:01 PM during an interview on 4/16/2025 at 2:01 PM, Infection Preventionist (IP) N was asked about the documented concurrent administration of the cefdinir 300 mg capsules and the ferrous sulfate 325 mg tablets. IP N reported that the concurrent administration would likely effect the absorption of the cefdinir. Review of the manufacturer's product information sheet for cefdinir capsules reflected Iron supplements, including multivitamins that contain iron, interfere with the absorption of cefdinir. If iron supplements are required during (cefdinir) therapy, (cefdinir) should be taken at least 2 hours before or after the supplement. The policy provided by the facility titled Medication Management effective 4/21/23 was reviewed. The policy reflected 1. Purpose, 1.1 The purpose is to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychological well-being, free of unnecessary drugs and outline the process for safe administration and storage of medication. And 2. Definitions .2.2 Independent Doublecheck (IDC): Process by which two licensed personnel separately (e.g. independently) check each component of the work process, prior to medication administration. An IDC included comparison with the prescriber's order as well as additional cognitive checks outlined below. 2.2.1 Comparison with prescriber's order ., This section included Right drug ., Right dose ., Right route ., Right resident . and Right time - Is this the prescribed frequency/time for drug administration? Review of the MAR for R88 for 4/9/25 through 4/16/25 reflected multiple licensed staff members had documented administration of the cefdinir and ferrous sulfate concurrently over seven days despite the prescriber's order to separate the two medications by at least 2 hours. This indicated that licensed staff did not check each component of the work process, prior to medication administration as directed by the policy provided by the facility. On 4/17/25 at 10:06 AM the Director of Nursing (DON) was asked for any additional documentation that could be provided that would indicate the cefdinir and the ferrous sulfate had been administered at least 2 hours apart. The DON reported that she would review the documentation but would likely will not be able to provide additional documentation. As of survey exit no additional documentation had been received from the facility.

This citation has two DPS's. DPS #1 Based on interview and record review, the facility failed to follow care guide instructions during the transfer of one resident (Resident #13), resulting in a fall. Resident #13 (R13) Review of a Face Sheet revealed R13 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia, seizure disorder, muscle weakness, at risk for falls, and gait abnormalities. Review of a Care Plan for R13 related to mobility and required assistance .interventions .extensive assist of 2 for transfers. Review of an Incident/Accident Report for R13, dated 03/17/23, reflected .(R13) is a two-person transfer. (R13) was transferred by one person. During an interview on 04/06/23 at 1:50 PM, the Director of Nursing (DON) stated that the incident/accident report related to the fall on 03/17/23 was not finished, that R13 was a two person transfer, and only one staff person transferred R13 at the time of the fall. The DON identified the staff person who made the transfer as Certified Nurse Aide U. Attempts were made to contact CNA U for comment via telephone call and the surveyor could not leave a message. 39083 DPS #2 Based on observation, interview, and record review, the facility failed to monitor and maintain resident hot water temperatures at a safe temperature, resulting in the potential for scalding water temperatures, affecting all residents in the facility. Findings include: On 4/5/23 at 1:18 PM, the hand sink located in room [ROOM NUMBER] bathroom was observed to feel hot to the touch. On 4/5/23 between 1:50 PM and 2:08 PM, the following water temperatures were taken using a digital probe thermometer: room [ROOM NUMBER] handsink hot water measured 123.8 degrees F. room [ROOM NUMBER] handsink hot water measured 121.6 degrees F. room [ROOM NUMBER] handsink hot water measured 122.5 degrees F. Shared Shower Room handsink hot water measured 123.3 degrees F; the shower head hot water measured 122.2 degrees F. During an interview on 4/5/23 at 2:30 PM, Maintenance Supervisor T stated that the facility has an automated computer monitoring system that monitors the domestic hot water temperatures. At this time, the monitoring system was only monitoring the returning hot water from the facility's water supply. Maintenance Supervisor T discovered that the hot water set point for distribution at the mixing valve was set to 125 degrees F. Maintenance Supervisor T was queried on if the maintenance staff ever monitors the hot water temperatures at the point of use and they said they haven't done that since they implemented the computer monitoring system. During an interview on 4/5/23 at 3:00 PM, the Administrator stated that they have no incident or accident reports regarding hot water scalding. According to the Resident Census and Conditions of Residents, of the 27 residents in the facility, 19 were identified to have a diagnosis of Dementia or Alzheimer's Disease.

Based on observation, interview, and record review the facility failed to operationalize the facility Medication Management policy when a medication cart was left unlocked and unattended, resulting in prescription medications readily accessible, and controlled substances not double locked resulting in the potential for diversion of medication, and inadvertent self-administration of medication by cognitively impaired residents. Findings: The policy provided by the facility titled Medication Management effective 1/19/23 was reviewed. Section 4.5 Storage and Security of Medications reflected, The following principles apply to the storage and security of medications: and included 4.5.5. All medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. And 4.5.18.2. Schedule II-V and controlled substances and other medications deemed by Facility to be at risk for abuse or diversion are immediately placed into a double locked secured storage. The CMS form 672 titled Resident Census and Conditions of Residents completed by the facility and dated 4/5/23 was reviewed. The CMS form 672 reflected the facility reported a resident census of 27 residents with 19 residents diagnosed with dementia/cognitive deficits. On 4/5/23 at 8:35 AM an unattended and unlocked medication cart was observed in the hall outside of room [ROOM NUMBER]. A review was conducted of the medication cart which revealed insulin pens in the top drawer and multiple packages of resident prescription medications in the second drawer. The Narcotic drawer, while locked, was not double locked in accordance with facility policy. After several minutes Licensed Practical Nurse (LPN) H stepped to the door of room [ROOM NUMBER] and stated I can't believe I did that (left the cart unattended and unlocked). I always lock it. LPN H then return to the interior of room [ROOM NUMBER] and the surveyor continued the review of the medication cart. Subsequently LPN H returned to the medication cart. LPN H acknowledged the medication cart is to be locked when left unattended. 37577 During an observation on 04/05/23 at 12:31 PM, the medication cart near the nurses station was unlocked and unattended. LPN H indicated that she had stepped away from the cart to take a phone call.

Based on observation, interview, and record review, the facility failed to develop and implement a Comprehensive Care Plan for one Resident (R1) and failed to implement care plan interventions for one Resident (R11). This deficient practice resulted in R1 developing two measurable open areas resulting in no established plan of care to address the new altered skin condition and R11 who was admitted with an unstageable pressure ulcer was not being measured and monitored weekly to assess for healing. Findings: Resident #1 (R1) R1 was admitted to the facility 1/10/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] reflected R1 was cognitively intact, required the assistance of one staff member for transfers with extensive assistance for dressing and personal care. Section M of the MDS titled Skin Conditions revealed R1 was at risk for developing pressure sores. The Medical Record reflected R1 was receiving Hospice services. On 1/10/22 at 11:22 AM, an observation and interview were conducted with R1 in her room. It was observed that R1 did not have a bed in her area and was sitting upright in a recliner chair. R1 reported she sleeps in a recliner chair because it is too painful for her to sleep in a bed. R1 reported she has three sores on her buttocks and indicated the areas are not healing. On 1/12/22 at 10:07 AM, an observation and interview were conducted with Licensed Practical Nurse (LPN) C during a dressing change on the wounds of R1. When the buttocks of R1 was exposed a four by four inch gauze dressing with taped edges dated 1/11/22 was observed affixed within the center of the gluteal crevice extending equally outward toward the lower left and right buttocks. LPN C removed this dressing revealing two small open areas on the left and right inner buttocks. On 1/12/22 at 3:04 PM, an interview and record review were conducted with the Director of Nursing (DON) during which several documents were provided. The DON reported the first document to be a Hospice note. This unsigned and untimed note dated 1/3/22 reflected, (R1) has two small stage II wounds one on each buttock (,) right buttocks measures 1 centimeter (cm)x 0.8 cm, left buttocks measures 0.7 cms 0.5 cm. The DON provided documentation reportedly from LPN C dated 1/10/22 at 1:01 PM that reflected a left gluteal measurement of 0.4 cm xo.6 cm and a depth of 0.1 cm and a medial gluteal measurement of 1.5 cm x o.8 cm and a depth of 0.1 cm. Review of the facility Care Plan provided by the DON reflected Problem: (R1) is at risk for compromised skin integrity related to The Care Plan further reflected, Goal: (R1) will not experience any preventable pressure ulcers. The DON reported that the at risk plan was the only skin plan in the facility Care Plan. This indicated the facility Care Plan had not been updated to include the actual altered skin integrity identified on 1/3/22. The facility provided the policy for Pressure Injury dated 5/14/21 for review. The policy reflected, Documentation .iii. Complete documentation of wounds and pressure injuries will be completed by the nurse on a weekly basis . 5. Vertical length (longest length) - weekly documentation minimum 6. Horizontal width (widest width) - weekly documentation at minimum .iv. Documentation of pressure injuries will be done at least once a week by the Nursing Supervisor or designee . Resident #11 (R11) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 5 out of 15 which represent R11 had severe cognitive impairment. The facility provided a copy of R11's care plan titled Stage IV pressure injury to sacrum dated 5/21/21 for review. The goal reflected, will demonstrate improvement in skin integrity AEB (as evidenced by) no s/sx (signs and symptoms) of infection, healing of pressure injury. Interventions included by not limited to, Complete wound documentation weekly the intervention was undated and was not able to determine when it was initiated. The facility provided a copy of R11's admission assessment. R11 admitted with the initial sacrum wound measurement (dated 5/14/21) of 8.0 cm x 7.0 cm which was determined to be unstageable pressure ulcer due to eschar covering the wound bed. The facility provided the following wound measurement from 10/29/21 to 1/10/22 for review: 10/29/21 1.8 cm x 1.6 cm x 1.0 cm 11/26/21 1.2 cm x 1.4 cm x 0.2 cm 12/31/21 1.3 cm x 1.8 cm x 2.0 cm 1/7/21 1.2 cm x 1.6 cm x 1.8 cm During an observation and interview on 1/12/22 at approximately 9:00 AM, CNA K assisted Nurse K with positioning R11 onto his right side, in his bed for a dressing change to the sacrum. R11 denied pain throughout the procedure. R11's peri wound was noted to be intact and no further break down noted. The wound was notably dimpled (indented) from the surrounding tissue with intact scaring surrounding the wound. During a record review and interview on 1/12/22 at approximately 2:05 PM, the Director of Nursing (DON) confirmed the wound was not measured weekly (per policy) and was unable to provide any further measurements. The DON stated that the facility has identified the need for a consistent staff member to measure R11's wound weekly.

Based on observation, interview, and record review, the facility failed to ensure weekly measuring and monitoring of a pressure ulcer for Resident #11 (R11) reviewed for pressure ulcers. The deficient practice resulted in the potential for R11 whom admitted with an unstageable pressure ulcer to the sacrum, to sustain non-healing of the wound. Findings included: The facility provided the policy for Pressure Injury dated 5/14/21 for review. The policy reflected, Documentation .iii. Complete documentation of wounds and pressure injuries will be completed by the nurse on a weekly basis . 5. Vertical length (longest length) - weekly documentation minimum 6. Horizontal width (widest width) - weekly documentation at minimum .iv. Documentation of pressure injuries will be done at least once a week by the Nursing Supervisor or designee . Resident #11 (R11) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 5 out of 15 which represent R11 had severe cognitive impairment. The facility provided a copy of R11's care plan titled Stage IV pressure injury to sacrum dated 5/21/21 for review. The goal reflected, will demonstrate improvement in skin integrity AEB (as evidenced by) no s/sx (signs and symptoms) of infection, healing of pressure injury. Interventions included by not limited to, Complete wound documentation weekly the intervention was undated and was not able to determine when it was initiated. The facility provided a copy of R11's admission assessment. R11 admitted with the initial sacrum wound measurement (dated 5/14/21) of 8.0 cm x 7.0 cm which was determined to be unstageable pressure ulcer due to eschar covering the wound bed. The facility provided the following wound measurement from 10/29/21 to 1/10/22 for review: 10/29/21 1.8 cm x 1.6 cm x 1.0 cm 11/26/21 1.2 cm x 1.4 cm x 0.2 cm 12/31/21 1.3 cm x 1.8 cm x 2.0 cm 1/7/21 1.2 cm x 1.6 cm x 1.8 cm During an observation and interview on 1/12/22 at approximately 9:00 AM, CNA K assisted Nurse K with positioning R11 onto his right side, in his bed for a dressing change to the sacrum. R11 denied pain throughout the procedure. R11's peri wound was noted to be intact and no further break down noted. The wound was notably dimpled (indented) from the surrounding tissue with intact scaring surrounding the wound. During a record review and interview on 1/12/22 at approximately 2:05 PM, the Director of Nursing (DON) confirmed the wound was not measured weekly (per policy) and was unable to provide any further measurements. The DON stated that the facility has identified the need for a consistent staff member to measure R11's wound weekly.

Based on interview, and record review, the facility failed to ensure a complete, and accurately documented medical record for Resident (R11). The deficient practice resulted in the potential for R11's care plan interventions not dated and able to identify when each intervention started to promote the healing of an unstageable pressure ulcer. Findings included: The facility provided the policy for Pressure Injury dated 5/14/21 for review. The policy reflected, Documentation .iii. Complete documentation of wounds and pressure injuries will be completed by the nurse on a weekly basis . 5. Vertical length (longest length) - weekly documentation minimum 6. Horizontal width (widest width) - weekly documentation at minimum .iv. Documentation of pressure injuries will be done at least once a week by the Nursing Supervisor or designee . Resident #11 (R11) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 5 out of 15 which represent R11 had severe cognitive impairment. The facility provided a copy of R11's admission assessment. R11 admitted with the initial sacrum wound measurement (dated 5/14/21) of 8.0 cm x 7.0 cm which was determined to be unstageable pressure ulcer due to eschar covering the wound bed. The facility provided the following wound measurement from 10/29/21 to 1/10/22 for review: 10/29/21 1.8 cm x 1.6 cm x 1.0 cm 11/26/21 1.2 cm x 1.4 cm x 0.2 cm 12/31/21 1.3 cm x 1.8 cm x 2.0 cm 1/7/21 1.2 cm x 1.6 cm x 1.8 cm During a record review and interview on 1/12/22 at approximately 2:05 PM, the Director of Nursing (DON) confirmed the wound was not measured weekly (per care plan) and was unable to provide any further measurements. The DON confirmed all interventions on resident care plans did not have a date unless the nurse actually included the date when each intervention is initiated. The DON was unable to identify any updates or revisions since R11 admitted on [DATE]. It is unknown which intervention was entered/added to promoted the healing of the pressure ulcer to the sacrum.

Based on observation, interview and record review, the facility failed to implement adequate infection control and follow the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) recommendations to control the spread of COVID-19 throughout the facility, resulting in the potential for avoidable exposure to and spread of COVID-19 and other pathogens throughout the facility among all residents and staff. Findings include: During an interview with the Nursing Home Administrator (NHA) on 11/19/2020 at 8:45 AM, she advised that all staff are utilizing the same precautions in regards to PPE (Personal protective equipment) for all residents in the building. Staff are to don gown, face shield, and gloves with hand hygiene in between each step. The facility has trained some staff to stay in the halls and assist staff with donning PPE and ensuring they are completing the proper steps. They are called PPE coaches or hot bosses. During an interview with PPE coach E on 11/19/2020 at 10:15 AM, they advised they are mostly there to assist with staff donning and doffing PPE. PPE coach E stated they will take the staff face shield or other equipment and sanitize it as they leave the room, tie gowns, be a set of clean hands and needed and replenish PPE stations. PPE coach E stated they also keep an eye out for appropriate hand hygiene and prompt staff if they are about to miss an opportunity for hand hygiene. During an observation on 11/19/2020 at 10:22 AM, Housekeeping staff F was viewed entering a resident room with no gown or face shield. At 10:28 AM they exited the room again with trash in their right hand as well as holding a glove in their ungloved hand. Their left hand still had a glove on. They placed the trash in another bag on the side of the cart, reached in their pocket with their right hand for keys, unlocked their cart and removed a bottle of cleanser and then locked the card again and placed the keys in their pocket without completing hand hygiene. Housekeeping staff F then reentered the room without a gown or face shield. Housekeeping staff F exited the room again with only a glove on their left hand, doffed the glove, took their keys out of their right pocket with their right hand, unlocked the cart and replaced the cleanser. Housekeeping staff F then regloved both hands, got a mop and then reentered the resident room without donning a gown or face shield or completing hand hygiene. Housekeeping staff exited the room again with gloves on, took their keys out of their pocket to open and close the cart again. During a majority of this observation, PPE coach E was viewed in the hall and Housekeeping staff F was in their line of sight. During an observation on 11/19/2020 at 10:50 AM, Housekeeping staff F entered another resident room with no gown, face shield or gloves. Housekeeping staff F was viewed to exit the room with gloves on and carrying trash, which they put into a larger bag on their cart. They opened the unlocked cart and saturated a cleaning cloth with a solution and then reentered the resident room without a gown or face shield and without completing hand hygiene. PPE coach E was again viewed in the hall and Housekeeping staff F was in their line of sight. Observation of the larger resident hall (not the covid unit) on 11/19/2020 beginning at 9:30 AM revealed only 4 of approximately 10 resident rooms with a Severe Respiratory Precautions sign. The sign indicated: 1. Wash hands or use hand sanitizer upon entering room and as leaving room [ROOM NUMBER]. Place patient in a private room, if available. Keep doors closed. Enter the patient's room wearing full PPE. Reference donning/doffing guide. 3. Everyone who enters room must put on: gown (secured with both ties), N95/PAPR, full face shield, and gloves (extended over gown cuffs). 4. Any equipment must be thoroughly disinfected before removing it from the room by using a hospital approved disinfectant for COVID-19. 5. If transport is necessary, the patient should wear a standard isolation mask. During an interview with the Director of Nursing (DON) on 11/19/2020 at 10:45 AM, she was asked about the limited signage on the doors and if the rooms were different levels of precautions. The DON indicated they are working on getting new signage for the doors and there is no difference between the level of precautions or PPE use in any of the rooms. The DON stated all staff are expected to use gown, gloves and face shield when entering the resident rooms. During an interview with Housekeeping staff F on 11/19/2020 at approximately 1:20 PM, cleaning procedures were discussed. Housekeeping staff F indicated one of the cleaners on the cart to be a quat solution and they thought that the wet contact time was 6 minutes for disinfecting, then staff F stated it could be 10 minutes, I would have to check. Staff F was asked how they keep track of the wet contact time and they stated it usually takes more than 6 or 10 minutes to clean the room and it (the surfaces) are still wet when I finish. Housekeeping staff F were asked about their training regarding PPE and they stated they had just watched a video and took a quiz this morning when starting their shift at 7:00 AM. Housekeeping staff F was asked if they were aware they needed to wear full PPE on entering resident rooms and they stated I just found out, they (gesturing to PPE Coach K) told me to do so this afternoon. Housekeeping staff F admitted they were not wearing full PPE when entering resident rooms earlier that day and stated I haven't worked for a few days and the last time I worked we weren't doing that (wearing full PPE). Review of facility provided policy COVID-19 Every Other Daily Cleaning Procedure dated 3/27/2020 revealed: Step 1: Use 3M25 Quat disinfectant. There was no wet contact time indicated in the policy.Step 6: Identify Hot Boss for the location you are cleaning. Make sure they watch you Donning your PPE. Step 8: (there was no Step 7) Perform hand hygiene with soap and water or alcohol hand sanitizer. Step 9: Don an isolation gown. Tie at the top and the middle. Step 10: Don the face mask and eye protection (shield or goggles) . Step 11: Perform hand hygiene with soap and water or alcohol hand sanitizer. Step 12: Don gloves. The gloves must come over the gown cuffs . Step 14: Set the mop stick against the wall. Set the supplies on a surface. If additional supplies are needed in the room Hot Boss will hand in supplies using pink basin. Minimize the time and duration patient room door is left open to hallway . Step 18 . We cannot leave the room to get supplies, use Hot Boss if additional items are needed . Step 22: Remove your gloves using proper doffing methods. Step 23: Sanitize your hands Step 24: Remove your gown being careful to only touch the strings. Step 25: Sanitize your hands. Step 26: Step out of the room with the clean mop handle and place the handle on the cleaning cart. Step 27: Sanitize your hands. Step 28: Don gloves. Grab the trash and linen bags from the doorway. Trash and linen are to be handled the same as other trash and linen. Step 29: Remove gloves and sanitize hands. Review of facility policy Infection Prevention Hand Hygiene Policy with an effective date of 05/10/2019 revealed: Hand hygiene is the single most important measure proven to reduce the risk of transmission of microorganisms. On 11/19/20 at 11:15 AM, a phone interview was conducted with the housekeeping supervisor D regarding the required use of PPE by housekeeping staff in resident rooms while providing housekeeping services. Staff D stated that all staff, when providing housekeeping services to any Covid-19 positive or suspected positive room were required to don full Personal Protective Equipment, including Gown, Gloves, N95 masks and face shields. Staff D stated that all housekeeping staff had been trained for this protocol. Additional interview information was gathered concerning the use of chemicals used as disinfectants for the elimination of the COVID-19 virus. Staff D stated the chemical used was on the approved EPA list N and required a wet contact time of ten minutes. When asked about a system that ensured that the surface being disinfected remained wet for the entire 10 minutes, Staff D stated there was not a system such as timers or formal time keeping that guaranteed a full 10 minute wet time.

Based on interview and record review, the facility failed to ensure 3 residents (R#2, R#27 and R#33) reviewed for hospitalized discharged and all residents recently discharged , were given written notification of the transfer policy following transfer to the hospital, resulting in the potential for the residents or their responsible parties not being fully notified of the reasons for the transfer, circumstances requiring the transfer, and location of the transfer. Findings include: Resident #33 Review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date of 7/15/19 revealed resident had an initial admission date of [DATE]. Resident #33 had [DIAGNOSES REDACTED]. Review of the Resident #33's Face Sheet with an admitted [DATE] revealed that the resident was not his own responsible party, and that the resident's granddaughter was his legal guardian. An interview on 11/01/19 at 12:34 PM, with Director Of Nursing (DON) and Nursing Home Administrator (NHA), revealed the following when R#33's discharge paper work was requested for 9/24/19, I did not document it, he (R#33) was outside and the police took him to the Emergency Department (ED) because our social worker and a Certified Nurse's Aide (CNA) could not get him back in and he was threatening to harm family, and staff. DON stated, I guess I did not document that, Guardian for R#33 was not notified that the resident was sent to the ED. I did not chart it that day, but I did talk to her (the guardian) she was angry. The DON further revealed that, No. They did not notify the guardian in writing about the transfer policy, and confirmed there was no documentation in the medical record of the guardian being notified. Review of R#33's progress notes revealed two entries documented for 9/24/19, neither entry reflected that R#33's guardian was notified of the resident being sent to ED or of a transfer policy being provided to the resident or guardian. Resident #27 A review of Resident #27's Admission Record, dated 10/31/19, revealed Resident #27 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #27's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/17/19, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed Resident #27 was cognitively intact. During an interview on 10/30/19 at 11:00 AM, Resident #27 stated she went to the hospital this past weekend (10/26/19 or 10/27/19), because I just wasn't feeling good and they weren't doing much for me. A review of Resident #27's medical record, dated 10/10/19 to 10/30/19 revealed Resident #27 had been transferred to the emergency department on 10/13/19 for increasing pain in her left leg (Nursing General Note) and on 10/27/19 for unrelieved nausea and vomiting, multiple loose stools, and poor appetite (Nursing General Note). A review of Resident #27's medical record, dated 10/10/19 to 10/30/19, failed to reveal information that Resident #27 had received written notification of transfer to the hospital before, or after, she was transferred to the emergency department on 10/13/19 and on 10/27/19. During an interview on 10/31/19 at 11:45 AM, the Director of Nursing (DON) was informed Resident #27's written notice of transfer to the hospital (emergency department) on 10/13/19 and 10/27/19 could not be located in Resident #27's medical record. A copy of the written notice of transfer that was presented to Resident # 27 on 10/13/19 and 10/27/19, or soon thereafter, was requested from the DON, if located. During an interview on 10/31/19 at 01:59 PM, the DON stated, We didn't give her (Resident #27) anything when she went to the ER (emergency room ). She's alert and oriented and knows why she went to the ER. In fact, she requested to go. She just goes down there with her chart and med (medication) list. When the DON was asked if it was correct that Resident #27 did not receive in writing the reason for her transfer to the emergency department/emergency roiagnom on [DATE] and 10/27/19, she shook her head in an up and down motion indicating yes. A review of the facility's admission, transfer, and discharge policy, dated 3/26/19, revealed, Emergency Transfers/Discharges . The following actions will occur upon emergency transfer/discharge . Provide transfer notice as soon as practicable to resident/patient and representative (p. 6). Resident #2 diagnosed Dementia and [MEDICAL CONDITION], Resident #2 admitted to the facility 7/24/16. Review of the Minimum Data Set ((MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of nine out of fifteen which reflected Resident #2 was cognitively impaired. Review of the medical record for Resident #2 revealed a document titled Durable Power of Attorney - Health Care for Resident #2 established 8/31/2013 with Family Member (FM) N as the responsible party for Resident #2. Review of the Electronic Medical Record (EMR) Clinical Notes reflected the facility initiated a transfer of Resident #2 to the hospital for an evaluation on 10/19/19 at 8:11 AM. The Clinical Record did not include an entry of written notice of transfer to FM N. Further review of the medical record through 10/30/19 did not reveal documentation that written notice of transfer had been provided to FM N. The policy provided by the facility titled, Admission, Transfer and Discharges of Patients and Residents - Continuing Care (Rehab and Nursing Centers) , Policy Version #4, effective 3/26/2019 was reviewed. Page four of the policy under the heading of Non-Emergency Transfers or Discharges a transfer or discharge notice is defined as a written document that is written in a language and a manner they understand at least thirty days before the transfer or discharge. However, on page six of ten under the heading Emergency Transfers/Discharges the policy reflects the facility will, Provide transfer notice as soon as practicable to resident/patient and representative.

Based on interview and record review, the facility failed to ensure 3 residents (R#2, R#27 and R#33) reviewed for hospital discharge were given written notification of the bed hold policy following transfer to the hospital, resulting in the potential for the residents or their responsible parties not being fully notified of the bed hold policy should they decided to return the residents to the facility after their hospitalization s. Findings include: Resident #33 Review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date of 7/15/19 revealed resident had an initial admission date of [DATE]. Resident #33 had [DIAGNOSES REDACTED]. Review of the Resident #33's Face Sheet with an admitted [DATE] revealed that the resident was not his own responsible party, and that the resident's granddaughter was his legal guardian. On 11/01/19 at 12:34 PM during an interview with Director Of Nursing (DON) and Nursing Home Administrator (NHA), the DON was asked for R#33's discharge paper work for 9/24/19 revealed that, I did not document it, he (R#33) was outside and the police took him to the Emergency Department (ED) because our social worker and a Certified Nurse's Aide (CNA) could not get him back in and he was threatening to harm family, and staff. During the interview the NHA revealed they did not provide the resident or guardian with a bed hold policy, but would have taken the resident back. Resident #27 A review of Resident #27's Admission Record, dated 10/31/19, revealed Resident #27 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #27's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 10/17/19, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed Resident #27 was cognitively intact. During an interview on 10/30/19 at 11:00 AM, Resident #27 stated she went to the hospital this past weekend (10/26/19 or 10/27/19), because I just wasn't feeling good and they weren't doing much for me. A review of Resident #27's medical record, dated 10/10/19 to 10/30/19 revealed Resident #27 had been transferred to the emergency department on 10/13/19 for increasing pain in her left leg (Nursing General Note) and on 10/27/19 for unrelieved nausea and vomiting, multiple loose stools, and poor appetite (Nursing General Note). A review of Resident #27's medical record, dated 10/10/19 to 10/30/19, failed to reveal information that Resident #27 had received written notification of the facility's bed hold policy or was informed of the facility's bed hold policy before, or after, she was transferred to the emergency department on 10/13/19 and on 10/27/19. During an interview on 10/31/19 at 11:45 AM, the Director of Nursing (DON) was informed Resident #27's written notice of the facility's bed hold policy prior to, or soon after, transfer to the hospital (emergency department) on 10/13/19 and 10/27/19 could not be located in Resident #27's medical record. A copy of the written notice of the facility's bed hold policy that was presented to Resident # 27 on 10/13/19 and 10/27/19, or soon thereafter, was requested from the DON, if located. During an interview on 10/31/19 at 01:59 PM, the DON stated, We didn't give her (Resident #27) anything when she went to the ER (emergency room ). She's alert and oriented and knows why she went to the ER. In fact, she requested to go. She just goes down there with her chart and med (medication) list. The DON further stated, We give them (the residents) the bed hold policy as a part of their admission packet. I don't think they sign it. They just sign that they received the admission packet. The DON indicated the only time a resident would sign the bed hold policy was when they are initially admitted and they sign they received the admission packet. When the DON was asked if it was correct that Resident #27 did not receive in writing the facility's bed hold policy when she transferred to the emergency department/emergency roiagnom on [DATE] and 10/27/19, she shook her head in an up and down motion indicating yes. During an interview on 10/31/19 at 02:20 PM, Social Worker (SW) B stated, I go over the admission packet and bed hold policy with the resident when they come in. I review it with them in easy to understand language and have them sign or initial that they received it. The bed hold policy is a part of the admission packet under Facility Policies (Admission Contract) and in another section (on the Admission Acknowledgements & Authorizations form). (Name of Resident #27) was not feeling well when she came in and had a lot going on. She refused to sign and initial her paperwork when she came in. I wanted to give her some time to adjust and was going to reapproach her to see if she'll sign and initial the admission packet and bed hold policy. SW B further stated, She's her own responsible party and had requested to go to the ER. She went on the weekend (10/27/19), so I wasn't here. I don't know if they talked to her about the bed hold policy when she went to the ER. They should have. If they did, it should be documented in her chart. Normally when a resident goes to the ER, it's an emergent situation. I don't always have time to talk to them or their responsible party before they go. But I do call the responsible party or talk to the resident as soon as I can after they're transferred about why they were transferred and the bed hold policy. SW B offered no explanation as to why Resident #27 was no given, or an attempt was made to give, the facility's bed hold policy when Resident #27 went to the emergency roiagnom on [DATE], except Resident #27 had refused to sign her admission paperwork when she was admitted on [DATE]. A review of Resident #27's Baseline Care Plan Summary, dated 10/16/19 and signed by Registered Nurse (RN) H, revealed, (Name of Resident #27) refused to sign /p (after) being reviewed /c (with) her. However, a review of Resident #27's undated and unsigned Admission Acknowledgements & Authorizations form and undated and unsigned Admission Contract did not indicated these forms were reviewed with Resident #27 or an attempt was made to review them with Resident #27. A review of the facility's admission, transfer, and discharge policy, dated 3/26/19, revealed, Emergency Transfers/Discharges . The following actions will occur upon emergency transfer/discharge . Provide a notice of the resident/patient's bed hold policy to the resident/patient and representative at the time of transfer, as possible, but no later than 24 hours of the transfer (sic) (p. 6). Resident #2 diagnosed Dementia and [MEDICAL CONDITION], Resident #2 admitted to the facility 7/24/16. Review of the Minimum Data Set ((MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of nine out of fifteen which reflected Resident #2 was cognitively impaired. Review of the medical record for Resident #2 revealed a document titled Durable Power of Attorney - Health Care for Resident #2 established 8/31/2013 with Family Member (FM) N as the responsible party for Resident #2. Review of the Electronic Medical Record (EMR) Clinical Notes reflected the facility initiated a transfer of Resident #2 to the hospital for an evaluation on 10/19/19 at 8:11 AM. The Clinical Record did not include an entry of verbal or written notice of the facility's bed hold policy when FM N was notified of the Resident's transfer from the facility. Further review of the medical record through 10/30/19 did not reveal documentation of written notice of the bed hold policy had been provided to FM N in accordance with facility policy and regulatory requirements.

Based on interview and record review, the facility failed to ensure a valid Advance Directive was in place for one resident (Resident #2) resulting in an invalid Do Not Resuscitate directive to be on file and the potential for the wishes for all facility resident's to be incorrectly documented or unconfirmed by the responsible party. Findings: diagnosed with [REDACTED].#2 admitted to the facility 7/24/16. Review of the Minimum Data Set ((MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of nine out of fifteen which indicated Resident #2 was cognitively impaired. Review of the medical record for Resident #2 revealed a document titled Durable Power of Attorney - Health Care for Resident #2 established 8/31/2013 with Family Member N as the Designee. The document reflected that Resident #2 was, unable to participate in medical treatment decisions (incompetent) and signed by two medical professions on 9/9/2014. Review of the section labeled Advance Directive of the medical record for Resident #2 revealed a document titled Resuscitation Status. The document reflected a Do Not Resuscitate status for Resident #2. The document reflected the status was determined by Patient and bore the signature of Resident #2. The line for the signature of the Durable Power of Attorney was unsigned. The document reflected the signature of a facility nurse and a physician dated 7/26/16; almost two years after declaring Resident #2 incompetent to make decisions. In an interview conducted at 1:40 PM on 10/31/19, the Director of Nursing (DON) reported the Code Status of resident's are only in the hard copy medical record and should be signed by the responsible party. During an interview on 10/31/19 at 2:34 PM, Social Worker B reported Advance Directives are discussed on admission to the facility and at Care Conferences. SW B was unable to provide any Care Conference documentation that the Advance Directive for Resident #2 was reviewed.

Based on observation, interview, and record review, the facility failed to develop a comprehensive Care Plan to address incontinence for one resident (Resident #13) with known incontinence, on diuretic therapy, and difficulty with mobility without a plan to manage the incontinence, resulting in frequent incontinence episodes and the potential for all facility residents assessed with [REDACTED]. Findings: admitted to the facility 7/28/19, Resident #13 was diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected this seventy-two-year-old Resident was cognitively intact scoring fourteen out of fifteen on the Brief Interview for Mental Status (BIMS). The MDS reflected Resident #13 had consistent use of diuretic medication (a medication that increases the excretion of water from the body) over the previous seven days, was always incontinent of urine and required assistance with mobility. Section V, Care Area Assessment (CAA) Summary, section V0200, line 06 reflected Urinary Incontinence had been triggered. Line 06 indicated Urinary Incontinence was, Addressed in Care Plan. During an interview conducted 10/29/19 at 1:56 PM, Resident #13 reported she doesn't engage in activities outside of her room because she takes [MEDICATION NAME] (a diuretic) and doesn't like to be too far from the bathroom. Resident #13 reported she always eats in her room for this reason. Resident #13 also reported delayed call light response for assistance to the bathroom to urinate, and, because of the [MEDICATION NAME], she has frequent incontinence episodes. During this interview Resident #13 indicated she had to use the bathroom and initiated a call light. Staff arrived in less than thirty seconds and as staff entered the room the Resident stated she had been incontinent just then. At the onset of a subsequent interview on 10/30/19 at 12:56 PM, Resident #13 reported she had just been incontinent just as I entered the room. The call light had not been initiated and the Resident indicated she did not have time to use the call light before she was incontinent. Review of the list of Care Plans in Electronic Medical Record (EMR) did not reveal a Care Plan with a focus on Urinary Incontinence. Review of the Individual Care Plans did not reflect an Incontinence plan. The Care Plan for Activities of Daily Living (ADL) indicated, Resident #13 requires assistance with ADLs and listed an intervention of Assist with ADLs as needed: see Resident Summary Template (RST). The RST is a summary of resident -specific care needs. Review of the RST indicated Resident #13 was incontinent of urine, wore a brief, was a high fall risk, and required limited assistance to use a walker to ambulate to the bathroom. The RST did not reflect an incontinence schedule or a plan to prevent episodes of incontinence. In an interview conducted 10/31/19 at 11:41 AM, Certified Nurse Aide (CNA) I reported Resident #13 is Definitely incontinent of bladder but is not on a toileting schedule. Review of the medical record did not reveal any documentation the Facility had attempted to restore or improve bladder function or attempted to devise a plan to address incontinence for the physical and psychological well-being of the Resident to the extent possible. During an interview conducted 10/31/19 at 12:11 PM, the Incontinence concern of Resident #13 was discussed with the Director of Nursing ((DON). On 11/1/19 at 3:10 PM, the DON reported she had no further information regarding Resident #13.

Based on interview and record review, the facility failed to follow physician orders [REDACTED].#29), resulting in the potential for unnecessary lab draws and resident discomfort. Findings include: Resident #29 A review of Resident #29's Admission Record, dated 10/31/19, revealed Resident #29 was an [AGE] year-old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #29's medical record revealed a pharmacy recommendation, dated 9/16/19, recommending a decrease in basic metabolic (BMP), CBC (comprehensive metabolic panel), and glycosylated hemoglobin lab draws (all labs collected from blood draws) from every 3 months to every 6 months secondary to stable values. In addition, Resident #29's pharmacy recommendation was signed by the physician on 9/18/19, the physician had marked the box AGREE (indicating he agreed with the recommendation), and had noted 9/18/19 @ (at) 1607 (4:07 PM) written on it. A review of Resident #29's (MONTH) 2019 Physician order [REDACTED].#29's current order for Comprehensive Metabolic Panel (CBC) with differential and Comprehensive Metabolic Panel (CBC) was dated 9/22/17 (a year before the pharmacy recommendation) and was to be drawn every three months. In addition, Resident #29's Physician order [REDACTED].#29's current order for Comprehensive Metabolic Panel (CBC) without differential, Comprehensive Metabolic Panel (CBC), and Hemoglobin (Hgb) A1C (glycosylated hemoglobin) was dated 6/12/19 (3 months before the pharmacy recommendation) and was to be drawn every one day. Resident #29's Physician order [REDACTED]. A review of Resident #29's Standing Physician order [REDACTED].#29 was to have a BMP drawn every three months, if on a potassium supplement or diuretic (a water pill). During an interview on 10/31/19 at 02:40 PM, the Director of Nursing (DON) stated, I looked at her (Resident #29's) lab orders and see they weren't changed to every 6 months. They still said to do them every 3 months. I don't understand why the schedule wasn't changed because the pharmacy recommendation is the physician's orders [REDACTED]. Someone noted the order and it was faxed. I don't know why it wasn't changed. (Name of Pharmacist K) would probably have caught it next month (November 2019 and 2 months after the recommendation was agreed on) when she comes in. She comes in every month and checks to see if recommendations were followed. She would have caught it anyway before it was drawn.

Based on observation, interview and record review, the facility failed to implement an incontinence plan for a one Resident (Resident #13) with known urge incontinence, on diuretic therapy, and difficulty with mobility resulting in frequent incontinence episodes and the potential for all residents with incontinence to not have a plan devised to address their incontinence. Findings: admitted to the facility 7/28/19, Resident #13 was diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected this seventy-two-year-old Resident was cognitively intact as indicated by a Brief Interview for Mental Status score of fourteen out of fifteen. During an interview conducted 10/29/19 at 1:56 PM, Resident #13 reported she doesn't engage in activities outside of her room because she takes [MEDICATION NAME] (a diuretic) and doesn't like to be too far from the bathroom. Resident #13 reported she always eats in her room for this reason. Resident #13 also reported delayed call light response for assistance to the bathroom to urinate, and, because of the [MEDICATION NAME], she has frequent incontinence episodes. During this interview Resident #13 indicated she had to use the bathroom and initiated a call light. Staff arrived in less than thirty seconds and as staff entered the room the Resident stated she had been incontinent just then. At the onset of a subsequent interview on 10/30/19 at 12:56 PM Resident #13 reported she had just been incontinent just as I entered the room. The call light had not been initiated and the Resident indicated she did not have time to use the call light before she was incontinent. Further review of the MDS dated [DATE], Section V, Care Area Assessment (CAA) Summary, section V0200, line 06 reflected Urinary Incontinence had been triggered. Line 06 also indicated Urinary Incontinence was, Addressed in Care Plan. Review of the list of Care Plans in Electronic Medical Record (EMR) did not reveal a Care Plan with a focus on Urinary Incontinence. Review of the individual Care Plans did not reflect Incontinence interventions. The Care Plan for Activities of Daily Living (ADL) indicated, Resident #13 requires assistance with ADLs and listed an intervention of Assist with ADLs as needed: see Resident Summary Template (RST). The RST is a summary of resident -specific care needs. Review of the RST reflected Resident #13 was incontinent of urine, wore a brief, was a high fall risk, and required limited assistance to use a walker to ambulate to the bathroom. The RST did not reflect an incontinence schedule or a plan to prevent or mitigate episodes of incontinence. In an interview conducted 10/31/19 at 11:41 AM, Certified Nurse Aide (CNA) I reported Resident #13 is definitely incontinent of bladder but is not on a toileting schedule. Review of the medical record did not reveal any documentation the facility had attempted to restore or improve bladder function or attempted to devise a plan to address incontinence for the physical and psychological well-being of the Resident to the extent possible. During an interview conducted 10/31/19 at 12:11 PM, the Incontinence concern of Resident #13 was discussed with the Director of Nursing ((DON). On 11/1/19 at 3:10 PM, the DON reported she had no further information regarding Resident #13.

Based on interview and record review, the facility failed to ensure adequate pain control and monitoring for one resident (Resident #12), resulting in unrelieved pain and the potential for all facility residents that experience pain to not receive adequate relief and not have pain monitored to ensure proper treatment of [REDACTED]. Findings: diagnosed with [REDACTED].#12 admitted to the facility 8/29/19. Review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was cognitively intact scoring a 15 out of 15 on the MDS Brief Interview for Mental Status (BIMS). In an interview conducted 10/29/19 at 10:11 AM, Resident #12 reported she has pain in her right hip and leg. The Resident reported she is given pain medicine but that it is ineffective in relieving the pain. Resident #12 reported she has told staff the pain medication do not work and she was told, well' that's what the Doctor says to give you. Resident #12 reported staff do not evaluate her pain after administration of pain medication. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the facility document titled, (MONTH) 2019 Treatments reflected Resident #12 had a pain evaluation 3 times a day using a 1 to 10 pain scale. The document reflected Resident #12 had reported a pain level of 8 on 10/19/19, 10/21/19, 10/22/19, and 10/27/19. Review of the medical record did not reveal administration of additional pain to include the Tylenol. The medical record Clinical Notes did not reflect documentation of a pain assessment. The medical record did not reflect implementation of non-pharmacological measures, a follow up assessment, or that the physician had been informed. An interview regarding the pain control for Resident #12 was conducted 11/1/19 at 11:27 AM, with the Director of Nursing (DON). The statements of Resident #12 and the findings in the medical record were discussed. The DON reported she did not consider a pain rating of 8 to be mild. The DON reviewed the medical record and reported that the pain level of 8 on 10/21/19 was documented at 4:46 PM. This is 2 hours and 46 minutes after 2 pain medications are scheduled (2:00 PM) to be administered. After further review of the medical record the DON reported she could not find documentation of any actions taken to address or follow up on the pain of Resident #12. The DON reported she had provided care to Resident #12 several days prior and reported that the Resident told her she was always in pain and that nothing seemed to help.

Based on observation, interview, and record review, the facility failed to post actual working hours of licensed and unlicensed nursing staff, resulting in the potential for inaccurate staffing information. Findings include: During an observation on 11/01/19 at 12:30 PM, the facility staff posting sheet for 11/1/19 was observed posted outside of the dining room. The facility staff posting sheet listed the number of licensed and unlicensed nursing staff scheduled for the Day Shift, Evening Shift, and Night Shift and the hours of each shift (e.g. 7:00 AM to 3:00 PM for licensed staff on Day Shift) of nurses and aides posted, but not actual hours worked. In addition, the total number of licensed staff, unlicensed staff, and number of residents (census) were listed for all 3 shifts for that day even though the Evening Shift and Night Shift hadn't occurred when the staff posting sheet was observed. A review of the facility staff posting sheets, dated 10/29/19 to 10/31/19, revealed the same information as the 11/1/19 facility staff posting sheet (number of licensed and unlicensed staff without actual hours each category of staff worked). During an interview on 11/01/19 at 01:00 PM, the Nursing Home Administrator (NHA) stated the facility had only been putting the number of nurses and aides (licensed and unlicensed nursing staff) working on the staff posting sheets and not the hours worked. We thought we were covered. We put the number of staff and the sheet is broken down by shifts with the hours of the shifts (e.g. Day Shift 7:00 AM to 3:00 PM for nurses and 5:30 AM to 1:30 PM for Certified Nursing Assistants). The NHA stated the staff posting sheets were posted at the beginning of the Day Shift for the entire day. Therefore, the staff posting sheets would not reflect changes that occur prior to the Evening and Night Shifts (e.g. call-in's and census changes). Upon further questioning, the NHA stated some of the nurses work 12 hour shifts and each nurse would be listed on 2 different shifts because the shifts are broken down in 8 hour increments (i.e. on Day Shift and on Evening Shift for 7:00 AM to 7:00 PM and on Evening Shift and Night Shift for 7:00 PM to 7:00 AM). Therefore, it would appear there were twice as many nurses working the Evening Shift than actually worked that shift because the shift hours and not the actual hours worked are listed on the staff posting sheet (i.e. 3:00 PM to 11:00 PM (8 hours each for 4 nurses) vs. 16 hours (8 hours each for a total of 2 nurses that were actually present during the 8 hour shift- 2 nurses for the first half of the shift and 2 nurses for second half of the shift).

Based on observation, interview, and record review, the facility failed to properly store and label medications in 1 of 2 medication carts (Odd Rooms Medication Cart) and the medication room, potentially affecting all residents at the facility, resulting in the potential for misappropriation of a controlled substance and the potential for expired TB PPD ([MEDICAL CONDITION] purified protein derivative) being used for TB testing and the potential for inaccurate TB test results. Findings include: During a medication administration observation on [DATE] at 10:45 AM, a [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]- a narcotic pain medication) tablet was observed in the top drawer (a single lock drawer) of the Odd Rooms Medication Cart. The [MEDICATION NAME] tablet was still in it's original packaging. The [MEDICATION NAME] tablet had a sticky note attached to it with the resident's name (Resident #281) on it and the time the medication was due. Registered Nurse (RN) G stated, I pulled the [MEDICATION NAME] at 9:26 AM (confirmed with the medication distribution machine at 12:00 PM). It was (removed from the machine) 15 minutes early (before the medication was due to be given). I put it in my drawer and figured by the time I pulled (removed from the medication cart) his (Resident # 28's) (other) meds (medications) it would be due. I usually don't pull a med and put it in the drawer for later. I just didn't expect you to be watching me. During an inspection of the medication room on [DATE] at 12:00 PM with RN G, a TB PPD ([MEDICAL CONDITION] purified protein derivative- a substance used to test for TB infection) vial was observed in box labeled with a use by date of [DATE]. The individual vial in the box was unlabeled. RN G stated, It's (the TB PPD vial) good for 30 days (after opening). We normally label the vial. I could label this vial. But I don't know for sure when the vial itself was opened. RN G verbalized agreement if the vial was separated from the box, she would not know when the vial was opened. RN G verbalized she would assume the vial was opened, and was to be used by, the date on the box, but wasn't absolutely certain that- that would be correct. During an interview on [DATE] at 9:50 AM, RN F stated, The TB (vial) is good for 28 days after opening. We label the vial when we open it. RN F further stated, If you get a med from the (brand name of the medication distribution system) and it's not time (e.g. it's too early to receive the pain medication), you can return it to the (brand name of the medication distribution system). I wouldn't put [MEDICATION NAME] in the top drawer (of the med cart). Narcotics have to be double locked. We do have a narcotics box in each med cart for narcotics and controlled substances that (name of outside pharmacy company) sends us for their residents. During an interview on [DATE] at 03:15 PM, Director of Nursing (DON) B stated, After the TB vial is opened, they are good for 30 days. They should be labeled when they are opened. DON B further stated, The narcotics should be locked up when they are in the cart. They shouldn't be pulled early. DON B indicated that if a narcotic needed to be kept in the medication cart, it should be locked in the narcotics/controlled substances box (a locked box in the medication cart with a lock on it- double locked) and not left in a drawer that is not double locked. A review of the manufacturer's instructions for the TB PPD, dated (MONTH) (YEAR), revealed, A vial of (brand name of TB PPD) which has been entered and in use for 30 days should be discarded. Do not use after expiration date. A review of the facility's medication safety policy, dated [DATE], revealed 3. Labeling of Medications- a. Medications that are not in the original packaging will include . ii. Date opened or date the medication will expire as needed . 5. Storage and Security of Medications . b) Controlled substances are stored under a double lock system.

Based on observation, interview, and record review, the facility failed to ensure dignified treatment of [REDACTED].#13 and Resident #1) resulting in undignified assistance, unmet needs, and the potential for feelings of worthlessness and loss of self-esteem of all facility residents that require assistance. Findings: Resident #13 Resident #13 was admitted to the facility 7/24/16, with [DIAGNOSES REDACTED]. Review the Minimum Data Set ((MDS) dated [DATE], indicated resident #13 required assistance with eating. On 12/10/18 at 12:38 PM, an observation of the noon meal service was conducted in the facility's main dining room. A large table was observed to have four residents that required assistance with eating. Three of the four residents were being assisted by Certified Nurse Aides (CNA) and the fourth was being assisted by a family member. CNA H was seated next to, and slightly in front of, Resident #13. CNA H was observed to be talking animatedly to other staff and the family member at the table. While talking, CNA H was observed to have food on a fork that was being held in a reverse manner with the fork tines extended past the back of the hand rather than in front of the palm. CNA H was observed waving the fork around while talking. When CNA H noted Resident #13 was ready for another bite the CNA would reach back (not facing the resident), give the Resident the food that was on the fork, scoop the next bite onto the fork then continued to wave the fork around while talking. During the observation CNA H rarely faced or interacted with Resident #13 but talked extensively toward the CNA's on the left and right. The CNA's on the left and right would nod occasionally to CNA H but were observed to be attentive to the residents they were assisting. Neither of the other CNAs were observed to redirect CNAH to focus on the needs of Resident #13. Through the meal service CNA H was observed to be laughing when talking about some little old lady, and, when asked to do something by another staff member CNA H replied loudly, when I'm done feeding. During the entire observation Resident #13 remained quiet and appeared to stoically accept the way the assistance had been provided. On 12/11/18 at 9:36 AM, an interview was conducted with Resident #13 in his room. Resident #13 reported he needed assistance with all his meals. Resident #13 was asked about the meal service the previous day. Resident #13 stated, I don't know how the CNA's concentrate on what they're doing. Resident #13 indicated staff will talk about their family matters and their kids. Resident #13 indicated that this sometimes bothered him. Resident #13 reported sometimes the food cools off too much during the meal. Review of the Competency checklist for CNA H reflected that CNA H had received facility instruction on Resident Rights, Dysphagia Management, and Dining Assistance on 9/6/18 and 9/7/18. On 12/10/18, at 1:39 PM, an interview was conducted with CNA H. CNA H reported she had had Dining Assistance training during her CNA certification courses 2 years prior. CNA H reported the facility had provided this training again during her new employee orientation. CNA H did not indicate that the noon meal service of 12/10/18, was any different for her than any other meal service. Resident #1 Resident #1 was a admitted to the facility 12/28/17, with [DIAGNOSES REDACTED]. On 12/11/18, at 11:04 AM, Resident #1 was observed in a wheelchair without foot pedals in the hall outside of the main dining room. As the surveyor was walking toward Resident #1 CNA H was observed approaching from the other direction. Resident #1 asked CNA H if she could get his foot pedals and assist him to his room. CNA H stopped next to Resident #1 and encouraged him to propel himself to his room. The surveyor continued to walk past the two talking and overheard Resident #1 indicate he had propelled himself to the dining room too early for lunch and he needed assistance to return to his room. At that time another CNA approached and walked past CNA H and the Resident and asked CNA Hif she was going to break. CNA H was overheard to say, yes. At approximately 11:06 AM, an observation and interview were conducted with Resident #1 in the hall by the dining room. Resident #1 indicated he had asked CNA H for assistance but that the CNA reported she was on break. Resident #1 then asked if the surveyor could obtain foot pedals and assist him to his room. Review of the facility document titled, Final Notice dated 11/8/18, reflected Unsatisfactory performance by CNA H. The Final Notice reflected CNA H had not consistently given scheduled showers or provided HS (night time) care to residents, had walked past call lights, was often found talking at the nurse's station, and was had been observed using a personal cell phone. The Final Notice document reflected previous performance discussions with CNA H regarding negativity and inability to take direction. The Final Notice reflected future performance expectations but did not indicate how or who was to monitor the CNA to ensure the needs of the residents were met or that the rights of the residents were observed.

This citation has 2 Deficient Practice Statements (DPS), 1 and 2. DPS 1: Based on observation, interview and record review the facility failed to maintain safe labeling and dating standards of food in the facility kitchen resulting in the potential for the serving to all facility residents outdated and/or contaminated food to a population vulnerable to a decline in health or outbreak of illness from food-borne pathogens. On 10/24/17, at 7:08 AM the initial Kitchen Tour was conducted with Cook H. Cook H indicated all food items were labeled and dated when opened and placed in use. During the tour the following findings were observed: Walk in cooler: A tray of sliced tomatoes labeled 10/12 with use by date of 10/19 An opened 5 pound (lbs) bag of Mozzarella cheese labeled as opened 10/15/17, with a use by date of 10/21 An opened, unlabeled plastic bag with a white creamy substance. Cook H reported the bag contained yogurt and indicated that the bag should have been labeled and dated when opened. 3 Door Freezer: A zip lock bag that contained meatballs with a label that read 10/8/17, and a use by date of 10/14/17. 6 cinnamon rolls individually wrapped in plastic wrap on a tray. The individual rolls were not labeled or dated. Cook H reported the date label for the wrapped rolls was on the tray. The tray label read 7/1 with a use by date of 10/1. Reach-in cooler: A small metal tub with 1 egg inside. The label on the tub read 10/17, with a use by date of 10/23. 1 opened quart carton of liquid egg whites with an opened date of 10/20/17, and a use by date of 10/22/17 . In an interview conducted 10/25/17, at 11:24 AM, Dietary Manager (DM) F reported all date labels, should be checked with truck deliveries on Tuesday and Friday. DM F reported the facility kitchen followed the labeling and dating time frame for food as, today plus 6 (days). DM F stated, we follow the Health Department Standards. Review of the Michigan Food Code 2009 effective October 1, 2012, 3-501-17 reflected, refrigerated, ready to eat potentially hazardous food (time/temperature controlled for food safety) prepared and held . shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of . (41ºF) or less for a maximum of 7 days. Review of the Michigan Food Code, 3-501-18 reflected, A food specified in 3-501.17 shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), . 2) Is in a container or package that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). DPS 2: Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services (oral foods) out of the facility's total census of 38 residents. Findings include: On 10/25/2017 during the dietary tour of the facility between the hours of 9:43 a.m. and 12:22 p.m. the following observations, record review and interviews took place: 1. Four plastic storage bins, 2 plastic cambro containers, 2 metal cambo containers, 2 container lids a measuring cup and a catering dish were observed with labels and sticker residue on each of the items surfaces while being stored on the ready for use, clean-dry storage rack. Upon interview with the dietary manager, staff F, they stated that they were unaware that these items were being put away as clean and ready for use. At this time the surveyor asked staff F for a copy of the facility's cleaning and sanitizing policy to review. On 10/25/2017 at 2:11 p.m. upon record review it was confirmed that the facility has a policy in place titled, Food Handling-Sanitation addressing how food contact surfaces and equipment are to be cleaned. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012 Chapter 4-603.14, Wet Cleaning, directs that: (A) Equipment, food-contact surfaces and utensils shall be effectively washed to remove or completely loosen soils by using the manual or mechanical means necessary such as the application of detergents containing wetting agents and emulsifiers; acid, alkaline, or abrasive cleaners; hot water; brushes; scouring pads; high-pressure sprays; or ultrasonic devices. (B) The washing procedures selected shall be based on the type and purpose of the equipment, or utensil and on the type of soil to be removed. 2. Improper sanitizing of items on two separate occasions was observed as cook, staff G, was observed not allowing for the sandwich station's cutting board to receive adequate contact time with sanitizer solution per the manufacture's recommendation. Additionally, staff G was observed not allowing for the cutting board to completely air dry prior to bringing it back into use as it was observed actively dripping by the surveyor. Upon observation the dietary manager, staff F, asked staff G to, please go get another cutting board. On 10/25/2017 at 2:11 p.m. upon record review it was confirmed that the facility has a policy in place titled, Food Handling-Sanitation addressing that sanitizer solution will be prepared and monitored per manufacture's guidelines. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012 Chapter 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under § 4-501.114. Contact times shall be consistent with those on EPA-registered label use instructions by providing: (3) A contact time of at least 30 seconds for other chemical SANITIZING solutions, or (4) A contact time used in relationship with a combination of temperature, concentration, and PH that, when evaluated for efficacy, yields SANITIZATION as defined in 1-201.10(B).